See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/313530690

The Delaire philosophy of cleft lip and palate repair

Article · January 2006

CITATIONS READS

5 3,385

3 authors, including:

Roberto Brusati Maurice Y Mommaerts

University of Milan University Hospital Brussels
159 PUBLICATIONS   2,967 CITATIONS    236 PUBLICATIONS   4,048 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

The effect of the 'Parent Focused Approach' on the communication development of children with cleft lip and palate View project

Aesthetic facial surgery View project

All content following this page was uploaded by Maurice Y Mommaerts on 14 November 2018.

The user has requested enhancement of the downloaded file.

 CHAPTER

The,'Delaire PhilosophyofClefl
lip ,a'nd Palate Repafr

ROBERTO BRUSATI, NICOlA MANNUCCI, MAURICE Y. MOMMAERTS

KEY POINTS
• Careful muscular reconstruction and alignment is key to good aesthetics and function of the soft palate, lip,
and nose.
• The concept of primary functional' cheilorhinoplasty is launched .
.• Subperiosteal undermining of the,cleft-sided cheek is considered a prerequisite for tension free-suturing of
the nasolabial musculature.
• Gingivoperiosteoplasty has been adopted and is in evaluation.
• Hard palate closure is pe;'formed with bipedicled flap~ of only fibromucosa of the palatal shelves, leavingthe
maxiUary fibromucosa untouched. When the deft is narrow, undermining of the palatal fibromucosa and
pairing of the edges is sufficient.

Treatment of deft deformity-which impairs functions
such as appearance, phonation, mastication, respiration,
and hearing-must be based on a sound knowledge of
anatomy, physiology, and development of the involved
regions, as weU as of the pathomorpholagy of the
deformity itself. AU of these aspects have been studied
extensively by Professor Jean Delaire, who has devel-
oped a philosophy concerning the significance, rela-
tionships, and interactions of the various structures,
from which he derived a rationale for the treatment of
deft lip and palate deformities.1-18 Although not aU of
his philosophy has not been scientifically supportedby
experimental data, his philosophy is logical and the
results obtained from its application are clinicallyvalid
To aUow the readers to understand Delaire'slogicto
the fuU, it is necessary ta begin by consideringthe
normal and pathological anatomy of the musclesand
structures involved in the deformity and the role that
some structures (e.g., the nasal septum, musculature
and tongue) and some functions (e.g., dental occlusion
and nasal respiration) play in maxillary and particularl
premaxillary growth.
PART 111 CRANIOFACIAL DEFORMITY 1027

ANATOMV OF THE NASOLABIAL which participate in the anatomy and physiology of the
MUSCULATURE AND THE MEDIAN upper lip.
SEPTUM OF THE UPPER LIP
Transverse Nasalis (or Constrictor Nares) Muscle
The orbicularis oris in the upper lip contains three
muscle strata or bands: horizontal internal orbicularis The transverse nasalis muscle originates at the level
bands, oblique external orbicularis bands, and incisal of the nasal dorsum ne ar the midline and runs down-
bands. The upper lip contains numerous other muscle ward superficiaUy to the lateral part of the upper lateral
insertions, aU of which form part of a system of three (triangular) cartilage. lts fibers intermingle with those of
interconnected rings extending from the u pper part of the levator labii superioris alaeque nasi and the levator
the face to the chin (Fig. 52_1).3,17,18 labii superioris to form a true modiolus lateraUy to the
nasal alae in the nasolabial fold, and then pass hori-
UPPER RING zontaUy under the nostril floor to insert onto the inci-
sive crest posteriorly to the top of the anterior nasal
The upper ring consists of a large number of muscles spine, and onto the perichondrium of the adjacent nasal
on both sides: the transverse nasalis, the levator labii septum, and superficiaUy onto the dermis of the naso-
superioris alaeque nasi, the levator labii superioris, the labial fold and the nostril floor.
zygomaticus minor and zygomaticus major, and the At the level of the nos tril floor, the transverse nasalis
levator anguli oris (caninus), the lower insertions of is in continuity with the depressor septi nasi that arises
from the incisive fossa and then inserts mediaUy onto
the septum and lateraUy in the posterior part of the alae.
The anatomical dissection and identification of these
terminations may be difficuit and may give rise to erro-
neous interpretations to the extent that, in their anatom-
~ \
\ ical studies, equaUy authoritative authors19 have localized
\
\ the lower insertion of the transverse nasalis muscle
\
\
\
to the incisive fossa. This last finding, together with
I clinical observations of the morphology of the nostrils
,.
:I during cleft lip surgery, was to become the basis of
6 ,I , one of Talmant's modifications20 to the Delaire's
I cheilorhinoplasty technique.
I'
7
,,, I

