In the United States, cleft lip with or without PEDIATRIC/CRANIOFACIAL

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1 PEDIATRIC/CRANIOFACIAL Comparison of the Rotation-Advancement and Philtral Ridge Techniques for Unilateral Cleft Lip Repair Jay M. Cline, M.D. Samuel L. Oyer, M.D. Hedyeh Javidnia, M.D. Shaun A. Nguyen, M.D. Jonathan M. Sykes, M.D. Richard M. Kline, M.D. Krishna G. Patel, M.D., Ph.D. Charleston, S.C.; and Sacramento, Calif. cpt Background: The Millard rotation-advancement flap has become the most widely used technique for unilateral cleft lip repair. The philtral ridge repair is a modified straight-line technique that was developed to further optimize the scar associated with the rotation-advancement flap. The purpose of this article is to introduce the philtral ridge repair and objectively compare the outcomes of these two techniques. Methods: Two senior board-certified surgeons, who are active members of their respective craniofacial teams, use different surgical techniques for the unilateral cleft lip: the philtral ridge and rotation-advancement repairs. The authors retrospectively analyzed preoperative and postoperative photographs of consecutive patients who underwent repair performed by each surgeon between 2003 and Using Adobe Photoshop imaging software, facial points on the cleft and noncleft sides were measured, including height and symmetry of Cupid s bow, width and height of the nasal vestibule, height of the vermilion, and alar base position. Ratios of cleft side to noncleft side measurements were calculated to standardize comparisons between patients. In addition, the symmetry of each lip repair was graded subjectively by health care professionals and the general public. Results: There were no differences in preoperative ratios between the two techniques with the exception of a wider cleft nasal vestibule in the rotation-advancement group (p = 0.04). There were no statistically significant differences in postoperative measures or subjective analysis of symmetry between the groups. Conclusion: Both the rotation-advancement and philtral ridge techniques produced outcomes with a high degree of facial symmetry and are excellent options for unilateral cleft lip repair. (Plast. Reconstr. Surg. 134: 1269, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. In the United States, cleft lip with or without cleft palate occurs in seven in 10,000 live births, making it the second most common of all congenital anomalies. 1 The immediate and long-term sequelae of this malformation and its treatment are vast and include potential difficulties with feeding, swallowing, speech and language development, hearing, psychosocial development, and behavioral issues. Murray and colleagues found that children with cleft lip with or without cleft palate tend to spend more time alone, have more From the Department of Otolaryngology Head and Neck Surgery and the Department of Surgery, Medical University of South Carolina; and the Department of Otolaryngology Head and Neck Surgery, University of California Davis Medical Center. Received for publication October 17, 2013; accepted April 23, Copyright 2014 by the American Society of Plastic Surgeons DOI: /PRS negative interactions with peers, and engage in group play less often. These children are at increased risk of being teased in school, having a lower self-image, and struggling with behavioral problems. 2,3 The goal of eliminating, or greatly reducing, these risks has been a motivating factor for the continual refinement of cleft lip surgical techniques through the years. The evolution of cleft lip repair began in the fourth century in the Chin Dynasty in China, where the first reported cleft lip repair took place. Numerous modifications and revisions have been introduced and popularized since that time, ranging from Rose and Thompson s straight line repair, to Malaigne and Mirault s introduction of the lateral advancement flap, to Disclosure: The authors have no financial interest to declare in relation to the content of this article

2 Plastic and Reconstructive Surgery December 2014 LeMesurier and Tennison s quadrangular and triangular flaps that were popular techniques through the 1950s and 1960s. 4 In 1955, Dr. Ralph Millard was using Le Mesurier s technique for unilateral cleft lip repair, but was not satisfied with his results. He noted that three-fourths of Cupid s bow was all on the medial side of the cleft and proposed that keeping this unit intact and rotating it downward would optimize the aesthetic outcomes of the repair. 4 Thus, the rotation-advancement flap, composed of downward rotation of the medial component of the cleft and a lateral lip advancement flap, was introduced out of this surgical philosophy. Since that time, the Millard rotationadvancement technique has gained widespread popularity and has undergone multiple modifications by Mulliken, Noordhoff, and Mohler. Today, 84 percent of surgeons from major craniofacial centers around the country use some form of the modified rotation-advancement technique. 