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A Technique to Improve the Geometric and Unnatural Appearance of the Inferior Triangular Flap in Primary Unilateral Cleft Lip Repair

Togashi, Shinji M.D.; Sekido, Mitsuru M.D.

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Plastic and Reconstructive Surgery: April 2012 - Volume 129 - Issue 4 - p 746e-748e
doi: 10.1097/PRS.0b013e318245e8da
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Forty-seven patients underwent unilateral cleft lip repair within 4 months of birth from February of 2006 to June of 2010. The center and high points of the Cupid's bow on the medial and lateral lips are marked (points 1 to 4) (Fig. 1). The center point of the columellar base and upper end of the philtrum are marked at the lip-columellar crease (points 5 and 6), and point 7 is marked to mirror point 6. The ideal lines of the final scar are drawn on the noncleft column. Point 8 is marked just above the white roll perpendicular to the vermilion border on the lateral lip. Points 8 and 9 are at equal distances from the vermilion border. From point 9, an approximately 1- to 1.5-mm-long line is drawn parallel to the vermilion border (point 10). A sigmoid line on the medial lip and an arcuate line on the lateral lip are designed.1 The C flap that is changed to one-fourth of the circular flap2 and a releasing incision of the nasal floor triangular flap are designed. Angle 4-8-11 is approximately 45 degrees, to permit an arcuate line. The design at the upper end of the lateral lip is drawn with reference to the inferiormost point on the alar-lip junction and to the contour around the nostril sill on the noncleft side. A nasal floor triangular flap is made (approximately 2 × 1.5 mm) to correct the flared alar base.3Figure 1 shows the ideal scar sought in this series. The inferior triangular flap was modified to conceal the scars within the contours of the upper lip.

Fig. 1
Fig. 1:
(Left) Schematic depiction of the final scar in this series; almost all scars exist along the contour. (Right) Design of incision.

Thirty-two patients had complete clefts and 15 had incomplete clefts. The patients were followed up for periods ranging from 5 months to 5 years 2 months (mean, 2 years 11 months). The cleft philtral column could be constructed with adequate length in all of the cases. Because of this modification, the inferior line became part of the white roll and insignificant, and its geometric and unnatural appearance was improved (Fig. 2).

Fig. 2
Fig. 2:
(Left) Complete unilateral cleft lip–cleft palate 7 months after secondary repair and (right) 1 year after secondary repair.

Ideal unilateral cleft lip repair should provide a symmetrical Cupid's bow and a natural-appearing philtrum. An inferior triangular flap has been used to fill out the vertical discrepancy of the medial lip mathematically, create the philtral dimple contour,2 and prevent scar contracture, but the final scar disrupts the vertical column in a zigzag fashion.4

The concept of our procedure is that all the scars in the upper lip should be hidden within the natural contour of the upper lip. Despite the width of the inferior line of the flap being one-third to one-fourth (approximately 1 to 1.5 mm) that of the philtrum, the white roll appears continuous and the inferior line scar is inconspicuous, dependent on the heterotic effect. Thus, a minimum scar around the cleft philtral column is finally achieved. The incision line crossing the philtral column is insignificant, and a well-camouflaged triangular flap is achieved on the cleft side in this series.

Shinji Togashi, M.D.

Mitsuru Sekido, M.D.

University of Tsukuba, Ibaraki Prefecture, Tsukuba, Japan


Parents or guardians provided written consent for use of the patient's images.


1. LaRossa D. Respecting curves in unilateral cleft lip repair. Oper Tech Plast Reconstr Surg. 1995;2:182–186.
2. Fisher DM. Unilateral cleft lip repair: An anatomical subunit approximation technique. Plast Reconstr Surg. 2005;116:61–71.
3. Nakajima T, Tamada I, Miyamoto J, Nagasao T, Hikosaka M. Straight line repair of unilateral cleft lip: New operative method based on 25 years experience. J Plast Reconstr Aesthet Surg. 2008;61:870–878.
4. Demke JC, Tatum SA. Analysis and evolution of rotation principles in unilateral cleft lip repair. J Plast Reconstr Aesthet Surg. 2011;64:313–318.


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