,,\ levatc5r labii Superioris Muscle

10 \
\
\ The levator labii superioris originates at the infra-
I
orbital rim, above the infraorbital foramen, runs down-
:11
I
,, ward superficiaUy to the caninus (levator anguli oris) and
11 runs caudaUy below the levator labii superioris alaeque
,,,,,
I
I
nasi until it reaches the nasolabial modiolus. Some deep
fibers attach to the oral vestibular fold mucosa to ensure
\
\
I its synchronous raising with that of the lips.
I
13 I
, 111
I
,, levator Anguli Oris (or Caninus) Muscle
I
,, I
Originating in the canine fossa, the levator anguli
oris runs lateraUy and deeply to the levator labii supe-
Fig. 52-1 Anatomy of the nasal and oral musculature: rioris and is inserted inferiorly in the outer border of the
I, Upper ring; 11, middle ring; lil, lower ring; 7, levator labii external orbicularis muscle bands.
superioris alaeque nasi; 2, levator labii superioris; 3, trans-
verse nasalis muscle; 4, alar cartilage; 5, nasal septum;
6, levator anguli oris (caninus) muscle; 7, zygomaticus levator labii Superioris Alaeque Nasi Muscle
minor; 8, external orbicularis labii superioris bands; 9, inter-
nalorbicularis labii superioris bands; 70, zygomaticus major; Originating in the upper part of the frontal process
77, buccinator; 72, orbicularis inferior muscle; 73, trian- of the maxilla, the levator labii superioris alaeque nasi
gularislabii muscle; 74, quadratus labii muscle; 75, mentalis. runs downward superficiaUy to the lateral portion of
1028 CHAPTER
the transverse nasalis muscle, wh ere it divides into two
fascicles. The first fascicle becomes inserted into the
skin and most lateral part of the lateral alar crus, where
it intermingles with the other muscular insertions in the
nasolabial modiolus. The second fascicle runs medially
in front of the fibers of the transverse nasalis muscle
and enters the most anterior part of the nasal vestibule.
There the muscle intermingles with the fibers of the
transverse nasalis and the depressor septi nasi and the
oblique bands of the orbicuJaris muscles, thus termi-
nating partially in the nasal spine and partially in the
anterior part of the caudal septum.
Zygomaticus Minor Muscle
The zygomaticus minor originates at the surface of
the zygoma, from where it runs downward and medi-
aUy until it fuses with the lateral part of the external
orbicularis bands superficially to the insertion of the
caninus muscle.
MIDDLE RING
The middle ring, which represents the oral sphincter,
fundamentally consists of the upper and lower lip
orbicularis oris. In the upper lip the orbicularis oris is
made up of three strata on each side (horizontal,
oblique bands, and incisal bands), to which should be
added the incisivus (myrtiformis) mus~le. The termina-
tions of the nasolabial muscles (upper ring) intermingle
with the intrinsic musculature of the upper lip. The
buccinator and zygomaticus major join the oral modio-
lus from laterally.
Orbicularis Labii Superioris Internal Bands
The orbicularis labii superioris internal bands are
the most well-known component, characterized by the
horizontal course of fibers extending from one com-
missure to the other, where they intermingle with the
fibers of the lower lip orbicularis oris and the bucci-
nato1'. They run the thickness of the upper lip just
below the depression of the philtrum and are inserted
superncially into to the mucocutaneous rim, giving it
the prominence of the so-called white roll. Contraction
of the horizontal bands shortens and lowers the supe-
rior lip, which compresses the underlying dentoalveolar
structures.
Orbicularis Labii Superioris External (or
Nasolabialis) Bands
The more media 1 fibers of the orbicularis labii supe-
rioris external bands run almost vertically, superficially
52 THE DELAIRE PHILOSOPHY OF CLEFT LIP AND PALATE REPAIR
to those of the internal orbicularis, and determine the
presence of the philtral crests. The other fibers fan out
from the nasal spine, the lower part of the columella,
and the nostril floor and then run downward and later-
ally in the direction of the commissures. At this point,
the bands intermingle with the fibers of the depressor
anguli oris, buccinator, risorius, platysma, and triangu-
laris labii muscles. As already described, the bands also
intermingle with the fibers of the upper ring, the zygo-
maticus major, and the depressor septi. Superficially,
the fibers are inserted into the labial dermis anel in
correspondence with the mucocutaneous rim. The con-
traction of the oblique bands raises the upper lip anc!
protrudes it forward.
Incisal Bands of the Orbicularis Oris Muscle
The incisal fibers of the orbicularis oris lie deeper
than the oblique fibers and are inserted medially il1to
the extern al border of the myrtiform fossa, from where
they run downward and laterally toward the commis-
sures in the same way as the oblique fibers of the
external orbicularis muscles do.
Incisivus (or Myrtiformis) Muscle
The incisivus is a small muscle ong1l1ating in the
incisive (myrtiform) fossa, which is on the vestibular
aspect of the premaxilla in correspondence with the
apex of the lateral incisor, and runing upward ra insert
in the proximity of the most anterior part of the nostril
floor, where it intermingles with the fibers of the
transverse nasalis muscle.
LOWER RING
The lower ring is incomplete and consists of the.
orbicularis oris inferior, the triangularis labii, anc!
the quadratus labii inferioris. Whereas the fibers of the
triangularis labii originate at the lower mandibular
border lateral to the chin and then extend upwarel until
they intermingle with the orbicularis oris of the upper
lip, those of the quadratus labii inferioris originate more
medially (but still in the chin region) and insert in the
inferior orbicuJaris muscle.
PHYSIOLOGY OF THE FACIAL MUS(LE
(HAIN: EFFECTS ON SKELETAL GROWTH
The organization of the perioral and perinasal muscle
rings as a chain affects the growth of the underlying
skeleton. The integrity of the first ring, which is dis-
rupted in the case of a cleft lip, is fundamental for
PART 111 CRANIOFACIAL DEFORMITY
allowing and sustaining the normal function of the
other two rings. The cartilaginous nasal septum, by
meansof all of the tendinous terminations reaching its
anteroinferior border, supports and draws forward the
tIpperand middle rings as it grows. Through them, the
first ring stimulates the periosteum of the anterior
maxi/laand thus constributes to the harmonious growth
of the latter. Labial motility, in addition to modeling
directlythe underlying dentoalveolar structure, also is
partof the "nasal septum system" and as such positively
innuences the fan-shaped growth of the premaxilla (see
the following discussion). The lower ring acts by mod-
elingthe dentoalveolar complex and the chin portion of
rhe mandible vertica11y and transversely.
GROWTHOF THE PREMAXILLA
The premaxilla consists of two symmetrical parts th at
are separated along the midline by a sagittal suture and
are joined to the rest of the maxilla by means of a
transverse suture that extends from the canine alveolus
ro the incisor cana!.
The premaxillary-maxillary suture closes externa11y at
7 10 8 weeks in utero. Starting at 6 to 7 years of age, the
su!ure gradually closes from the outside in, from the
nast! floor to the oral cavity, though evidence of this
structure remains visible in adults.
The premaxilla grows under the influence of various
mechanisms including tongue pressure, the t~oth devel-
opment, occlusal forces, and the force transmitted by
the "median septal system" (see the fo11owing discus-
sion) and the nasolabial muscles. The growth is charac-
terized by three elements: a principa11y fan-shaped
movement (Fig. 52-2) with the rotation of each hemi-
premaxilla around a pivot represented by the canine
reeth, anterior bony apposition, and a transverse trans-
lation of each hemi-premaxilla. Of particular interest in
terms of the pathological condition under consideration
is the role of the median septal system and the mus-
culature.
The median septal system is made up of five com-
ponents: the nasal cartilaginous septum, Latham's liga-
ment,21the median ce11ular septum, the median frenum,
anel the insertion of the nasolabial muscles. Latham's
ligament unites the lower part of the anterior border of
rhe cartilaginous septum to the nasal spine and the
nasal (upper) surface of the premaxilla. The median
cellular septum6 extends vertica11y from the septal carti-
lage to the median frenum of the upper lip. The median
cellular septum originates in the dermis and has its
eleep insertion throughout the length of the median
suture, penetrating deeply where the suture is wide (the
alveolar process). This system therefore transmits to the
1029
Fig. 52-2 The growth of the premaxilla is characterized by
a fan-shaped movement with rotation of each hemi-
premaxilla around a vertical axis located at the level of the
cuspids. A, Premaxillary-maxillary suture; B, interincisive
suture; C, cuspid.
premaxilla not only the traction forces developed by the
anterior growth of the septum but also those originating
from the movements of protruding or laterally stretch-
ing the lips. Perhaps the main role in the transverse
and anterior growth of the premaxilla is played by the
nasolabial muscles, which by their insertion in the
incisal crest and nasal spine exert a transverse traction.
Furthermore, the insertion of these muscles into the
cartilaginous septum means th at the anterior growth of
the latter provides constant functional stimulation to the
vestibular aspect of the premaxilla by means of a mus-
culoperiosteal tent and consequent periosteal apposition.
PATHOMORPHOLOGY OF CLEFTING
The pathomorphology of cleft lip and palate varies
greatly, depending on the type of deformity. For this
reason, we sha11 analyze unilateral and bilateral clefts
separately, bearing in mind further differences in the
clinical picture according to whether the cleft is limited
to the primary palate (lip and premaxilla up to the
incisor cana!) or also involves the secondary palate
(hard and soft palate, from the incisor canal on).
UNILATERAL COMPLETE CLEFT
Alterations in Nasolabial Musculature
The lack of fusion of the maxillary and nasal processes
prevents the laterally derived vascular, nervous, and
muscular elements from reaching the midline. Conse-
quently, a11 of the muscle groups th at norma11y insert
onto the nasal spine, the septum, and the external
aspect of the premaxi11a become massed at the lateral
border of the cleft.
1030 CHAPTER
The behavior of the musculature in the deft border
is subject of controversy in the literature. Accoreling to
some,22 the musde fibers run parallel to the boreIer of
the deft anel insert into the base of the nasal alae anel
the columella.
Accoreling to others,23 the boreIers of the deft are
characterizeel by a chaotic massing of musde fibers
anel by their e1isorelered insertion into the deft borelel'
e1ermis without any evielence of fascides parallel to the
deft itself. This absence of a central insertion leaels
to elisequilibrium of the first anel seconel musde rings
(Fig. 52-3).
Nasal Abnormalities
The base of the nasal septum, anel therefore the
columella, is e1eviateel towarel the contralateral siele of
the deft as a result of the unbalanceel traction of the
musdes inserteel into the nasal spine anel anterior part
of the maxilla on the healthy siele and of the later-
alization of the greater maxillalY segment. COl1versely,
the tip of the nose is e1eviateel toward the same siele as
the deft and is characterized l;?ya diastasis between the
domes of the alar cartilages. In particular, the alar carti-
lage of the affecteel siele is ptotic, stretcheel, anel rotateel,
Fig. 52-3 The lack of correct insertion of the nasolabial
muscles leads to a disequilibrium of the first and second
musele rings with stretching, rotation, and displacement of
the alar cartilages, septonasal contralateral deviation,
premaxillary contralateral deviation, lowering of the oral
commissure at the e1eft side, and chin deviation toward the
e1eft side.
52 THE DELAIRE PHILOSOPHY OF CLEFT LIP AND PALATE REf
anel there is a simultaneous lowering of the ipsilatE
upper lateral cartilage. The meelial crus anel the do
are also lowereel (Fig. 52-4). The cartilaginous structu
are e1eformed anel elislocateel (but not hypoplast
because of the e1irect action of the mllsculature insert
into the nasal ala anel the eleformatiol1 of the underlyi
maxillary skeleton, which is hypoplastic anel retruded
the level of the pyriform aperture.
Mucocutaneous Abnormalities
Delineation of the mucoclltaneous abnarmalities
essential because these proviele the basis far identifyiJ
the funelamental eJements necessary for deft lip repa
On the meelial anel lateral deft segments, it is importa
to elifferentiate the skin of the nostril floar from that
the lip. The farmer has a fine-graineel appearance ar
is flat anel lightly haired, whereas the latter is more fin
lineel anel buiging because of musde retraction. Tl
two components of the lateral segment can be diffe
entiateel easily by elrawing a line from the base of tI
nasal ala perpenelicular to the mucocutaneous junctie
line (Fig. 52-5). As far as the meelial segment is cal
cerneel, it is necessary first to identify the base of tr
columella on the deft siele (the same elistance as th:
from the upper internal angle of the nos tril to the ba5
of the nondeft siele) anel then to trace a line from th.
Fig. 52-4 Nasal deformities. Alar displacement at the e1eft
side with downward rotation of the do me and luxation from
the upper lateral (triangular) cartilage (not represented); the
nasaI septum and noneleft alar cartilage are displaced
contralaterally.
PART 11I CRANIOFACIAL DEFORMITY
Fig. 52-5 A line drawn perpendicular to the mucocuta-
neous junction line trom the alar and columellar base allows
the differentiation ot the skin ot the nostril tloor trom that ot
the lip. The latter is marked gray. A line drawn perpendicular
to the mucocutaneous junction line trom thè peaks ot the
cupid's bow allows the differentiation ot the dry mucosa
(zone ot Klein, vermilion) trom that ot the' sterile mucosa.
