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The purpose of this study was to analyze the geometry of the primary cleft lip nasal deformity using three-dimensional computerized tomography in a group of 3-month-old infants with complete unilateral cleft lip and palate before surgical intervention. Coordinates and axes were reconfigured after the three-dimensional image was oriented into neutral position (Frankfurt horizontal, true anteroposterior, and vertical midline). Display and measurement of skin surface and osseous tissues were achieved by adjusting the computed tomographic thresholds. S-N, N-ANS, S-N-O, and S-N-ANS were measured from true lateral views. Biorbital (LO-LO), interorbital (MO-MO), intercanthal (en-en), and nasal (al-al) widths were measured from the anteroposterior view. The bony alveolar cleft width was measured from the inferior view. The study group was divided into two groups on the basis of skeletal alveolar cleft width: six patients with clefts narrower than 10 mm and six patients with clefts wider than 10 mm. Only the S-N-ANS angle differed between the two groups, i.e., it was greater in the group with the wider clefts (p < 0.05). Coordinates of six landmarks at the base of the nose [sellion (se), subnasale (sn), cleft-side and noncleft-side subalare (sbal-cl and sbal-ncl), and the most posterior point on the lateral piriform margins (PPA-CL and PPA-NCL)] were obtained for analysis of the nasal deformity. On average, the subnasale point was anterior to sellion and deviated to the noncleft side; the cleft-side sbal point was more medial, posterior, and inferior than the noncleft-side sbal point; and the PPA point on the cleft-side piriform margin was more lateral, posterior, and inferior than the PPA point on the noncleft side. These discrepancies were not universally observed. However, in all patients, four findings were observed without exception (p < 0.01): (1) subnasale (sn) was deviated to the noncleft side (mean distance from midline, 5.0 mm; range, 2 to 9.5 mm), (2) the cleft-side alar base (sbal-cl) was more posterior than the noncleft-side alar base (sbal-ncl) (mean difference, 3.6 mm; range, 1 to 5.5 mm), (3) the noncleft-side alar base (sbal-ncl) was further from the midline than the cleft-side alar base (sbal-cl) (mean difference in lateral distances of sbal-ncl and sbal-cl from the midline, 2.8 mm; range, 0.5 to 7 mm), and (4) the cleft-side piriform margin (PPA-CL) was more posterior than the noncleft side piriform margin (PPA-NCL) (mean difference, 2.1 mm; range, 0.5 to 4 mm). In conclusion, the nasal deformity in unilateral cleft lip and palate that has not been operated on is characterized by these four features and increased S-N-ANS angle with increased alveolar cleft width.

The white skin roll is a useful term to describe the cutaneo-vermilion border of the lip. The muco-vermilion border line parallels the white skin roll and is described as the red line. The lip vermilion should be constructed so that these lines are parallel and widest at the base of the philtral column. It is suggested that the triangular lateral lip vermilion flap be used in unilateral cleft lips. In bilateral cleft lips, a white skin roll vermilion-mucosal muscle flap is used for reconstruction of vermilion.

Eight patients, aged 9 months to 9 years, each with unusual complete cleft of the primary and secondary palate on one side and a complete cleft of the secondary palate on the opposite side, were evaluated. All showed varying deficiencies of median facial mesodermal dysgenesis characterized by absent frenulum, indefinite cupid's bow, deficient septal cartilage and nasal spine, and absent central and lateral incisor of the cleft side of the premaxilla. Computerized tomographic scan confirmed the absence of the central nervous system anomalies seen in midline clefts. Cephalometric studies revealed maxillary hypoplasia and no evident hypotelorism. These patients demonstrate a definable lack of median mesodermal penetration along with failure of lateral mesodermal penetration. It is to be noted that median facial dysgenesis can occur without recognizable central nervous system disorders. It is quite possible that microforms of median facial dysgenesis occur in unilateral and bilateral cleft lip and palate patients. This would help explain the wide variations of clefting seen clinically.

Over a period of 8 years 140 bilateral cleft lips were operated using a muscle-repositioning banked fork-flap cheiloplasty. The use of buccal mucosal flaps in the intercartilaginous incision is helpful to decrease scarring and contracture by facilitating alar cartilage repositioning and wound closure without tension. Adding mucosa from the inferior turbinate makes complete wound closure relatively easy without tension. A lateral lip orbicularis muscle flap with white skin roll and vermilion is recommended for reconstruction of the Cupid's bow. Muscle continuity by freeing the muscle in one sheet and repositioning in front of the premaxilla with creation of a buccal alveolar sulcus is stressed to prevent the necessity of reentering the lip in a second procedure. The elongation of the columella is done at 1 to 6 years of age by advancing nasal floor tissue onto the columella and repositioning the alar cartilages superiorly and medially. When nasal floor tissue is inadequate, columellar lengthening is done by the use of a composite free ear graft.