5 There are many components of the rotationadvancement repair that have led to excellent outcomes over the years. One of the advantages of this technique is the placement of the scar within the philtral column, which preserves the philtral dimple and Cupid s bow. 6 In addition, the use of specifically designed flaps provides greater vestibular lining and increases columellar length, which aids in creating symmetry of the Cupid s bow. The tension of the closure lies beneath the alar base and is beneficial in reducing nasal flare and molding of the underlying alveolus. 7 Flexibility is another advantage of the rotation-advancement technique, allowing the surgeon to modify components of the repair throughout its execution. 8 Although the majority of the scar lies within the philtral ridge for the rotation-advancement technique, one of the disadvantages is that the superiormost portion of the scar crosses the philtral dimple at the base of the columella. The philtral ridge repair is a modified straight-line repair developed by a senior surgeon (R.M.K.) in this study. The technique was designed in an attempt to eliminate this scar at the columellar base and instead place the scar entirely within the philtral column. This technique has never been described in the literature. Previous studies have compared outcomes of various cleft lip repair techniques 9 11 ; however, there has never been a direct comparison of outcomes between two senior surgeons (J.M.S. and R.M.K.) with similar years of experience that have adhered to a specific technique. The purpose of our study is to introduce the philtral ridge repair and to compare the objective aesthetic outcomes between the rotation-advancement and the philtral ridge unilateral cleft lip repair. PATIENTS AND METHODS Techniques Rotation-Advancement Flap Repair: Jonathan M. Sykes, M.D. The key technical components of the rotationadvancement repair used in this study are listed below and illustrated in Figure The reference points for the lip repair are marked with ink or methylene blue (Fig. 1, above) before injection of local anesthesia. The points define the borders of the following: A, full-thickness rotation flap; B, full-thickness advancement flap; c, columellar skin flap; l, mucosal lateral flap, and m, mucosal medial flap. 2. The key maneuver rests with proper markings, with the goal of obtaining symmetric lip lengths on the cleft and noncleft sides. The foreshortened cleft lip must be lengthened through a back-cut from points 5 to x. Figure 1, center summarizes the proper measurements. 3. The l, m, and c flaps are raised in the subdermal/submucosal plane. 4. The full-thickness A and B flaps are raised in a preperiosteal plane over the maxilla. Once the flaps are raised, all abnormal insertions of the orbicularis oris onto the alar base and columella are released. The orbicularis oris is dissected free from the underlying skin and mucosa for 2 to 3 mm on the advancement and rotation flaps; however, the separation of the muscle from the skin in the region of the philtrum on the A rotation flap is minimized to maintain the natural dimpling of the philtrum. 5. Primary rhinoplasty is performed by dissecting along the columella and ala with curved iris scissors and freeing the lower lateral cartilage from the overlying skin. 6. A base suture extending between the columella and the alar base is placed deeply to set the width of the nostril on the cleft side. 7. Mucosal l and m flaps are sutured into the gingivobuccal sulcus, or used to close the alveolus or nasal floor on the oral cavity side. The mucosal edges of the A and B flap are reapproximated. 1270

3 Volume 134, Number 6 Rotation-Advancement and Philtral Ridge 8. The orbicularis oris is reapproximated with downward tension on the vermilion suture to ensure the lip length is equal to the noncleft side. If there is still discrepancy in length, the x back-cut is further lengthened to ensure proper downward rotation of the lip. 9. The c flap is inset into the potential space at the columellar base created by the x backcut, or is used to lengthen the columella, or is used to close the nasal floor. The c flap has versatile use and should be inset into the area most needed. The nasal floor skin is reapproximated with superficial sutures. 10. Subdermal sutures are placed along the cleft skin edges and the tension-free epidermis is reapproximated with dermal glue. 11. The nose is further shaped by placing percutaneous sutures with bolsters to correct alar hooding and reset the tip-defining point on the cleft side. Philtral Ridge Repair: Richard M. Kline, M.D. The philtral ridge repair leaves a scar that mimics the appearance and position of a normal philtral ridge from the base of the columella to the peak of the Cupid s bow, while still allowing Fig. 1. (Above) Important reference points for the Millard rotation-advancement technique. 