The latter is marked in black.
point perpendicular to the mucocutaneous junction
line. As already mentioned, the lip skin is retracted as a
result of the action of the underlying museles. Gn the
medial segment, the lip skin usually shows' a vertical
contraction, whereas on the lateral segment it shows a
concentric contraction with the raising of the skin. The
mucocutaneous rim (white rol!), which consists of the
cutaneous insertion of the fibers of the external orbicu-
laris bands, tends to decrease in size on the medial
segment to just beyond the midline. Gn the lateral
segment, laterally to the point of maximum lip thickness
(corresponding to what will become the cupid's bow
peak), it tends to disappear within 2 to 3 mm.
The mucosa lining the borders of the eleft is also
different from the normal dry mucosa making up the
vermilion; it is a mucosa that Veau24 called "sterile" and
is better removed. Differentiation of the sterile mucosa
from the normal vermilion is not easy, but this can be
done by tracing a line perpendicular to the muco-
cutaneous junction on the media 1 and lateral segments
at those points identified as the peaks of cupid's bow
(see Fig. 52-5).
Skeletal Abnormalities
One encounters profound differences in the skeletal
abnormalities when treating an isolated eleft lip (in
1031
which skeletal alterations are virtually absent), a eleft
of the lip and primary palate, and a complete eleft
involving the lip and the primary and secondalY palate.
In the latter, it is necessary to distinguish the positional,
morphological, and developmental abnormalities of the
greater and lesser maxillary segments.
The most typical situation is that of a complete eleft
lip, alveolus, and palate. The greater maxillary segment
is rotated outwardly with a fulcrum located in the
pterygoid region as a result of the simultaneous pres-
sure of the tongue and traction of the musculature of
the noneleft side, which is not counterbalanced by that
of the eleft side. The anterior part of the alveolar arch
presents a less accentuated curve, with hypoplasia of
the alveolar portion of the premaxilla, which lies
between theeleft and the interincisive suture. This is
due not only to the absence of the transmission of
mechanical stresses to this part of the premaxilla but
also to the frequent hyoplasia or even agenesis of the
lateral incisor. The lesser maxillary segment shows signs
of maldevelopment and, to alesser extent, posterior
malpositioning. The malpositioning may be due to its
outward rotation as a result of the interposition of the
tongue in the eleft or to its collapse with a narrow eleft
as result, particularly in the anterior part of the hard
palate. The lack of vertical development is particularly
noticeable in the most anterior part of the lesser maxil-
lary segment, but its anteroposterior dimensions are
also reduced. These alterations normally are accom-
panied by an increase in the transverse dimension
between the maxillary tuberosities and pterygoid
processes because of the nonfusion of the palatal
muscles along the midline. Finally, as a result of the
lateral shift of the greater maxillary segment, the bony
and cartilaginous parts of the nasal septum are stretched
toward the healthy side, with a convexity in the lower
part toward the eleft side.
Musculomucosal Hard and Soft Palate Alterations
Delaire18.25,26 states that the soft palate comprises two
anatomically and physiologically different parts. The
anterior part is constituted by the tensor veli palatini
museles, the fibers of which are oriented transversely.
The main function of the soft palate is the opening
and elosing of the orifice of the eustachian tube. The
posterior part is formed by several museles, ineluding
the levator veli palatini, the palatopharyngeus, the
palatoglossus, and the posterior parts of the uvula
museles. The soft palate contributes to the functions of
phonation and swallowing. The posterior fibers of the
palatopharyngeus are not located at the level of the
base of the uvula, but behind and above it. The uvula
is not the most posterior part of the soft palate.
1032 CHAPTER
The levator veli palatini and palatopharyngeus stretch
the soft palate backward, and the latter musde prolongs
the soft palate above and behind the uvula. A soft
palate deft leads to a disturbance in the palatal muscu-
lature, which not only disrupts the musde ring at the
midline but also modifies the direction of the fibers and
gives rise to abnormal insertions. Different interpre-
tations have been made of the pathological anatomy of
the levator musdes. Kriens2ï considers that all of the
fibers of the tensor and levator palatini musdes are
parallel to the border of the deft and are inserted into
the posterior border of the palatal shelves. Pigott28
considers that the more anterior fibers are inserted into
the posterior part of the deft and that the majority insert
perpendicularly into the border of the deft.
According to Delaire,14,18it is important to differ-
entiate three types of fibromucosa on the hard palate.
Gingival fibromucosa lines the cervical region of the
teeth, extending cranially for some millimeters to cover
part of the alveolar process, making a significant contri-
bution tG its vertical growth. The maxillary fibromucosa,
which is rich in vessels and nerves, is particularly
important for the vertical and u:ansverse growth of
the palate as a whole. The fibromucosa of the palatal
shelves is particularly thin at the center and gradually
thickens as it approaches the maxillalY fibromucosa; it
allows the lowering of the palatal shelves, which during
the course of their growth, undergo resorption on the
nasal side and apposition on the oral side. In defts the
lesser maxillary segment is characterized by a reduction
in the fibromllcosa of the palatal shelf as a conseqllence
of the underdevelopment of the shelf, whereas the
maxillary and gingival fibromucosa remain practically
normal in position and size. Also of note is that the
reduction in the fibromucosa of the palatal shelves also
is callsed by a contraction of the periosteum (which
effectively is reduced), and its incision makes it possible
to extend the fibromllcosa to cover an almost normal
width. The greater maxillary segment has the palatal
shelf normally fused to the septum, which at its base
is characterized by a convexity toward the deft. The
transition side between the vomerine mucosa and the
fibromucosa of the palatal shelf therefore is shifted
toward the healthy side and is not in its expected
position when referring to the perpendicular portion of
the septum.
TOTAl BllATERAl ClEFTS
Alterations in Nasolabial Musculature
The muscular abnormalities in the lateral segments of
complete bilateral defts are similar tG those fOllnd in
unilateral defts, but the situation is profoundly different
52 THE DELAIRE PHILOSOPHY OF CLEFT LIP AND PALATE REPAIR
in the median tuberde, which far emblyonic reasons
bears no traces of musde because the mesoderm
migrates within the maxillary processes and stops at
the border of the deft. Although the media tubercle is
seldom usabie, in incomplete farms some musculature
is partially present in its superior part.
Nasal Alterations
Nasal alterations are similar to those described for
the affected side of a unilateral deft, the only difference
being that they are symmetrical. Between the diastatic
domes, the anteriar border of the cartilaginolls septum
is positioned nearer the surface and sometimes even
can be visible at the tip of the nose.
Mucocutaneous Alterations
The laterallip segments are similar to those obselved
in the case of unilateral defts. The skin of the median
tuberde is underdeveloped (particlilarly vertically) as
a result of concentric retraction because it is not sub-
jected to physiological downward stretching by muscIe.
The ptosis of the medial crura also is accompanied
by the downward migration of the skin of the col-
umella, which therefore joins that of the median tuber-
de and creates the typical shortness of the columella
itself.
The mucosa covering three quarters of the circum-
ference of the prolabium is characterized by the
absence of vestibule and in complete defts by the
absence of the white roll. The white roll is considered
to be the muscular insertion of the external orbicularis
bands in the mucocutaneous rim.
Skeletal Abnormalities
The lateral maxillary segments show the same alter-
ations as those described for lInilateral defts, although
the diastasis of the maxillary tuberosities is greater.
Abnormalities indude a form with an anterior collapse
of the lateral segments behind the protruding premax-
illa and another form with externally rotated lateral
segments and broad defts. PremaxillalY alterations are
highly pronounced. The premaxilla is protuberant and
is rotated fOlward (with its fulcrum at the level of the
nasal spine) because of the absence of the muscular
cingulum, which should counterbalance the pressure of
the tongue. The transverse dimensions of the premaxilla
are reducecl because of the uncleractivity of the inter-
incisive suture, which does not undergo the musculo-
periosteal traction leading to its activation. The frequent
absence of lateral incisor germs also contributes to the
redllCed volume of the premaxilla.
PART 111 CRANIOFACIAL DEFORMITY
Musculomucosal Hard and Soft Palate Alterations
Musculomucosal hard and soft palate alterations are
substantially the same as those described in the case
of unilateral complete clefts, with the difference of
bilateral involvement. The posterior part of the nasal
septum is underdeveloped vertically and does not reach
the level of the palatine processes, a sitllation that has
therapeutic implications. At the level of the premaxilla,
the palatine fibromucosa takes on the form of a triangle
with a posterior apex and is vascularized by nasopala-
tine vessels and an intraosseous network anastomosed
to the soft parts of the vestibule.
PREOPERATIVE ORTHOPEDIC
TREATMENT AND LIP ADHESION
PROCEDURES
Delaire initially was strongly opposed to presurgical
orthopedic therapy, whether active or passive, because
he could not find a rationale and he considered the
social impact of frequent visits or hospital stay to be
disadvantageous1•8•29In 1991, Delaire16could agree with
the logic of a plate acting against collapse of the seg-
ments, especially when surgical concepts different from
his were applied. He also could see the benefit of an
early plate expanding narrow palates. Delaire was not
a proponent of lip adhesion procedures in unilateral
clefts. However, he used a preliminary clo~ure, cuta-
neous and muscular, of the upper part of the lip in wide
bilateral complete clefts.
REPAIR OF A UNILATERAL
COMPLETE CLEFT
Influenced by Poupart, Delaire16 opted for lip and nose
repair together with soft palate repair. For the lip and
nose repair, he waited for the incisors to erupt in order
to avoid the inversion that frequently takes place if the
operation is carried out before.3O This did not apply
for incomplete cleft forms, for which repair could be
brought forward to the fOUlth month. Lip and nose
repair (and closure of the primalY palate with a cau-
dally based Muil' flap3l) was performed at 7 months and
hard palate repair, at 14 to 18 months of age. The latter
was postponed to 3 years when the palatal cleft
remained wide after the Eirstoperation.
REPAIROF THE SOFT PAlATE
The principle of good palatal reconstruction is to push
the velum backward (without doing the same to the
palatine fibromucosa of the hard palate, because of
1033
the effects that this may have on maxillary growth),
lengthening and prolonging it.
Veau24showed that it is useless to release the Eibers
of the tensor veli palatini at the posterior border of
the palate, except maybe in the largest clefts and only
for the most internal Eibers. Elongation occurs sponta-
neously if the posterior part of the soft palate (levator
veli palatini and palatopharyngeus) are reconstituted
properly.
When necessalY (as in the case of a short palate) and
feasible (for a cleft that is not too wide) Delaire et al.l4
suggested using a series of small Z-plasties. The use of
muscular reconstruction and Z-plasties makes it possi-
bIe to obtain a true lengthening of the palate.32
PRIMARY FUNCTIONAl CHEllORHINOPlASTY
The objective of cheilorhinoplasty is to restore the
anatomy of the no se and lip in a physiological mannel'
by ensuring that the correct repositioning of the variOlls
structures (particularly those of the nose) is the conse-
quence of two principles: the release of the dislocated
structures (above all the alar cartilage) and the careful
reconstruction of the nasolabial muscles. The use of
suspension stitches or splints is not what wil! ensure
the quality of the result. Cleft lip surgery involves nasal
surgelY, and aftel' the extended release, the reconstruc-
tion is first a rhinoplasty and then a cheiloplasty. The
peculiarity of this procedure is the simple identiEication
of some anatomical points without the need for meas-
urements, which would have little meaning in relation to
tissues that are rett'acted as a result of the clefting itself.
For the deformed and hypoplastic elements to develop
nOri11ally,aftel' the operation, it is crucial that the upper
lip has normal and projecting movements, that the lip
frenum and median cellular septum are intact and acti-
vated, and that nasal respiration is normal.l6
The objectives of the repair therefore are the following:
• SymmetlY of the nares at the nasal tip, with the
raising of the ptotic dome, and at the nasal base,
with floors at the same level
• A labial scar that is positioned in a way that is sym-
metrical with the contralateral crest of the philtrum
• A correctly reconstructed labial musculature, with
good lip pout
• A continuous mucocutaneous line with the restora-
tion of cupid's bow
• A symmetrical vermilion border
• A lip height that is the same on the operated and the
healthy side
These objectives should be reached progressively,
beg inning from above (with the nose) and moving
downward (to the vermilion).
1034 CHAPTER 52 THE DELAIRE PHILOSOPHY OF CLEFT LIP AND PALATE REPAIR

