British ~oumol ofPlastic Surgery (1980), 33, 266-269

@I 1980 The Trustees of British Association of Plastic Surgeons

THE USE OF A CUTANEOUS-MUSCULAR FLAP FOR

PRIMARY NASO-LABIAL REPAIR WITH A MODIFIED
TENNISON-RANDALL TECHNIQUE

By DR CARLOSLEON-VALLE
Department of Plastic Surgery,
I.M.S.S. Specialties Hospital, Puebla, Pue, Mexico

A cleft of the lip is almost always associated with a deformity of the nostril. Even if a
highly successful primary repair of the lip is achieved, the nasal deformity usually
remains and calls for treatment. The task is not an easy one, as is shown by the succession
of new techniques that appear in the plastic surgical literature. In young children and in
adults, correction of the nasal deformity is even more difficult.
The outcome of any secondary rhinoplasty will be conditioned by the degree of
existing deformities, which are the result of displacement of the maxillary segments and
muscular asymmetry due to mal-alignment of the orbicularis muscle. The characteristic
nostril deformity is all too familiar. On the affected side the alae are depressed or
flattened out. The longitudinal axis of the nostril opening tends to become horizontal
rather than vertically oblique. The anterior border of the medial crus is laterally
displaced, baring the anterior border of the septum and distorting the columella. The
floor of the nostril may be widened, narrowed or sunken.
Whatever the degree and variety of the deformities, the outstanding morphological
alteration is that of the nostril on the affected side. As Nishimura and Ogino (1977)
point out, our main goal should be to produce symmetry of the nostrils. To achieve it
we must correct first the alar cartilage, then the position of the alar base and finally the
floor of the nostril.
In our experience, it is feasible to correct primarily and simultaneously both the lip
and the nose in children with unilateral cleft lip, even when they are referred for treat-
ment at the age of g years and older.
Using Tennison-Randall’s technique, we fashion a musculocutaneous flap from
the outer border of the defect and advance it towards the corresponding hemicolumella.
This provides adequate columellar support, restores a height equal to that of the colu-
mella on the unaffected side, raises the alar cartilage on the affected side, and so
restores the symmetry of the nostrils.

METHOD
Incision lines are drawn on the midline of the columella and the dorsum of the
nasal tip, in addition to the lip markings used in Tennison-Randall’s technique of lip
repair (Fig. I).
A midcolumellar incision is then made reaching towards the nasal tip where a small
triangle is resected. Both alar cartilages are exposed and the alar cartilage on the affected
side is completely freed. When the degree of distortion is severe, both alar cartilages are
completely freed enabling the surgeon to reshape and restore the nasal tip (Fig. 2).
An incision is then made on the membranous septum to free the medial crus of the
alar cartilage from its base and to allow the upward displacement of the hemicolumella
Address for reprints: Manuel Rivadeneyra, 2130, Colonia Bella Vista, Puebla, Pue, Mexico.
266
 THE USE OF A CUTANEOUS-MUSCULAR FLAP 267

FIG. r. A. The markings on the lip follow those used in the Tennison-Randall technique. Note the
extension of the lip incision into the columella, with a small triangle of skin to be excised later over the
B. Detail of the incisions in the nasal floor showing the donor site of the cutaneous muscular
%Fz% also the incision in the midcolumella that allows dissection and complete mobilisation of each
alar cartilage.

FIG. z. Both alar cartifages are separated in the midline and the lateral crura are also freed. This allows
the surgeon to lift the nasal tip on the affected side to the correct height.

together with all of the alar cartilage in the shape of a flap whose thickness is around 4
mm. This manoeuvre permits adequate positioning of the cartilage at the desired height
(Fig. 3).
The lip repair is carried out using the Tennison-Randall technique. A musculo-
cutaneous flap is made from the outer border of the labial defect and the mucosal layer
is discarded. The epithelium at the free end of the flap is removed for about 4 mm, which
allows the surgeon to fold over the underlying muscle and so increase its volume (Fig. 4).
The length of the flap should be equal to the length of the upward displacement of the
columellar flap we have already described.
268 BRITISH JOURNAL OF PLASTIC SURGERY

FIG. 3. The lip and nasal segments can now be placed in their new position.

FIG. muscular flap is now in a position to provide a very pleasing the nostril and
close the defect at the base of the left hemicolumella.

The closure of the lip is now begun by displacing the musculocutaneous flap
towards the defect created by raising the columellar flap. The fold in the muscle at the
tip of the labial flap fills out the defect at the base of the columella and provides a very
pleasing aud symmetrical cohunella base (Fig. 5).
The lip repair is then completed. The new height of the alar cartilages is established
and two or three Dermalon 6-o stitches are inserted. By pulling the nasal tip upwards,
the hemicolumella is raised creating the bed into which the labial flap is inserted. The
resection of a small skin triangle from the dorsum of the nose compensates the upwards
and backwards displacement made by raising the alar cartilages.
 THE USE OF A CUTANEOUS-MUSCULAR FLAP 269

FIG. 5. The tip of the cutaneous-muscular flap is de-epithelialised over a distance of 3 or 4 mm. The
denuded muscle is folded upon itself to increase its volume. The flap is then sutured into position to
reconstruct the nasal floor and base of the columella. The lip repair is completed.

DISCUSSION

We have used this technique in patients whose ages ranged from 9 to 21 years, and
who had received no previous treatment whatever. It imports tissue from the lip to the
nose, as a musculocutaneous flap, after symmetry of the nasal tip has been achieved. At
the same time it enables the surgeon to alter the longitudinal axis of the deformed
nostril from the horizontal to a vertical oblique direction. Traction on the alar base
through the musculocutaneous flap, and elevation of the alar cartilages, complete this
rotation.

REFERENCES
BERKELEY, W. T. (1969). Correction of secondary cleft lip nasal deformities. Plastic arid
Reconstructive Surgery, 44, 234.
GUERRERO-SANTOS, J., MACHAIN, 0. P. and CASTAREDA, A. (1965). The use of a denuded
flap of vermilion in the repair of cleft lip. Plastic and Reconstructive Surgery, 36, III.
MATTHEWS,D. N. (1968). The nose tip. British Journal of Plastic Surgery, 21, 153.
NISHIMURA,Y., OGINA, Y. (1977). The use of two v-flaps for secondary correction of the
cleft lip nose. Plastic and Reconstructive Surgery, 60, 390.
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ORTIZ MONASTERIO,F., OLMEDO, A., TRIGOS, I., YUDOVICH,M., VELAZQUEZ,M. and
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