1, center (low point of Cupid s bow); 2, peak of Cupid s bow (noncleft side); 3, peak of Cupid s bow (medial cleft side); 4, alar base (noncleft side); 5, columellar base (noncleft side); 6, commissure (noncleft side); 7, commissure (cleft side); 8, peak of Cupid s bow (lateral cleft side); 9, medial tip of advancement flap (cleft side); 10, alar base (cleft side); x, back-cut point. (Center) Proposed incision for the rotation flap (3 to x) and the advancement flap (8 to 9). Cleft lip and noncleft lip lengths should be equal such that, 8 to 9 = 3 to 5 to x. (Below) Incision design for the full-thickness flaps (A and B) and subdermal/submucosal flaps (l, m, and c). (Illustration by Emma Vogt.) 1271

4 Plastic and Reconstructive Surgery December 2014 complete release and reconstruction of the orbicularis oris muscle. Initially, inadequate lip height is present on the medial side of the cleft (points 2 through 6) (Fig. 2, above). Adequate length of this border has traditionally been obtained by various techniques, all of which require extending the scar into other locations. Adequate length in the described method is achieved by widely curving the medial incision, which is followed by secondary lengthening of the initially short skin segment in the postoperative period, presumably through the action of the reconstructed orbicularis oris. 1. A key component of this technique is the recruitment of potential vertical length for the medial border of the wound by curving the incision between point 2 and point 6 laterally along the outermost border of nonvermilion lip epithelium. 2. The medial aspect of the alar bases is denoted by points 1 and 4. Point x is derived in the following manner (Fig. 2, center). a. An arc of radius 3 to 4 (noncleft alar base to noncleft columellar base) is swung from point 1 (alar base cleft side) to the subjacent lip medially, toward the cleft border. b. Another arc of radius 3 to 8 (noncleft columellar base to noncleft peak of Cupid s bow) is swung from point 5 (last point of full white roll) to the superjacent lip medially, toward the cleft border. Point x is at the intersection of these two arcs. 3. With flap insetting, point x will abut point 2 (base of columella cleft side), thus ensuring that (1) the alar base to columellar separation on the cleft side will be symmetrical with the separation on the noncleft side, and (2) lip height symmetry with the noncleft side will be present at the lateral border of the wound before closure (Fig. 2, below). Measurement 2 to 6 (straight line from the columellar base to the peak of Cupid's bow), which actually defines lip height at the time of closure, is initially quite short. We have found, however, that in time it lengthens (as documented in the Results section), and eventually the curved vertical scar straightens and lengthens to maximize the vertical lip height. The precise mechanism of this lengthening is not clear, but we propose that the absence of a straight epithelial scar between points 2 and 6 allows this tissue to be effectively lengthened by the reconstructed orbicularis muscle (i.e., if a straight scar rather than a curved scar connected points 2 and 6, a similar degree of lengthening as that observed would not occur). 4. Primary rhinoplasty is not typically used by the primary surgeon because of concerns for scar formation that may increase the difficulty of future rhinoplasty procedures. However, a tip rhinoplasty could easily be performed with this technique at the time of lip repair. Study A retrospective review was performed for the charts and photographs of consecutive patients who underwent unilateral cleft lip repair performed by each surgeon between 2003 and Patients were excluded if there were no documented follow-ups or postoperative photographs greater than 1 year after surgery. Evaluation at a minimum follow-up of 1 year was chosen to allow time for healing and scar maturation. Specific information was recorded for each patient, including age at the time of repair, length of follow-up, side of cleft, incomplete versus complete cleft, and the use of nipple-alveolar molding preoperatively. Using Adobe Photoshop imaging software (Adobe Systems, Inc., San Jose, Calif.), various measurements were taken of preoperative and postoperative photographs for each patient to evaluate specific areas of interest, including symmetry of the Cupid s bow, height and width of the nasal vestibule, height of the alar base, width of the vermilion, and distance from the Cupid s peak to the oral commissure. To account for differences in resolution, size, and angle of each photograph, the noncleft side of each patient was used as the control for evaluation of the measurements. In addition, using the software program, an intercanthal line was marked on each photograph and then the photograph was rotated until this line was in a horizontal plane. Measuring from this line to specific points of interest created a standardized method of assessment. Frontal view photographs were assessed preoperatively and postoperatively for all patients, and base view photographs were also assessed. For the frontal view evaluation, the preoperative measurements included the following: alar base to intercanthal line; mid-ala to intercanthal line; Cupid s peak to subnasale; subnasale to alar base; and distance from Cupid s peak, on the lateral edge of the cleft, to subnasale (Fig. 3). The postoperative measurements included alar 1272