TECHNIQUE
Incision Lines on the Skin and Mucous Membrane

The skin incision line varies e1epeneling on the extent

of retraction anel elasticity of the skin anel the charac-
teristics of the mucocutaneous rim (white roll). The
upper part of the incision line remains more or less
constant, but as a result of the aforementioneel anatom-
ical factors, the lower part may change even e1uring the
operation. Make the incision on the meeliallip segment,
following a Clu'veel course that begins at point 1, passes
through point 2, anel enels at point 3, before being
continueel in a straight course to point 4 (Fig. 52-6).
From point 2, a seconel incision line goes up along the
mucocutaneous junction until it reaches the base of
the alveolar process. Discarel the sterile mucosa of the
meelial lip segment. If the white rol! is particularly
accentuateel, incise the mucocutaneous junction from
point 3 to point C. On the laterallip segment, make an
incision from point 5 to point 6 anel then, provieling the Fig. 52-6 Identification of landmarks before cheilorhino-
white roll is not particularly pronounceel, from point 6 plasty. A, The upper corner of the noneleft nostril; A', the
to point 7 anel from point 7 to poi~.lt 8 (Fig. 52-7, A). upper corner of the cleft nostril; B, base of columella at
When the white roll is pronounceel; it is necessalY to the noneleft side; C, the center line of the philtrum and of
preserve that part of the white roll that runs from point the future cupid's bow; 0, the peak of cupid's bow at the
7 to point E in the form of a small triangular flap (Fig. noneleft side; E, the end of the mucocutaneous rim (white
52-7, B). Moving upwarel, take the incision from point roll) on the laterallip segment; 7, the landmark on the base
of the columella on the e1eft side, at a distance from the
6, along the mucocutaneous junction, until it reaches
midline that is equal to the distance from the midline to B
the base of the alveolar process of the lateral segment.
(the line B-l will be parallel to the line A-A'); 2, the landmark
The sterile mucosa from these lanclmarks towarel the
at which the continuation of the line B- 1 intersects the
skin can be preselvecl in the form of a Muil' flap,31 mucocutaneous rim; 3, the land mark on the mucocutaneous
cauelally peeliclecl at the alveolus for possible use in rim the distance of which from the midline of the philtrum is
aelvancing the base of the nasa I ala or for closing the just a little less than that of the distance C-D (in fact, account
primary palatal cleft. Aelclitional Z-plasties may be usecl must be taken of the transverse retraction of the skin); 4, the
to lengthen the lip aftel' the reconstruction of the nose landmark on the border between the vermilion and the wet
anel the upper part of the lip musculature. Once the mucosa, the distance of which to the median frenum is equal
skin incisions anel the excision or preselvation of the to the distance C-3; 5, the base of the nasal ala on the e1eft
sterile mucosa have been performeel, incise the mucosa side; 6, the intersection of the mucocutaneous rim by a
perpendicular to it originating from landmark 5; 7, the
of the alveolar process of the lateral segment hori-
landmark of greatest vermilion height on the e1eft side,
zontally from the boreIer of the cleft to the molar region,
where the mucocutaneous rim begins to diminish (future
maintaining a elistance of at least 1 mm from the lateral peak of cupid's bow); 8, land mark on the wet line,
attacheel gingiva. This incision simultaneously involves marked by the perpendicular to the mucocutaneous rim
the periosteum of the alveolar process. originating in landmark 7.
We thus have e1escribeel the process for the following:

