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Unilateral Cle+ Lip RepairAnatomic Subunit Approach
Vivek Panchapakesan BSc MD FRCSC DABPSToronto, Canada
Tuesday, 22 November, 11
Goals of Unilateral Cle+ Lip Repair
• Symmetric Lip Length
• Level Cupid’s Bow
• Adequate Vermilion Thickness
• Inconspicuous Scar
• Restore Muscle ConKnuity
• Address Nasal Deformity
Tuesday, 22 November, 11
Historical Background
Tuesday, 22 November, 11
ROSE-‐THOMPSON EFFECT
W. ROSE
On Harelip and Cle- Palate. London: HK Lewis, 1891
J.E. THOMPSON
An arKsKc and mathemaKcally accurate method of repairing the defect in cases
of harelip.Surg Gynaecol Obstet 14: 498, 1912
Picture from Patel P.K, Unilateral Cle- Lip Repair Treatment & Managementh[p://emedicine.medscape.com/arKcle/1279641-‐treatment#a1133
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THE REPAIR OF THE UNILATERAL CLEFT LIP BY THE STENCIL METHOD
C. TENNISON
San Antonio, Texas
Plast Reconstr Surg 9: 115, 1952
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A TRIANGULAR FLAP OPERATION FOR THE PRIMARY REPAIR OF UNILATERAL CLEFTS
OF THE LIP
P. RANDALL
Philadelphia, Pennsylvania
Plast Reconstr Surg 23: 331, 1959
Tuesday, 22 November, 11
COMPLETE UNILATERAL CLEFTS OF THE LIP
D. RALPH MILLARD
Miami, Florida
Plast. Reconstr. Surg. 25: 595, 1960
The Primary Camouflage of the Unilateral Hare-‐ look. TransacGons of the InternaGonal Society of PlasGc Surgeons, First Congress, Stockholm
(1955); 1957. pp. 160e166
Tuesday, 22 November, 11
ROTATION-‐ADVANCEMENT MODIFICATIONS
Millard DR, Refinements in rotaKon-‐advancement cle+ lip technique. Plast
Reconstr Surg 33:26, 1964
Millard DR, Extensions of the rotaKon-‐advancement principle for wide
unilateral cle+ lips. Plast. Reconstr. Surg 42: 535, 1968
Tuesday, 22 November, 11
ROTATION-‐ADVANCEMENT MODIFICATIONS
Millard DR, Refinements in rotaKon-‐advancement cle+ lip technique. Plast
Reconstr Surg 33:26, 1964
Millard DR, Extensions of the rotaKon-‐advancement principle for wide
unilateral cle+ lips. Plast. Reconstr. Surg 42: 535, 1968
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
L.R. MOHLER
Columbus, Ohio
Plast Reconstr Surg, Vol 80(4): 1960,
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
“The Red Line”
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
“The Red Line”
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
“Noordhoff’s Point”
“The Red Line”
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
“Noordhoff’s Point”
“The Red Line”
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
“Noordhoff’s Point”
“The Red Line”
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
M.S. NOORDHOFF
Taipei, Taiwan
The Surgical Technique for the Unilateral Cle- Lip-‐Nasal Deformity OperaGve
Syllabus© 1997 Noordhoff Craniofacial
FoundaKon
Tuesday, 22 November, 11
QUADRILATERAL MIRAULT FLAP OPERATION
A.B. LE MESURIER
Toronto, Ontario
Plast Reconstr Surg 16:425, 1955
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UNILATERAL CLEFT LIP REPAIR
H.G. THOMSON
Toronto, Canada
Oper Tech Plas. Reconstr. Surg 2: 175, 1995.
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
H.G. THOMSON
Toronto, Canada
Oper Tech Plas. Reconstr. Surg 2: 175, 1995.
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
H.G. THOMSON
Toronto, Canada
Oper Tech Plas. Reconstr. Surg 2: 175, 1995.
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
H.G. THOMSON
Toronto, Canada
Oper Tech Plas. Reconstr. Surg 2: 175, 1995.
