Today, we will be discussing the lip markings for the bilateral cleft lip repair. This is according to the John Mulliken repair technique. We begin these markings by marking the tip-defining points of the nose, where the lower lateral cartilages reach their tip point. Then we mark the alar light reflex of both ala. This comes down into the sub-alar point of the ala, and then the alar insertion point where the ala meets the nostril sill. We mark these points and reinforce them so that we can develop a symmetric repair of the lip and the nose complex. Once the nasal points are marked out, we go to the lip, and we begin on the prolabium. We mark our midpoint of the lip-calumellar junction, and then two points adjacent to this, which are approximately 1.5 millimeters, emulating the top of our filtral columns bilaterally. Then we take our markings to the lip-vermilion junction. Notes that these lower points of the Cupid's bow are skin only. They do not involve any vermilion. And we usually make these lengths about 2 to 2.5 millimeters. The prolabial tag will be wider in the bottom than it is at the top in order to recreate a normal-appearing filtral column and Cupid's bow complex. These marks are then reinforced with methylene blue and drawn out. We have a slight concavity to the filtral columns in order to create a more naturally-appearing filtral unit. From the lip-calumellar junction, we mark two points going into the sill and into the nose so that we have an area to close the upper part of the lip and recreate the nostril sill. These markings are symmetric so as to create a symmetric and equal-length nostril sill closure. A line on the mucosa-vermilion junction is marked and used the mucosal points to recreate the anterior part of the gingival buccal sac. We go to the lateral lip elements. We find Nordhoff's point on the lateral lip element by looking at the vermilion-mucosal junction line as well as the white roll and finding a point which satisfies our Nordhoff point requirement, including enough vermilion and a very distinct white roll. The same is extrapolated to the left lateral lip element underneath the prolabial tag, which is the exact same distance, approximately 2.5 millimeters, from Nordhoff's point. Therefore, we'll be incorporating white roll from lateral lip elements as well as vermilion from lateral lip elements in order to create the central tubercle of the lip. We then measure our lip length on our prolabial tag and extrapolate that onto our lateral lip elements and then draw that out. This connects to the white roll segment. I usually make this a little bit longer than our actual prolabial lip length in order to a slight amount of skin redundancy on the lateral lip elements to recreate the filth roll columns. At the top of the lip length on the lateral lip elements, we recreate a concave portion of skin to assist with our sill closure points, and these are done symmetrically and bilaterally. Then we remove mucosa, or we cut mucosa in order to get rid of the cleft margin, and we try to preserve as much mucosal tissue as possible. We try to follow Gilley's principles of never throwing anything away during this operation, even though we'll be throwing away some of the prolabium. What's important to know is that the vermilion and mucosa, as well as the white roll of the lip repair, come from the lateral lip elements, and the skin of the prolabium is all that is there. These are the eventual markings of the bilateral lip.

bilateral cleft lip repair

John Mulliken technique

nasal and lip markings

symmetrical repair

aesthetic outcome