• Recovering from both the cleft segments the nasal

skin that has migrateel e10wnwarcl with the aim of
reconstructing the nasal floor as effectively as pos-
sible
• Obtaining a scar location that is as similar as possible
to the philtral crest (although it may be necessalY to
perform a small Z-plasty in the lower part)
• Reconstructing a gooel cupiel's bow anel a normally
shapeel lip, with the elimination of the pathological
mucosa
Finding the Muscles on the Sides of the Cleft and
Their Insertion Zones
Iclentification of the muscle groups in the lip seg-
ments, as weil as their insertions, is important. The
transverse nasilis muscle is founel in the lateral lip seg-
ment, immecliately beneath the nasal skin at the base of
the ala (above the line 5-6; see Fig. 52-6). After under-
mining a few millimeters of skin in a lateral clirection,
PART 11I CRANIOFACIAL DEFORMITY
Fig. 52-7 The lower part of the skin incision varies according to the characteristics of the
white roll. A, Incision without an evident white rail. B, In a case of an evident white rail,
the insertion of the lateral white rail into the medial lip segment is indicated.
the levator labii superioris alaeque nasi is found in the
nasolabial modiolus, lateral to the alar base. Caudal to
the line 5-6, the external orbicularis bands are identified
at the border of the deft and, more deeply, the internal
orbicularis bands and incisivus musde, lhe lower por-
tions of which adhere to the vermilion. Àt the mucosal
level, one should identify just a few millimeters of
musde, taking care not to detach the fibers of the
levator labii superioris at the vestibular fornix. These
fibers are inserted in the mucosa and will keep the
fornix weil raised once the reconstruction has been
completed. In the mediallip segment, isolate the inter-
nal orbicularis bands from the mucosa, takiJ?-gcare not
to confront the median frenum. Denude the periosteUln
of the vestibular surface of the premaxilla on the deft
side along with the nasal spine and the anterocaudal
part of the cartilaginous septurn.
Subperiosteal Undermining of the Anterior Part of
the Maxilla
Ta ensure tension-free suturing of the nasolabial
musculature, the muscular origins on the anterior face
of the maxilla must be widely undermined.10,16,18 The
most physiological way of doing this is not supra-
periosteally, as many authors have daimed, but sub-
periosteally, a procedure that does not seem to have
any effect on facial growth.33 The release and advance-
ment of the periosteum should lead to new bone
apposition on the external surface of the maxilla, which
is underdeveloped precisely because of the collapse of
the overlying musculature.lO Through the incision made
in the fornix, the subperiosteal dissection has to be
extended to the frontal process of the maxilla, induding
its endonasal side, to the orbital rim Cgoing armmd
the infraOl'bital nerve), and as far as the maxillomalar
buttress.
1035
Subperichondrial Undermining and Release of the
Cleft Alar Cartilage
Ta ensure that the reconstructed nasolabial muscular
ring is in a condition to render the nasal deformities
symmetrical, it is necessary to free the pathological half
of the nose completely from its connections with the
healthy half.
The pathological alar cartilage als0 must be freed
from its cover. This is done by reaching the lower
border of the nasal septum at the level of the nasal
spine and then undermining all of the mucoperichon-
drium of the septum on the deft side from its base as
far as the tip of the nose and the nasal bones them-
selves. Subsequently, through incision 1-2 (see Fig.
52-6), use a pair of small blunt dissection scissors to
dissociate the two medial crura in the midline of the
columella, reaching the tip and then extending to the
separation of skin from the lateral crus on the deft side.
Perform the same undermining of the skin in the dame
of the healthy side and over the triangular cartilages
of both sides. Then complete the freeing of the two
halves of the nose by sectioning the midline connective
bridges that separate the intercrural tunnel from the
previously dissected septal subperichondrial space.
Further release the base of the columella on the de ft
side by means of submucosal dissection.
Reconstruction of the Nasal Floor, Muscle,
Mucosa, and Skin
If necessalY, bring forward the base of the ala by
means of an incision in the endonasal lining along the
border of the pyriform aperture. Having positioned
the small mucosal flap taken from the deft border of
the lateral segment CMuir's modified procedure31),
reconstruct the nasal floor. Brusati and Mannucci32 limit
this to the anterior portion, without extending it to the
1036 CHAPTER
alveolar cleft, so as not to find any scar at this level
during subsequent surgery. Suture the nasal vestibular
mucosa from the deep layers toward the surface. Next,
suture the oral vestibular mucosa. If necessary, the
lateral mucosal flap can be mobilized by means of a
posterior vertical release incision. The suturing begins
posteriorly in the fornix and continues between the
medial and lateral lip segment to stop at the inferior
third of the lip. Suture this part and the vermilion at the
end of the operation.
The next step constitutes the most important part of
the intelvention: the muscu]ar reconstruction. Muscular
reconstruction begins with the media] insertion of
the transverse nasalis muscle, which is anchored in the
original procedure to the anterocaudal border of the
cartilaginous septum, the nasa] periosteum of noncleft
premaxilla, and the septo-premaxillary ligament. To
avoid excessive raising of the nasa] floor and the base
of the ala, Talmant34 prefers a lower anchorage on the
facia] periosteum of the premaxilla. Suture the levator
labii muscles and the extern al orbicularis bands to the
nasal spine and the anatomical e]ements just cranially
and medially to it. Suture the internal palts of the exter-
nal banels to their contralateral parts. Follow this by
su turing the internal orbicularis banels to their contralat-
era] parts coming down to the vermilion. Precise juxta-
positioning of the previously identified and tattooed
landnurks on the mucocutaneous rim is essential. Two
results thus are obtained irnmeeliately: the nostrils are
maele symmetrical, with correction of alar ptosis, and
the upper lip is projected, taking on the shape of a
ship's prow. Then complete the intelvention with the
suturing of the skin of the nasal floor anel the upper half
of the lip. Also suture the lowd half of the lip anel the
mucocutaneous rim subcutaneously, regarelless of
whether the initial incision was linear or in the form of
a small triangle containing the white roll. If the lip is
symmetrical or only slightly short, the skin of the lower
half also can be sutureel. If the lip is too short, it is
possible ra perform a small Z-plasty just above the muco-
cutaneous rim. It is essential that the lip is symmetrical
or at most only slightly short at completion.
The intervention concludes with reconstruction of
the vermilion. To ensure continuity, release the mucosal
layer for a few millimeters from the underlying orbicu-
laris muscle, after the muscle has been sutured. The
final step is the completion of the suturing of the
vestibular mucosa of the lower third of the lip, which
was excludeel from the first phase of the intervention.
Finally, place some transfixing sutures in the nasal
ala anel elome simply ra reeluce the eleaelspace between
cover and lining (Fig. 52-8). No meelication or restraint
(Logan's arch) is necessary because the reconstruction
52 THE DELAIRE PHILOSOPHY OF CLEFT LIP AND PALATE REPAIR
must be free of tension. Feeding by breast, bott]e, or
spoon can be resumed on the daV of the operation
without any problem. The baby is only requireel to wear
rigiel arm braces for 2 weeks.
REPAIR OF A BILATERAL COMPLETE
CLEFT
The timing of repair is eletermineel partly by the position
of the premaxilla anel the lateral lip segments. If these
are favorably positioned, surgery is recommended from
the fourth month on. As already described in the case
of unilateral complete clefts, the operation begins with
the repair of the soft palate. The vomer is vertically
unelereleve]opeel in its posterior part, anel reconstruction
of the nasal layer by suturing it to vomer flaps would
cause a high anchorage of the nasal floor and subse-
quently hampered maxillalY growth (particularly verti-
cal). Therefore, suture the two nasal layers together
below the intact vomer at the posterior part of the hard
palate.
After completing soft palate reconstruction in the
same way as for unilateral clefts, the next step is ta
reconstruct the lip, both sieles of which are repaired
during the same surgical session.
The objectives of the repair are as follows:
• Symmetrical nostrils
• The repositioning into the columella of skin that
has descended, which thus leads to columella
lengthening
• The symmetrica] reconstruction of the lip and the
vermilion, with a cupiel's bow, anel scars positioned
along the crest of the philtrum
• The reconstruction of the underlying muscles
These objectives are reached progressively, moving
from above (nose) to below (vermilion), and from the
eleepest point (fIoor of the nose anel mucosallayer) ta
the surface (skin).
TECHNIQUE
The outline of incision lines in the skin and mucous
membrane drawn on the lateral segment is exactly the
same as that used for unilateral clefts (Fig. 52-9, A and
B): a perpendicular line from the base of the a]a to the
mucocutaneous junction separates labial skin from the
skin of the nasal floor. From the point corresponding to
the tip of the future cupid's bow, draw the cutaneous
incision line just above the white roll and along the
mucocutaneous border as far as the base of the alveolar
process. No sterile mucosa is eliscarded, however. Ielen-
PART 111 CRANIOFACIAL DEFORMITY 1037

