the important landmarks so that we do not lose them during the operation. We do this with a 25-gauge needle and methylene blue. After all the areas are tattooed, we begin the surgery by cutting the prolabial skin tag with a wet blade. This is a small ophthalmologic knife which allows for precision and the ability to preserve our marks. We're discarding the vermilion from the prolabial area and using the mucosa as the posterior wall of our gingival buccal sulcus. Here we're using the wet blade to cut our lateral lip elements and preserve our marks. An 11 blade is used in order to cut across the vermilion to preserve the muscles orientation with the red part of the lip. A 6-7 beaver blade is used to excise the cleft margin. We begin on the left side of the cleft with the same exact procedure. This is with all the cleft margins excised. Now we dissect our muscles, our orbicularis oris muscle, from our overlying skin and underlying mucosa in order to create a nice layered closure. Try to prevent any significant amount of trauma to the tissues by excessive electrocautery. This is dissecting the mucosa off of the prolabial tag, the very low setting electrocautery in order to recreate our gingival buccal sulcus. During your consultation with the families, you should tell them that after repair the lip will look very tight. Given the fact that it's a bilateral lip repair, this tightness will resolve itself with time and over a series of days. But this needs to be counseled to the family so they know what to expect at the end of the repair. Obviously, the wider the bilateral cleft, the tighter this repair can be. And if it's too wide, then a recommendation for a lip adhesion should be done. Here we're using a 3-O-Vicryl to recreate the posterior part of the gingival buccal sulcus. And now we're closing our mucosa with a 4-O-Vicryl suture. We begin by closing mucosa first because once you repair the muscles, it's very difficult to repair the mucosa from underneath. Now we're using a 5-0 PDS to close the marginalis portion of the orbicularis oris muscle. Same PDS suture to close the commonalis or the major portion of the orbicularis oris muscle. These sutures will obviously bring the nasal bases closer together. Now we're using a 5-0 monocryl to inset the prolabium. These sutures have very small and precise bites so as to prevent any necrosis of the prolabium given its compromised blood supply. If the prolabium at any point turns white or does not appear vascularized, you need to remove sutures to restore its blood supply. Otherwise you could have necrosis of this area. We're using 7-0 proline to inset the prolabium and we use a nasal stent in order to help shape the nose after surgery. They look very tight after surgery but after a week these will soften out and the appearance will be very natural.

bilateral cleft lip repair

surgical techniques

tissue preservation

nasal stent

postoperative care