5 Volume 134, Number 6 Rotation-Advancement and Philtral Ridge Fig. 2. (Above) Important reference points for the philtral ridge technique. 1, alar base (cleft side); 2, apex of philtral column (medial cleft side); 3, apex of philtral column (noncleft side); 4, alar base (noncleft side); 5, peak of Cupid s bow (lateral cleft side); 6, peak of Cupid s bow (medial cleft side); 7, center (low point of Cupid s bow); 8, peak of Cupid s bow (noncleft side); x, intersection of arcs swung from points 1 and 5. (Center) Segment 1 to X is equivalent to segment 3 to 4. Segment 5 to X is equivalent to segment 3 to 8. Arcs are drawn from these measurements to determine X, which forms the corner of the lip incision to be inserted into the base of the columella, point 2. (Below) Proposed incisions and advancement closure for philtral ridge repair. (Illustration by Emma Vogt.) base to intercanthal line, mid-ala to intercanthal line, Cupid s peak to subnasale, subnasale to alar base, Cupid s peak to intercanthal line, width of vermilion, and Cupid s peak to oral commissure (Fig. 4). For the base view evaluation, the preoperative and postoperative measurements included the following: base of columella to medial edge of alar base, base of columella to lateral edge of alar base, mid columella to medial edge of ala, and mid columella to lateral edge of ala (Fig. 5). All measurements were taken on the cleft and noncleft sides and were performed by two study members independently. The measurements obtained by the study members were averaged to create a mean, which was used to calculate ratios to compare the cleft side to the noncleft side of each patient. These ratios were used to compare symmetry between patients. The measurements 1273

6 Plastic and Reconstructive Surgery December 2014 Fig. 3. Preoperative frontal view measurements. 1, noncleft alar base to intercanthal line; 2, noncleft mid ala to intercanthal line; 3, cleft mid ala to intercanthal line; 4, cleft alar base to intercanthal line; 5, noncleft subnasale to alar base; 6, cleft subnasale to alar base; 7, noncleft Cupid s peak to subnasale; 8, lateral edge of cleft Cupid s peak to subnasale; 9, medial edge of cleft Cupid s peak to subnasale. Fig. 4. Postoperative frontal view measurements. 1, cleft alar base to intercanthal line; 2, cleft mid ala to intercanthal line; 3, noncleft mid ala to intercanthal line; 4, noncleft alar base to intercanthal line; 5, cleft subnasale to alar base; 6, noncleft subnasale to alar base; 7, cleft Cupid s peak to subnasale; 8, noncleft Cupid s peak to subnasale; 9, cleft Cupid s peak to oral commissure; 10, cleft width of vermilion height; 11, noncleft width of vermilion height; 12, noncleft Cupid s peak to oral commissure. between study members were assessed for interrater reliability. The photographs were assessed subjectively by a group of 13 individuals composed of surgeons Fig. 5. Base view measurements. 1, noncleft columellar base to inner ala; 2, noncleft columellar base to outer ala; 3, noncleft midcolumella to inner ala; 4, noncleft mid columella to outer ala; 5, cleft columellar base to inner ala; 6, cleft columellar base to outer ala; 7, cleft mid columella to inner ala; 8, cleft mid columella to outer ala. and the general public. Each member of the surveying group privately rated the photographs in an electronic survey format. Photographs were arranged in a random order. The cleft lip repairs were given a numeric rating based on the symmetry of the repair (i.e., 1 = poor symmetry, 2 = fair symmetry, 3 = good symmetry, 4 = above average symmetry, and 5 = excellent symmetry). The mean rating for each repair type was calculated and evaluated for statistical significance. Institutional review board approval was obtained from both academic institutions involved in the study. Statistical Analysis All data analyses were performed with Med- Calc (MedCalc Software, Ostend, Belgium), Sigma Stat 3.5 (Systat Software, Inc., Chicago, Ill), and IBM SPSS Version 22.0 (IBM Corp., Armonk, N.Y.). Demographic variables such as sex, age at time of repair, side of cleft, and use of preoperative nasoalveolar molding are summarized by means of summary statistics. Simple descriptive statistics such as frequency, mean, median, standard deviation, minimum, and maximum were calculated for all outcome variables. All continuous variables were assessed for normality using the Kolmogorov-Smirnov test. For comparison between the two groups with continuous variables, a t test (normal distribution) or a Mann- Whitney/Wilcoxon rank sum test (not normal distribution) was used to compare the two groups. 1274