A B

c D

E F
Fig. 52-8 Unilateral cleft lip and palate repaired at 5 months by simultaneous
cheilorhinoplasty and soft palate repair. A, Preoperative view. Note lip and nose deformities
and the width of the cleft. B, Preoperative view of the wide hard and soft palate c1eft.
C, Immediate postoperative view after soft palate repair without lateral release incisions.
D, Intraoperative view showing wide nasal dissection (not the same case). E, Intraoperative
view showing the muscular dissection. Note in the lateral segment the separation of the
transverse nasilis muscle from the orbicularis oris (not the same case). F, Immediate
postoperative view after lip and nose repair. Note the reconstructed cupid's bow.
Continued
 1038 CHAPTER
Fig. 52-8, cont'd G and Hl 'Lip and nose appearance
hard palate and alveolar deft before gingivoperiosteoplasty.
years af ter surgery.
tification of the nasolabial muscles, incision of the
alveolar mucoperiosteum, and wide subperiosteal under-
mining on the anterolateral side of the maxilla are as
described for the treatment of a unilateral cleft.
Concentric skin contraction in the prolabium caused
by the absence of muscle action consequently leads to
a descent of colume11ar skin into the prolabiurn. One
can consider that in the dimension running from the
upper inside angle of the nos tril openings to the future
tip of the cupid's bow, the upper half is colume11arskin
and the lower half labial skin.
Therefore mark two symmetrical points (2) as the
ideal extension of the lateral borders of the colume11a,
and identify the two cupid's bow peaks (3) (see Fig.
52-9, A). These peaks need to be marked closer to each
other than is envisaged in the end result because the
ensuing skin stretch will separate them considerably.
From point 2 to point 3, make an incision fo11owing a
S2 THE DELAIRE PHILOSOPHY OF CLEFT LIP AND PALATE REPAIR
J
2 years after surgery. " Residual
J, Soft palate appearance 5
curve media11yconcave, and then continue the incision
to the midline fo11owing a curve cauda11y concave,
extending a little in the mucocutaneous rim. At the
midline, the incision meets the corresponding contra-
lateral incision. In this way, the prolabial skin delimited
by the incisions takes on the shape of a shield, a
modification of Mi11ard'sdesign.16 Fror~ point 2, make
another incision perpendicular to the mucocutaneous
junction. On reaching the junction, prolong the incision
to the premaxillary periosteum. Eliminate the dry mucosa
of the prolabium, and use the wet mucosa to construct
the premaxillary mucosal lining of the fornix.
If there is little white ro11 in the lateral segment,
Brusati and Mannucci32 prefer to descend with an inci-
sion from the two mucocutaneous points (3) to 4 to 5
mm inside the prolabial mucosa, thus circumscribing
and preserving a mucosal triangle with a superior base
that wi11constitute the center of the reconstructed lip
PART 111 CRANIOFACIAL DEFORMITY
B highest part of the external orbicularis bands of both
c what lengthens the columella itself). Proceeding equally
Fig. 52-9 Bilateral deft lip repair. A, Identification of
landmarks: 1, upper corner of deft nostril; 2, point marked
on the ideal extension of the lateral borders of the columella
(considering that in the dimension running fram 1 to 3 the
upper half is columellar skin and the lower half is labial skin);
3, points of the two peaks of cupid's bow; on the lateral
segment, as in a unilateral deft, a perpendicular line from
the base of the ala to the mucocutaneous rim separates
labial skin from the skin of the nasal floor. B, The deft
repaired. C, Unlike Delaire, if there is little white rail in the
lateral segment, Brusati and Mannucci32 prefer to descend
with an incision from the two mucocutaneous points (3) to
4 to 5 mm inside the prolabial mucosa, thus circumscribing
and preserving a mucosal triangle with a superior base that
will constitute the center of the reconstructed lip.
1039
(Fig. 52-9, C). Lift the prolabial skin by cleaving it from
the underlying periosteum. Upon reaching the nasal spine
and lower border of the septal cartilage, expose these
together with the lower border of the pyriform aperture.
At this point, a certain degree of bilateral subperichon-
drial and subperiosteal undermining of the septum is
performed to ensure good mobility when advancing
and projecting the columella and the tip of the nose.
Aftel' having bilaterally reconstmcted the anterior
part of the primary palate with the sterile mucosal flaps
of the cleft borders, reconstrllCt the muscles. Suture the
transverse nasalis muscle on both sides to the vestibular
periosteum about halfway up the premaxilla. Suture the
sides to the apex of the nasal spine, at the level of the
septo-premaxillalY ligament. Muscle suturing then con-
tinues in the direction of the vermilion until the border
of the lip is reached. Given that this suture considerably
narrows the distance between the two lateral lip seg-
ments, it is worth separating the skin from the under-
lying musculature for a distance of a few millimeters in
order to be able to position the prolabial skin portion.
Aftel' eliminating the subcutaneous excess, while taking
care not to damage the skin vascularization by overthin-
ning, use a median subcutaneous stitch to anc hor the
point separating the columellar and prolabial skin to the
base of the septum (this leads to the redistribution of
columellar skin in its natural location and also some-
on both sides, complete the anterior part of the nasal
floor and the upper part of the skin closure. üften a
vertical disproportion exists between the skin of the
lateral segments and th at of the prolabium. Suture these
without any lateral skin resection by first suturing the
landmarks at the level of the mucocutaneous rim that
we re drawn at the beginning of the procedure for the
purpose of reconstmcting cupid's bow.
This leads to some stretching of the skin of the pro-
labium and the presence of an excess of skin laterally.
Even when the prolabial skin is considerably under-
developed, the action of the underlying muscular
cingulum leads to its vertical growth over time. There is
nothing less aesthetic or more difficult to correct than a
bilateral cleft lip with an exaggerated vertical dimension
(Fig. 52-10).
SPECIFIC PRIMARY PROCEDURES IN
BILATERAL CLEFT CASES
LIP ADHESION
In case of a bilateral complete cleft with a considerable
distance between the prolabium and the lateral lips
1040 CHAPTER 52 THE DELAIRE PHILOSOPHY OF CLEFT LIP AND PALATE REPAIR

~"~~'tJ~'

, nr',

A B

c D

E F
Fig. 52-10 Bilateral (Ieft lip and soft palate repaired at 6 months. A to D, Preoperative
view. E and F, Postoperative view.

segments, Delairell,16 recommends the reconstruction of
the transverse nasa lis musde, the upper part of the lip,
and the nasal floor, without wonying about the correct
reconstruction of cupid's bow and the lower part of the
lip (Fig. 52-11). This intervention would be performed
at the age of 4 to 5 months together with the repair of
the soft palate. About 8 to 10 months later, the anatom-
ical situation should allow definitive lip repair at the
same time as the repair of the residual deft of the hard
palate and gingivoperiosteoplasty.
PRIMARY LENGTHENING OF THE
COlUMEllA
Columellar repair using prolabial skin makes it possible
to achieve a certain lengthening of the columella. When
PART lil CRANIOFACIAL DEFORMITY 1041

G H
Fig. 52-10/ cont/d G and H, Lip, nose, and soft palate appearance 5 years after surgery.

the columella is extremely short (or practically absent),
however, Brusati and Mannucci32 prefer to use other
primary procedures. Given the observation that the short-
ness of the columella is caused by the lateral migration
of the alar domes, which also are twiste.d downward
and therefore have lost their correct relationship with
the upper lateral cartilage,35 the rationale underlying
their approach is that the correct positioning of the
domes leads to normal projection of the media I and
intermediate crura and tip of the nose. This is achieved
after extensive perialar release and muscular recon-
struction in order to eliminate the cause of the dislo-
cation of the cartilaginous domes. The approach for
releasing and repositioning the domes valY fr~m author
to author. McComb35 prefers a Vincision (to be Y
sutured) at the tip of the nose, which allows the method
to be performed exactly as necessary with a wide trans-
cutaneous access. The considerable lengthening of the
columella is obtained at the cost of a rather visible scar
and a bulbous nasal tip. The intervention preferably
should be performed at the time of lip adhesion to
avoid detaching the prolabium from the premaxilla and
with possible ischaemia. Mulliken36 obtains the same
result using a marginal incision associated with a short
midline cutaneous incision in the tip of the nose, an
intervention that is performed at the same time as the
definitive lip repair. The median scar is practically invis-
ible, whereas the skin excision made at the upper angle
of the nostrils sometimes can lead to a little residual
asymmetry. Blood supply to the prolabium is random
and hazardous.
REPAIR OF THE HARD PALATE
As a result of the modeling action of the reconstructed
anterior orofacial and posterior soft palate muscular
rings, the residual deft undergoes a gradual narrowing
that brings the alveolar deft borders into contact with
each other and, at the level of the palate, sometimes
reduces the deft size to negligible proportions.

Fig. 52-11 A and B, Lip adhesion according to the Delaire concept of reinserting the
transverse nasalis muscle and reconstructing the upper part of the lip and the nasal floor.
1042 CHAPTER 52 THE DELAIRE PHILOSOPHY OF CLEFT LIP AND PALATE REPAIR

Although the alveolar segments are in contact with A

each other, a gap of usually a few millimeters exists
between the bony segments underneath the alveolar
mucoperiosteallining. Premaxillary growth is optimized
not only by the muscular reconstruction but also by
the mucoperiosteal continuity of the nasal floor, the
palate, and the vestibular side of the alveolar process.
The vertical and anteroposterior growth of the lesser
maxillary segment also is influenced favorably by its
connection to the large segment with which it forms
a single complex that is influenced by the growth of
the nasal septum and by the harmoniously recon-
structed functional matrix. The restoration of maxillary
continuity finally allows the correct eruption and align-
ment of the deciduous teeth, making early orthodontics
possible and stabie, even of those teeth erupting in
the deft.
For all of these reasons and starting with the expe- B
rience of Millard,37-39Delaire13,16 adapted the gingivo-
periosteoplasty concept, which he performed at the
time of the repair of the hard palate when thepatients
were 14 to 18 months old. The mycoperiosteal flaps
that are prepared at the level of the alveolar flaps are
practically identical40 to those described by Boyne and
Sands41 for a secondalY bone graft (Fig. 52-12). The
cervical incision begins at the level of the central incisor
and is extended laterally until it reaches the border of
the deft. The incision then passes around the mesial
border of the deft to the base of the fornix, from where Fig. 52-12 Gingivoperiosteoplasty. Gingival and mucosal
it descends on the distal side of the deft until reaching incisions are shown on the palate (A) and vestibular (B)
surfaces extending along the cleft borders.
the neck of the canine or, if this has not, yet erupted, the
alveolar crest of the first molar. The cervical incision
continues distally for at least 1 ,cm (in the neck of the
second molar or, if this is absent, along the alveolar (particularly transverse) of the maxilla and the alveolar
crest) until reaching the base of the fornix by means of arch. The tensionless rep air of the vestibular plane is
a release incision. On the palatal side the incision facilitated by a periosteal release incision at the base of
follows the borders of the deft until it reaches the soft the distal flap. This creates a pyramidal space between
palate. After extensive subperiosteal undermining, during the aforementioned mucoperiosteal planes facing the
which the posterior border of the palatal process is bony deft borders.
skeletonized in order to be able to obtain the freedom The procedure is almost identical in the case of
for a fUlther posterior dislocation of the soft palate by bilateral defts, the difference being that the nasal layer
means of the subsequent median suture, the palatal and is reconstructed with septal mucop~riosteum only in its
vestibular sides of the nasal plane are reconstructed. anterior third. The nasal layer may not be adherent to
The hermetic reconstruction of the nasal plane is vital the septum in the central and posterior part of the hard
in order to achieve a good result (Fig. 52-13). Given the palate because of possible negative effects on vertical
narrowness of the deft and the high arched shape of maxillary growth. The undermining of the vestibular
the palate, the suturing of the palatal plane usually can periosteum of the premaxilla also must be reduced to a
be carried out without any difficulty. In cases of broader minimum to maintain its vascularization (Fig. 52-14).
defts, the dosure can be obtained without lateral Timed at the beginning of speech, the gingivoperiosteo-
release incisions by means of submucosal section of the plasty procedure ensures the definitive dosure of the
fascia of the tensor of the palate and the periosteum.42 palate with a minimum of surgical insult and an anatom-
This avoids bare lateral surfaces the secondary healing ical reconstruction of the functional matrix of the maxilla.
of which may have consequences for the growth This leads to the ossification of the de ft in the alveolus
PART 11I CRANIOFACIAL DEFORMITY 1043

