In this video, we're going to talk about marking the unilateral cleft lip repair technique via the Fischer repair given to us by Dr. David Fischer and made popular during his publication in 2008. When addressing the unilateral cleft lip as a primary repair, it's important to understand all of the deformities that you're trying to correct, specifically to address the deformities in the nose as well as the lip. We like to use a quill-type pen in methylene blue. We start with a top-down approach by marking the asymmetries found in the nose. The Xs here mark the tip-defining points of the nose, and you can see there's a discrepancy there. Then we move to the Alar light reflex and mark that point all the way until it inserts onto what we call the Alar insertion point, where the Ala inserts into the nostril sill. In addition, we mark the very caudal-most portion of the nasal Ala on the non-cleft side, something called the sub-alarate point. Once these points are marked, we make the same points on the cleft side. You can automatically notice the asymmetry in the nose with a different-shaped nostril. We mark the sub-alarate point as well as the Alar insertion point. Marking the nose this way helps to further clarify what the nasal asymmetry is. In addition, you can look at the shape of the nostrils, and that can help guide you on what you should do during the primary repair for correction. Next we proceed to the Lip-Columellar Junction. We mark the midpoint of the Lip-Columellar Junction, and specifically mark not within the junction itself, but just inferior to it so that our methylene blue doesn't run within the crease. After we mark the central point, we mark the height of the filthral column on the non-cleft side. So this should be the very top of the filthral column, and we should be able to identify where our filthral column is based on this height as marked there. Once we've made this mark, we can extrapolate it to the cleft side and mark the height of the shorter filthral column, or the cleft-sided filthral column. What this will do is then allow us to measure our non-cleft-side filthral column and compare it to our cleft-side filthral column so that we can understand the length difference that we need to make up for in our lateral lip advancement flap. Now that we have the lip-columellar points marked, we're going to go to our arbitrary point within the nostril sill. This is an easy point to mark on the non-cleft side because essentially it's a mark from our alar insertion point to an arbitrary point along the nostril sill. Usually this is a straight line marking, meaning a straight line, if you drew a straight line from the top of our filthral column point to our alar insertion point, this arbitrary point would be along that straight line. It's not angled in any position. The reason we make it easy for us is so that when we extrapolate it to the cleft side, we know that that orientation is straight, and so we can subsequently advance our ala in a predictable position. For instance, if the ala is lower, we can make it straight and then correct for that. If our ala is higher, we can make it slightly lower so that we can correct for that as well. So what this does is allows for you to reposition the nasal ala in a more predictable fashion. But it also sets the length of your nostril sill so that your alar collumellar length are symmetric. Once we have these points marked, we make a little V wedge into the nose, and this will begin our excision of our cleft margin, both on the lateral and the medial lip, and they'll come together to form a straight line. So that's the very top of our incision for our cleft lip repair.

Fischer technique

unilateral cleft lip repair

nasal asymmetry

lip-columellar alignment

V wedge excision