Fisher 2005 - NEJM -Cleft lip repair
Jing Qin Tay
10/1/2023
Summary
This article describes a surgical technique for repairing unilateral cleft lip developed by Dr. David Fisher.
The goal of the technique is to achieve a lip and nose of normal form and function, with a scar line that follows the natural anatomical subunits.
Key steps:
Precise marking of anatomical landmarks on the medial and lateral lip elements. This includes points above the cutaneous roll to allow downward rotation of the cleft side peak of Cupid's bow.
Measurements taken to calculate the size of a small inferior triangle above the cutaneous roll for lengthening the vertical height of the medial lip. This is typically 1-2mm.
Lateral lip markings adjusted based on its vertical height. The base of the philtral column and nostril sill closure point are kept constant.
Dissection and freeing of the lip muscle elements. For complete clefts, nasal dissection is also performed.
Rotation advancement and approximation of the medial and lateral lip elements. The inferior triangle provides tension for optimal lip contour.
Muscle and skin closure. For complete clefts, special flaps may be used for the nasal layer closure.
Primary rhinoplasty maneuvers for repositioning the alar base and achieving nostril symmetry.
Surgical Technique
Markings
Precise markings made on medial lip for philtral column height, Cupid's bow peaks, opening incision.
Lateral lip markings adjusted based on vertical height. Noordhoff's point for philtral column base kept constant.
Nostril sill closure point positioned symmetrically.
Measurements
Vertical lip heights measured to calculate inferior triangle size above cutaneous roll. Triangle kept small (1-2mm).
Lateral lip triangular markings planned if lip short or long.
Dissection
Muscle freed from skin/mucosa without undermining philtral dimple. More extensive on lateral lip.
For complete clefts, vestibular web released, turbinate flap raised.
Repair
Medial and lateral elements approximated with inferior triangle providing tension.
Muscle, dermis, skin closure performed. Lateral vermilion flap inset if needed.
For complete clefts, special nasal layer flaps created (turbinate, lateral, medial flaps).
Primary rhinoplasty with alar base repositioning.
Results
144 consecutive cases reviewed. Mean vertical height discrepancy 2.4mm, inferior triangle 1.2mm.
Allows anatomical subunit repair with minimal scarring.
In summary, this technique allows precise planning and placement of incisions to achieve an anatomical repair of unilateral cleft lip and nose. The small inferior triangle technique minimizes scarring while providing optimal lip contour.