What is the operative technique for cheiloplasty?

Operative Technique for Cheiloplasty

The operative technique for cheiloplasty depends critically on whether you are performing primary repair of a cleft lip (unilateral vs. bilateral) or secondary/augmentation procedures, with each requiring distinct surgical approaches and tissue handling principles.

Primary Unilateral Cleft Lip Repair

Patient Selection and Timing

• Perform primary cheiloplasty at approximately 6 months of age (range 5-12 months) for optimal tissue handling and healing 1
• Evaluate the gap width between labial segments preoperatively—smaller gaps allow for less aggressive techniques 1

Meara's Technique (for Small to Moderate Gaps)

For isolated cleft lip or narrow gaps without cleft alveolus, Meara's cheiloplasty offers superior outcomes with less tissue manipulation 1:

• Surgical duration: Average 85 minutes 1
• Key advantage: Produces less geometric, more harmonic flaps compared to traditional rotation-advancement techniques 1
• Simultaneous rhinoplasty: Perform primary rhinoplasty concurrently if nasal asymmetry is present 1
• Postoperative feeding: Resume oral feeding 4 hours post-procedure; withhold bottle-feeding for 2 weeks 1
• Expected outcomes: Symmetrical lip height, well-balanced nose, and acceptable scar appearance in all cases 1

Traditional Rotation-Advancement Technique (for Wider Gaps)

• Reserve advancement-rotation flaps or quadrangular flaps for more severe cases with wider gaps 1
• These techniques involve more aggressive tissue manipulation but are necessary when Meara's approach cannot achieve adequate closure 1

Primary Bilateral Cleft Lip Repair

Adult Patients with Unrepaired Bilateral Clefts

Perform simultaneous premaxillary repositioning and cheiloplasty in a single stage for adult patients with severe premaxillary anterior projection 2:

• Critical principle: Single-stage approach prevents the need for multiple procedures and achieves optimal aesthetic results 2
• Vascular safety: No avascular necrosis of the premaxilla occurs with proper technique 2
• Indication: Previously unrepaired or poorly repaired bilateral cleft lip and palate in adults 2

Muscle-Repositioning Banked Fork-Flap Technique

For pediatric bilateral cleft lip, use muscle-repositioning banked fork-flap cheiloplasty with buccal mucosal flaps 3:

Mucosal Management

• Utilize buccal mucosal flaps in the intercartilaginous incision to decrease scarring and contracture 3
• Add mucosa from the inferior turbinate to facilitate complete wound closure without tension 3

Muscle Reconstruction

• Free the orbicularis muscle in one continuous sheet and reposition it anterior to the premaxilla 3
• Create a buccal alveolar sulcus during initial repair to prevent need for secondary procedures 3
• Use a lateral lip orbicularis muscle flap with white skin roll and vermilion for Cupid's bow reconstruction 3

Columellar Lengthening

• Perform at 1-6 years of age by advancing nasal floor tissue onto the columella 3
• Reposition alar cartilages superiorly and medially 3
• If nasal floor tissue is inadequate, use composite free ear graft 3

Augmentation Cheiloplasty

For lip augmentation without cleft pathology, use V-to-Y advancement of two triangular distally-based flaps 4:

Surgical Steps

• Advance two triangular distally-based flaps in V-to-Y configuration 4
• Plicate the orbicularis muscle to enhance the thickening effect 4
• Advantages: Inconspicuous scars, satisfactory results, minimal complications 4

Secondary Cheiloplasty

Indications and Timing

• Perform when residual imperfections remain after primary repair, especially in bilateral clefts 5
• Optimal timing: At school entry age, when psychological impact becomes significant 5
• Combine with alveoloplasty when indicated (GPVP: alveolar transplantation with vestibulo and labio-plasty) 5

Objectives

• Address both functional and aesthetic corrections 5
• Utilize all available cosmetic surgery techniques to optimize outcomes 5

Critical Technical Principles Across All Approaches

Wound Closure

• Achieve tension-free primary closure in all cases 3
• Use adequate mucosal advancement to prevent contracture 3

Muscle Continuity

• Establish complete orbicularis muscle continuity during primary repair to avoid secondary procedures 3
• Proper muscle repositioning is essential for functional outcomes 3

Scar Management

• One case of lip scar retraction can be managed with triamcinolone infiltration 1
• Minimize geometric flap designs to reduce visible scarring 1

Postoperative Care

• Early oral feeding (4 hours) is safe and well-tolerated 1
• Restrict bottle-feeding for 2 weeks to protect the repair 1