What are the steps for performing a Z-plasty on a cleft lip?

Z-Plasty Technique for Cleft Lip Repair

Z-plasty is a well-established component of unilateral cleft lip repair that provides vertical lengthening of the lip while limiting visible scarring, and can be performed using either a simple asymmetric approach or as part of a layered functional repair. 1, 2

Pre-Operative Planning

Patient Selection and Timing

• Perform primary cheiloplasty at 3-6 months of age when the infant meets the "rule of 10s" (10 weeks old, 10 pounds weight, hemoglobin 10 g/dL) 3
• Ensure the procedure is performed by a pediatric plastic surgeon or general plastic surgeon with appropriate cleft training and experience 3
• Coordinate care through a multidisciplinary cleft palate team before proceeding 3, 4

Anatomical Assessment

• Identify the highest point of "good" lip skin on the lateral lip unit (non-cleft side) - this determines your Z-plasty limb length 1
• Assess the degree of cupid's bow elevation on the medial (cleft) side 5, 6
• Evaluate philtral column depth and symmetry 5, 6
• Document orbicularis oris muscle diastasis and degree of hypoplasia 2, 6

Surgical Steps for Z-Plasty Cleft Lip Repair

Step 1: Marking the Z-Plasty Design

• Mark the lateral limb from cupid's bow to the highest point of good lip skin on the lateral (non-cleft) side 1
• Scribe an arc from both cupid's bows using the lateral limb length as your radius 1
• Mark the releasing incision where the arcs intersect - this determines both length and direction (angles are NOT predetermined as in classic Z-plasty) 1
• For microform clefts, consider double unilimb Z-plasty at the vermilion-cutaneous and vermilion-mucosal junctions to correct vertical asymmetry while limiting scar to the lower half of the lip 6

Step 2: Incision and Tissue Mobilization

• Make incisions "on block" through skin, muscle, and mucosa simultaneously - this minimizes bleeding by avoiding separate muscle dissection 1
• Perform wide undermining and release of the orbicularis oris muscle on the lateral (non-cleft) side to allow redraping and lengthening 2
• Create the medial and lateral flaps according to your marked Z-plasty design 1

Step 3: Muscle Reconstruction

• Transpose the orbicularis oris muscle downward (toward the free border) on both medial and lateral sides 1
• Perform step-by-step layered closure starting with mucosa, then muscle, then skin 2
• Overlap the orbicularis oris muscle flap through an intraoral incision to create philtral depth 5
• Ensure muscular continuity across the cleft is restored to enable normal lip function 3

Step 4: Flap Transposition

• Transpose the flaps to upright the isosceles triangle-shaped philtrum 1
• Align the cupid's bows symmetrically during transposition 1
• The medially based flap under the nose provides permanent fullness and length to the upper lip 1

Step 5: Skin Closure and Final Adjustments

• Close skin in layers to achieve downward rotation of cupid's bows along with the philtral dimple - this provides attractive fullness and pout to the lower lip 1
• For microform clefts, perform eversion of orbicularis oris at the vermilion border 6
• Consider dermal graft augmentation of the philtral ridge if needed for symmetry 6

Step 6: Nasal Correction (if indicated)

• Perform reverse-U incision and V-Y plasty for cleft lip nasal deformity correction 5
• Medially position the alar base and elevate the lower lateral cartilage 6
• Note that definitive rhinoplasty is typically deferred to later childhood 3

Technical Pearls and Pitfalls

Advantages of This Approach

• No predetermined angles - the tissue available dictates the design, making it adaptable to all degrees of cleft severity 1
• Minimal bleeding due to "on block" technique without separate muscle dissection 1
• Simple, rapid, and dependable with reproducible results even for surgeons with limited cleft experience 2
• Maintains horizontal lip length while achieving adequate vertical height 2

Common Pitfalls to Avoid

• Avoid facial malposition of tissue - ensure proper alignment of cupid's bow peaks to prevent visible asymmetry 1, 2
• Do not sacrifice horizontal lip length for vertical lengthening - the Z-plasty should provide both 2
• Ensure adequate muscle release on the lateral side - insufficient undermining leads to tension and poor redraping 2
• Preserve the alar-facial groove during dissection - loss of this landmark requires secondary revision 2

Expected Outcomes

• Good skin scar achieved in approximately 83% of cases (10 of 12 patients in one series) 2
• Maintained alar-facial groove in 75% of cases (9 of 12 patients) 2
• Normal horizontal lip length achieved in 100% of cases 2
• Secondary surgery rate of approximately 75%, though in 50% this is for nasal deformity correction rather than lip revision 2
• Minor scar revision needed in approximately 22% of cases (4 of 18 patients) at long-term follow-up 5

Post-Operative Considerations

Immediate Post-Operative Care

• Ensure proper lip seal is established for normal feeding mechanics 3
• Monitor for airway complications in complex cases requiring inpatient admission 7

Long-Term Follow-Up

• Coordinate with speech-language pathologists beginning at 6-18 months for speech assessment 4
• Monitor for otitis media with effusion every 6 months, as children with cleft lip/palate have nearly universal middle ear involvement 8, 4
• Plan palatoplasty around 1 year of age - this takes priority over secondary lip revision due to its critical impact on speech development and hearing 4