Bilateral Cleft Lip Repair: Surgical Tutorial for Professionals

A bilateral complete cleft lip, which has been previously treated with nasoalvoelar molding, is repaired with the Millard-Mulliken technique, which employs reconstruction of the orbicularis oris muscle by advancing bilateral muscular segments.

This tutorial for medical professionals was developed to supplement learning of a common surgical technique and is not intended to replace formal surgical training.

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Bilateral Cleft Lip Surgical Tutorial

This surgical tutorial illustrates the steps in bilateral cleft lip repair.
Bilateral cleft lip repair shares many of the same goals with unilateral repair.
The orbicularis muscle should be reunited at the midline when possible, the philtrum should be recreated, and the white roll continuity should be reestablished. For most surgeons the prolabium (the midline element) will not contribute to the white roll or vermillion – it will contribute philtral skin and mucosa to deepen the upper buccal sulcus (Millard technique).
Marking begins with the prolabium and then proceeds to the lateral lip elements. Begin by marking the midline columellar base as shown by the marker within the photo.
Now mark the height of the philtral column to the left and right of this midline marking. These marks should be symmetric. This will be slightly more narrow than the markings for cupid’s bow.
Mark the midline of the prolabium at the cutaneous-vermillion junction. Finding the true midline is typically accomplished by placing gentle traction on the prolabium.
Next, mark a symmetrical 5mm philtrum by placing symmetrical points 2.5mm lateral to the midline marking.
This neo-philtrum will contribute philtral skin but not white roll (it contains none).
The prolabium contains no orbicularis muscle. Its vermillion (shaded in the picture) will be used to deepen the upper buccal sulcus and make no contribution to the lip vermillion.
Place a marking lateral to the lip-columellar markings at the skin-mucosa junction. Make these two marks precisely symmetric.
Attention is now turned to the lateral lip segments. First mark the alar base bilaterally.
Now mark Noordhoff’s point – the medial point where the white roll still has full thickness and before the vermillion has thinned. The points will meet at the midline to make the white roll contiguous.
Now mark a back cut from Noordhoff’s point laterally 2.5mm or the width of half of the proposed philtrum. This point on each side will meet with the lateral corner of the new philtrum.
Now mark a point medially from the last point a distance equal to the height of the proposed philtrum (illustrated with lines).
Now mark a point medially from the last point a distance equal to the height of the proposed philtrum (without lines).
Mark a point towards the cleft that is the same distance as the markings from the columellar base to nasal sill point (illustrated with lines).
Mark a point towards the cleft that is the same distance as the markings from the columellar base to nasal sill point (without lines).
Mark the wet-dry border on each side.
This final picture illustrates how these incisions will converge when the repair is complete.