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
H.G. THOMSON
Toronto, Canada
Oper Tech Plas. Reconstr. Surg 2: 175, 1995.
a
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UNILATERAL CLEFT LIP REPAIR
H.G. THOMSON
Toronto, Canada
Oper Tech Plas. Reconstr. Surg 2: 175, 1995.
a b
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
H.G. THOMSON
Toronto, Canada
Oper Tech Plas. Reconstr. Surg 2: 175, 1995.
a b
c
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
H.G. THOMSON
Toronto, Canada
Oper Tech Plas. Reconstr. Surg 2: 175, 1995.
a b
c
a ≥ b + c
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
H.G. THOMSON
Toronto, Canada
Oper Tech Plas. Reconstr. Surg 2: 175, 1995.
a b
c
a ≥ b + c
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR
H.G. THOMSON
Toronto, Canada
Oper Tech Plas. Reconstr. Surg 2: 175, 1995.
a b
c
a ≥ b + c
Tuesday, 22 November, 11
THE SUBUNIT PRINCIPLE IN NASAL RECONSTRUCTION
G.C. BURGET, F.J. MENICK
Chicago, Illinois & Tuscon, Arizona
Plast Reconstr Surg 76: 239, 1985
Tuesday, 22 November, 11
Ideal Line of Repair
• Ascends from cle+ side of cupid’s bow
• Mirrors the non-‐cle+-‐side philtral column
• Reaches base of the nose
• ConKnues superolaterally
• Borders lip-‐columellar crease, ascending to the nostril sill
Tuesday, 22 November, 11
Ideal Line of Repair
• Ascends from cle+ side of cupid’s bow
• Mirrors the non-‐cle+-‐side philtral column
• Reaches base of the nose
• ConKnues superolaterally
• Borders lip-‐columellar crease, ascending to the nostril sill
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR: AN ANATOMICAL SUBUNIT
APPROXIMATION TECHNIQUE
DAVID M. FISHER
Toronto, Canada
Plast Reconstr Surg 116: 61, 2005
Tuesday, 22 November, 11
UNILATERAL CLEFT LIP REPAIR: AN ANATOMICAL SUBUNIT
APPROXIMATION TECHNIQUE
DAVID M. FISHER
Toronto, Canada
Plast Reconstr Surg 116: 61, 2005a – b – 1mm = c
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Markings
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Lesser Lip Height (Base width of inferior triangle)
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Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
Tuesday, 22 November, 11
Lesser Lip Height (Base width of inferior triangle)
= Total Lip Height – Greater Lip Height – 1mm
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ModificaKons
Fisher D.M., Plast Reconstr Surg 2005; 116(1): 61-‐71.
Tuesday, 22 November, 11
ModificaKons
Fisher D.M., Plast Reconstr Surg 2005; 116(1): 61-‐71.
Base width of Inferior Triangle:μ = 1.24mm (0 – 2mm)
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Protocol (Sickkids)
• Presurgical NAM• Lip Repair/ Rhinoplasty• Palatoplasty ± M&T• ± Lip Revision• ± VPI CorrecKon• ± Lobule Rhinoplasty• Alveolar Bone Gra+• ± Septorhinoplasty• ±Orthognathic Surgery
• 2 weeks – Lip Repair• 3 – 5 months• 11 – 14 months• > 3 years prn• > 4 years prn• > 6 years prn• 8 – 12 years• > 12 years prn• Skeletal Maturity prn
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Primary Rhinoplasty
• ConservaKve…Goal = Improvement– CentralizaKon of columellar base– Symmetrical alar base reposiKoning– Nostril margins of equal circumference– Release LLC-‐ACC from piriform– Anteromedial advancement of cle+-‐side lateral crus
– CreaKon of ULC-‐LLC overlap– No dissecKon of dome
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Conclusions
• Reliable– Based on previously described repairs and principles
• Rose-‐Thomson lengthening allows for a smaller triangle
• Triangle posiKoned according to Noordhoff’s descripKon
• Repair along lines of anatomical subunits• ConservaKve approach to the nose
Tuesday, 22 November, 11
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