A B

C D

E F
Fig. 52-13 Alveolar and hard palate closure by gingivoperiosteoplasty in a unilateral
case. A and B, Preoperative view on the residual cleft in hard palate and alveolus.
C, Intraoperative view of the alveolar cleft after closure of the nasal and mucoperiosteal
flaps and before vestibular mucoperiosteal flap suture. 0, Immediate postoperative view
of hard palate and vestibular suture. E, Alveolar morphology 3 years after ging ivo-
periosteoplasty. F, Detail of panoramic x-ray film: Note the spontaneous bone obliteration
of the right alveolar cleft from the floor of the nose to the alveolar margin.
 1044 CHAPTER 52 THE DELAIRE PHILOSOPHY OF CLEFT LIP AND PALATE REPAIR

A B

c D

E F
Fig. 52-14 Bilateral a/veolar and hard palate cleft repair and simultaneous gingivo-
periosteoplasty. A and B, Preoperative view. C, Intraoperative view of the right alveolar cleft
af ter closure of the nasal and oral mucoperiosteal flaps and before vestibular
mucoperiosteal flap suture. 0, Immediate postoperative view of the right alveolar cleft
repair. E and F, Dental occlusion and alveolar morphology 4 years after surgery.

and anterior maxilla that does not require secondary
bone grafts as needed after primary procedures involv-
ing periosteal grafts or flaps.43-45The latter procedures
do not reconstruct the anatomy of the alveolar region
fully, and the result is a modest quantity of bone that is
usually insufficient for good tooth eruption. However,
ossification after gingivoperiosteoplasty is of excellent
quality in 95% of cases,40 a finding confirmed by means
of computed tomography investigations46 The quality
of the results is proportional to the width of the deft.
PART 111 CRANIOFACIAL DEFORMITY
G H
Fig. 52-14, conl'd G and H, Detail of status x-ray film and computed tomography
showing good ossification in the alveolar c1efts (horizontally and vertically).
Hence a good primary musde reconstruction that har-
monizes the relationships between the maxillary
segments is important, particularly in bi1ateral cases.
ISOLATED CLEFT PALATE
An isolated deft palate is an entity in itself, with its own
treatment protocol.
If the deft is particularly wide, Delaire has·developed
a hard palate procedure that makes use of bipedided
flaps of only the fibromucosa of the palátal shelves,
delimited by a mucoperiosteal incision that runs between
the maxillary fibromucosa and that of the palatal
shelves.14,18 This requires two secondary healing areas
the location of which has practically no negative effect
on maxillary growth. Usually, the hard palate can be
closed using only the palatal mucosa that covers the
cleft margins after a wide subperiosteal dissection.18
Soft palate defts and submucous defts, if identified
early, are treated at an age of 10 to 12 months using the
same procedure as that described for a complete deft
lip, alveolus, and palate. Early treatment greatly reduces
the frequency of functional problems.47
ISOLATED CLEFTS OF THE PRIMARY
PALATE
A deft lip, be it complete or incomplete, with or with-
out a deft of the primary palate, can be operated on at
an age of 4 months insofar as the base of the maxilla is
not defted or is only fissured in its anterior portion and
is therefore capable of sustaining earlier musde recon-
struction. The principles of the reconstruction are the
1045
scan
same as for complete defts, with the identification of
the areas of nasal skin that have slipped downward. In
the case of an incomplete deft, this skin is apparently
excessive. However, not too much of this skin should
be eliminated because on the basis of the principles
already described, after musde reconstruction involving
more or less wide-ranging subperiosteal undermining
and primary rhinoplasty (depending whether there are
also nasal deformities), the skin adjusts to the under-
lying musde bed and any excess on the nasal floor
normalizes in a short time.
Skeletal involvement may range from mild defting
(more evident on the nasal floor than at the alveolar
level) 1'0 a complete deft of the primary palate. In the
former case, primary periosteoplasty is performed during
the course of the reconstruction of the musculature and
the nasal floor by raising the latter from the underlying
fissured or depressed bone. In the case of a complete
deft of the primary palate, providing it is not too wide,
primary gingivoperiosteoplasty according to the proce-
dure described is indicated. The raising of the muco-
periosteal plane will be more difficuIt as a result of
the underlying presence of unerupt~d tooth germs.
However, if the deft is very wide and the premaxilla is
externally rotated, it is better to limit the initiaI interven-
tion to cheilorhinoplasty and to schedule the gingivo-
periosteoplasty for when the patient is 14 to 18 months
old and his or her anatomical condition is more favor-
abIe with the alveolar segments in contact.
CONClUSION
Delaire considers the items listed in Box 52-1 to be
fundamental 1'0 his philosophy of the primary treatment
of deft lip and palate.
1046 CHAPTER 52 THE DELAIRE PHILOSOPHY OF CLEFT LIP AND PALATE REPAIR