7 Volume 134, Number 6 Rotation-Advancement and Philtral Ridge Table 1. Patient Characteristics of the Philtral Ridge and Rotation-Advancement Groups Characteristics PR RA Male-to-female ratio 9:7 9:1 Age at repair, mo Complete-to-incomplete ratio 8:8 7:3 Right-to-left ratio 9:7 5:5 Postoperative evaluation, mo Nasoalveolar molding 0/16 3/10 PR, philtral ridge; RA, rotation-advancement. Kappa analysis was used to determine interrater agreement among the investigators. A finding of p < 0.05 was considered indicative of a statistically significant difference for all tests. RESULTS Those who met the inclusion criteria were 10 and 16 children who underwent rotation-advancement repair and philtral ridge repair, respectively. Of those who had a rotation-advancement repair, seven (70 percent) had a complete cleft and three (30 percent) had an incomplete cleft. Among the children with a philtral ridge repair, eight (50 percent) had a complete cleft and eight (50 percent) had an incomplete cleft. The mean age at the time of cleft lip repair was 4 months for the rotationadvancement group and 3 months for the philtral ridge group. Postoperative photographs were taken an average of 47 months (range, 12 to 120 months) after surgery for the rotation-advancement group and 58 months (range, 13 to 129 months) in the philtral ridge group. Nasoalveolar molding was used preoperatively in three patients (30 percent) in the rotation-advancement group to aid with lip approximation and no patients in the philtral ridge group (Table 1). The ratios of cleft-side measurements to noncleft-side measurements were analyzed for each group. The mean ratio for each specific point of interest was calculated and a t test was used to compare the groups at each specific point (Tables 2 and 3). There was a statistically significant difference in the preoperative ratio of the width of the nasal vestibule on the cleft side to the noncleft side between the two groups, with a slightly higher ratio in the rotation-advancement group. However, there was not a statistically significant difference in the same measurement postoperatively. All other preoperative and postoperative measurements showed no statistically significant Table 2. Mean Ratio of the Cleft Side to the Noncleft Side of Specific Preoperative Points of Interest for Each Group* Preoperative Measurements Figure Points PR RA p Alar base height Fig. 3 4: Mid alar height Fig. 3 3: Cleft nostril width: noncleft nostril width Fig. 3 6: Subnasale to medial cleft peak: subnasale to normal peak Fig. 3 9: Subnasale to lateral cleft peak: subnasale to normal peak Fig. 3 8: Width mid-inner ala Fig. 5 7: Width mid-outer ala Fig. 5 8: Width base-inner ala Fig. 5 5: Width base-outer ala Fig. 5 6: PR, philtral ridge; RA, rotation-advancement. *See Figures 3 and 5 for diagrams of measurements associated with each point. Statistical significance between groups (p < 0.05). Table 3. Mean Ratio of Specific Postoperative Points of Interest for Each Group* Postoperative Measurements Figure Points PR RA p Alar base height Fig. 4 1: Mid alar height Fig. 4 2: Cleft nostril width: noncleft nostril width Fig. 4 5: Cupid s peak to subnasale Fig. 4 7: Cupid s peak to oral commissure Fig. 4 9: Ratio of vermilion width Fig. 4 10: Width mid-inner ala Fig. 5 7: Width mid-outer ala Fig. 5 8: Width base-inner ala Fig. 5 5: Width base-outer ala Fig. 5 6: PR, philtral ridge; RA, rotation-advancement. *See Figures 4 and 5 for diagrams of measurements associated with each point. Statistical significance between groups indicated by p <

8 Plastic and Reconstructive Surgery December 2014 difference, including other measurements of nasal vestibular width. The postoperative ratios of alar base height (Fig. 4, 1 and 4) and vestibular width (Fig. 5, 4 and 8) closely approximated the value 1 in both groups, thus indicating that these measurements were the points that most closely achieved symmetry with the noncleft side. The postoperative vestibular width at the base was the most asymmetric between the cleft and noncleft sides as indicated by the ratio margin farthest from the value 1 in both groups (Fig. 5, 1 and 5). Figure 6 demonstrates examples of preoperative and postoperative photographs in each group. The subjective analysis revealed similar ratings of symmetry between the two repair types. The philtral ridge repair had a mean rating of 3.3 and the rotation-advancement repair had a mean rating of 3.4. There was no statistically significant difference between the two groups (p < 0.54). The kappa analysis revealed very good or good interrater agreement for the measurements. DISCUSSION The rotation-advancement repair has historically produced excellent results and is currently the most common technique used for unilateral cleft lip repair. 