BOX 52-1 • Although multicenter studies using similar proto-

Fundamental Points of Delaire's cols are lacking, they would be a good beginning
to understanding which techniques are beneficia!.
Philosophy of the Primary Treatment of
• Good evidence is lacking in which outcome
Cleft Lip and Palate measures are important. More patient input to the
1. The dissection and identification of the nasolabial process is required.
muscles in the c1eft borders. • Much of the so-eallecl eviclence of outcomes is
2. The extended subperiosteal undermining of the basecl more on the ease of measuring than its
anterior maxilla, the nasal pyramid, and the lower relevance. The evidence, therefore, is skewecl
orbital border. towarcl orthodontie outcomes.
3. The subperichondrial undermining of the nasal
septum of the cleft side extending to the nasal bone.
4. The identification of the anterior border of the
septum, nasal spine, and septo-premaxillary ligament. REFERENCES
5. The separation of the medial crus and the domes of
the alar cartilages on the midline and their release 1. Delaire J: Traitement chirurgicaux et orthopédiques des
from the overlying skin. becs-de-lièvre et divisions palatines, Reu OJ1hop Dento
6. The reconstruction of the muscular planes of the nasal Faciale 5:104-140, 1971.
floor and the nostril floar, with the fixation of the
2. Delaire J: La cheilo-rhino-plastie primaire pour fente labio-
musculature to the septum and the septo-
premaxillary ligament. maxillaire congénitale unilatérale: essai de schématisation
7. The reinsertion of the external orbicularis muscle d'une technique, Reu Stomatol 76:193-215, 1975.
bands to the nasal septum and the contralateral 3. Delaire J: Influence du voile du palais SUl' la statique
musculature. linguale et la croissance mandibulaire: déductions
8. The reconstruction of the rest of thè lip: mucosa, thérapeutiques, Reu Stoma tol 77:821-834, 1976.
musculature, and skin. 4. Delaire J, Feve JR, Chateau JP et al: Anatomie et physiologie
9. The two-stage closure of all wide palatal c1efts (soft des muscles et du frein médian de la lèvre supérieure:
palate first). premiers résultats de l'electromyographie sélective, Reu
10. The one-stage closure of narraw palatal c1efts using Stomatol 78:93-103, 1977.
the fibramucosa of the palatal shelves.
11. The reconstruction of the anatomicofunctional 5. Delaire J, Chateau JP: Comment le septum nasa I
equilibrium of the palate by moving backward and influence-t-il la croissance prémaxillaire et maxillaire:
making a sphincter at the anterior part, rengthening déductions en chirurgie des fentes labio-maxillaires, Reu
the intermediate part (small Z-plasty), and extending Stomatal 78:241-254, 1977.
the posterior part (bringing together the posterior 6. Delaire J: The potential role of facial muscles in moni-
palatal pillars). toring maxillalY growth and morphogenesis. In McNamara
12. Closure of the soft palate at 7 months and the hard JA, editor: Muscle adaptation in the craniofacial J-egion,
palate at 16 to 18 months. Hárd palate repair can be Monograph no. 8, Craniofacial growth series, Ann Arbor,
postponed up to the age of 3 years if closure would 1978, Center for Human Growth and Development,
necessitate transposition of maxillary fibramucosa.
niversity of Michigan.
13. The vomerine mucoperiosteum is not used in palate
7. Delaire J: Theoretical principles and technique of func-
closure because this may cause a defect in the vertical
development of the palate itself. tional closure of the lip and nasal aperture, j Maxillojàc
14. If the patient is first seen after the age of 12 years, Surg 6:109-116, 1978.
even very braad palatal clefts can be corrected by 8. Delaire J: La chronologie de la cheilorhinoplastie
means of the mobilization of the entire palatal fonctionelle et de l'orthodontie dans la correction des
fibramucosa without interfering with maxillary séquelles labio-maxillaires, Orthod Fr 49:95-113, 1978.
growth. 9. Delaire J, Precious D: Avoidance of the use of vomerine
mucosa in primalY surgical management of velopalatine
clefts, Oral Surg Oral Med Ora! Pathol 60:589-597, 1985.
10. Delaire J: The advantage of wide subperiosteal exposure
in primalY surgical correction of labial maxillary clefts,
Scandj Plast ReconstrSurg 22:147-151,1988.
PITFALLS 11. Delaire J: Le revètement cutaneo-l11uqueux dans les fentes
labio-maxillaires: déductions chirurgicales. In Brunati S,
• In most aspects of deft surgery, randomized editor: La rehabilitation fonctionelle chirurgicale et
studies do not exist. orthopédique des fentes labio-maxillo-palatines congéni-
• However convineing, reports of successful out- tales, vol 2, Lipomo, Como, Italy, 1989, Tipografia Cesare
comes from single surgeons or isolated centers ani.
must be viewed with caution. 12. Delaire J, Precious D, Gordeeff A: Intéret des grands
décollements sous-periostes dans la correction chirurg i-
PART 111 CRANIOFACIAL DEFORMITY
cale primaire des fentes labio-maxillaires. In Brunati S,
editor: La rehabilitation fonctionelle chirurgicale et
orthopedique des fentes labio-maxillo-palatines congeni-
tales, vol 2, Lipomo, Como, Italy, 1989, Tipografia Cesare
Nani.
13. Delaire J: Premiers resultats de la gingivo-periosto-plastie
primaire (avec ou sans osteo-plastie. In Brunati S, editor:
La rehabilitationfonctionelle chirurgicale et orthopedique
des fentes labio-maxillo-palatines congenitales, vol 2,
Lipomo, Como, Italy, 1989, Tipografia Cesare Nani.
14. Delaire J, Mercier J, Gordeeff A et al: Les trois fibro-
muqueuses palatines: leur róle dans la croissance du
maxillaire-déductions thérapeutiques dans la chirurgie
des divisions palatines, Reu Stomatol Chir Maxillofac
90:379-390, 1989.
15. Delaire J: Un exemple de chirurgie physiologique: la
rehabilitation 'primaire' du premaxillaire dans le fentes
labio-maxillaires, Reu Orthop Dento Faciale 25:453-475,
1991.
16. Delaire J: Fentes labials congénitales. In Lévignac J, editor:
Chirurgie des lèures, Paris, 1991, Masson.
17. Marcus AF, Delaire J, Smith WP: Facial balance in deft lip
and palate. 1. Normal development and deft palate, Er j
Oral Maxillofac Surg 30:287-295, 1992. _
18. Delaire J: General considerations regarding primary
physiologic treatment of labiomaxillopalatine defts, Atlas
Oral Maxillofac Surg Clin North Am 12:361-378, 2000.
19. Tajima S: The importance of the musculus nasalis and the
use of the deft margin flap in the repair of complete
unilateral deft lip, j Maxillofac Surg 11:64-70, 1983.
20. Talmant JC: Nasal malformations associated with unilat-
eral deft lip: accurate diagnosis management, Scand j
Plast Reconstr Surg Hand Surg 27:183-191, 1993.
21. Latham RA:The septopremaxillary ligament'and maxillary
development, j Anat 104:584, 1969.
22. Fara M: The musculature of deft lip and palate. In
Converse JM, editor: Reconstructiue plastic surgery, vol 4,
Philadelphia, 1977, Saunders.
23. Kernahan DA, Dado DV, Bauer BS: The anatomy of the
orbicularis oris musde in unilateral deft lip based on a
three-dimensional histological reconstruction, Plast
Reconstr Surg 73:875-879, 1984.
24. Veau V: Division palatine, anatomie, chirurgie, phonétique,
Paris, 1931, Masson.
25. Delaire J: Considérations sur I'accroisement du prémaxi!-
laire chez l'homme, Reu Stomatol Chir Maxillofac 75:951-
970, 1974
26. Delaire J, Verdon P, Tulasne JF: Etat du voile et statique
linguale: incidences thérapeutiques, Orthod Fr 47:129-
137, 1976.
27. Kriens 0: Fundamental anatomie findings for an intravelar
veloplasty, Cleft Palate j 7:27, 1970.
28. Pigott RW: Objectives for deft palate repair, Ann Plast
Surg 19247, 1976.
29. Lebourg L, Delaire J, Landais H: Que faut-i! faire en
View publication stats
1047
présence d'un bec-de-lièvre et d'une division palatine
congénitale? Actual Odontostomatol (ParisJ 34:299-306,
1956.
30. Petit P, Psaume J: The age in which it is convenient to
operate in hare lip and deft paJate. Sem Hop 22:3595-3597,
1954
31. Muir J: Repair of the deft alveolus, Er j Plast Surg 19:30-
36, 1966
32. Brusati R, Mannucci N: Primary repair of the lip and
palate using the Delaire phi!osophy. In Ward Booth P,
Schendel SA, Hausamen J-E, editors: Maxillofacial
surgery, vol 2, Edinburgh, 1999, Churchill Livingstone.
33. Mannucci N, D'Orto 0, Biglioli F et al: Comparison of the
effect of supraperiosteal versus subperiosteal dissection
on the growing rabbit maxilla, Cleft Palate Cranio{ac j
39:36-39, 2002.
34. Talmant .jC: Reflexions sur l'etiopathogenie des fentes
labio-maxillo-palatines et l'evolution de leurs traitements,
Ann Chir Plast Esthet 40:639-656, 1995.
35. McComb H: PrimalY repair of the bilateral deft lip nose:
a 15-year review and a new treatment plan, Plast Reconstr
Surg 86:882-889, 1990
36. Mulliken JB: Bilateral complete deft lip and nasal defor-
mity: an anthropometric analysis of staged to synchronous
repair, Plast Reconstr Surg 96:9-23, 1995.
37. Millard DR: Cleft craft 111, Boston, 1980, Little Brown.
38. Millard DR, Latham RA: Improved primary surgical and
den tal treatment of defts, Plast Reconstr Surg 86:856-871,
1990.
39. Mommaerts MY: The traditional "Millard" approach to lip
and palate repair. In Ward Boorh P, Schendel SA,
Hausamen J-E, editors: Maxillofacial surgery, vol 2,
Edinburgh, 1999, Churchill Livingstone.
40. Brusati R, Mannucci N: The early gingivoalveoloplasty:
preliminary results, Scand j Plast Reconstr Surg Hand
-Surg 26:65-70, 1992.
41. Boyne PJ, Sands NR: Secondary bone grafting of residu al
alveolar and palatal defects, j Oral Surg 30:87-92, 1972.
42. Brusati R, Mannucci N: Repair of the deft palate without
lateral release incisions: results concerning 124 cases,
j Craniomaxillofac Surg 22:138-143, 1994.
43. Skoog T: The use of periosteal flaps in the repair of deft
of the primary palate, Cleft Palatej 2:332, 1965.
44. Rintala AE, Ranta R: Periosteal flaps and grafts in primary
deft repair: a follow-up study, Plast Reconstr Surg 83:17,
1989.
45. Stricker M, Chancholle AR, Flot F et al: La greffe periostée
dans la réparation de la fente totale du palais primaire,
Ann Chir Plast 22:17, 1977.
46. Brusati R, Mannucci N, Autelitano 1: Computed tomog-
raphy evaluation of alveolar deft treated by primary
gingivo-alveolo-plasty, j Craniomaxillo{ac Surg 24(suppl
1):22-23, 1996.
47. Dorf DS, Curtin JW: Early deft palate repair and speech
outcome, Plast Reconstr Surg 70:74, 1982.