4,12 The philtral ridge repair is a modified straight-line closure that has had anecdotal success with a senior author, but it has never been formally described or evaluated. Comparing these two repair types provides further evidence into the advantages and disadvantages of the rotation-advancement repair and offers insight into the potential value and utility of the philtral ridge repair. The ratios for the measurements to the preoperative points of interest were very similar between the two groups. This indicates a comparable degree of cleft severity between each group. Likewise, the number of complete clefts was also similar in each group (eight of 16 and seven of 10). There were four measurements taken for each base view photograph in evaluation of vestibular width. One of these measurements (midcolumella to outer ala) showed a significant difference between the two groups. However, the remaining three ratios were not significantly different, making the possibility of a true difference in nasal deformity less likely. The evaluation of postoperative photographs showed no statistically significant differences in the ratios of the measurements, indicating very similar objective outcomes with each repair type. More importantly, many of the postoperative cleft side measurements, such as height of the alar base, height of the alar rim dome, and height of Cupid s peak or lip height, were nearly identical to the noncleft side, demonstrating excellent facial symmetry in both groups. Height of vermilion and width at the base of the vestibule had the greatest difference in cleft and noncleft measurements in both groups. Based on these findings, there does not appear to be an advantage of one repair type compared with the other. Numerous studies have examined the outcomes of the rotation-advancement repair with various other repairs. Reddy et al. subjectively evaluated the white roll, vermilion border, scar, Cupid s bow, lip length, nostril symmetry, and appearance of alar dome and base in patients who had undergone repair with a rotation-advancement repair, Pfeifer wave line incision, and Afroze incision. They found that all three repair types have similar results for the alar dome and base but that the Afroze incision gave superior results for the other areas of interest. 13 Reddy et al. also used soft-tissue measurements to objectively compare the rotation-advancement repair to the Pfeifer wavy line incision and found the rotation-advancement repair to have better vermilion match and the Pfeifer method to have better lip length. 14 Lazarus et al. objectively and subjectively assessed five different repair types (Millard rotationadvancement, Davies Z-plasty, modified Z-plasty, Tennison-Randall triangular flap, and Nakajima- Yoshimura straight line) and found similar results for all, with the exception of increased number of shortened lips with the rotation-advancement repair. 15 The rotation-advancement repair had superior outcomes compared with the Noordhoff triangular flap repair in a study described by Jan et al. 16 To date, there has not been a study that compares two senior, experienced surgeons and the outcomes of their respective chosen types of repair. This type of evaluation decreases the variable of surgical inexperience by providing examples of the optimal outcomes of a given technical repair. This aids in clearer delineation of the strengths and weaknesses of a repair type. A recent survey shows that 86 percent of surgeons do not change their technique based on preoperative cleft characteristics. 5 The objective comparison of the rotation-advancement and philtral ridge repairs showed no significant differences in the clinical points of interest between the two groups. This further supports the concept that the best outcomes may result from selecting a specific technique and perfecting this over many years. Limitations to the study include the small and unequal sample size of each group. This objective analysis did not account for subjective points of interest such as scar camouflage and deficiency at the nasal sill. 1276

9 Volume 134, Number 6 Rotation-Advancement and Philtral Ridge Fig. 6. Preoperative and postoperative photographs. (Above) Preoperative philtral ridge; (second row) postoperative philtral ridge; (third row) preoperative rotation-advancement; (below) postoperative rotation-advancement. 1277

10 Plastic and Reconstructive Surgery December 2014 The philtral ridge repair is a novel technique for repair of the unilateral cleft lip that has not been previously described. It has objective outcomes comparable to those of the rotation-advancement repair, which has produced high-quality outcomes for many years. Both techniques are excellent options for repair of complete and incomplete unilateral cleft lips. cpt Jay M. Cline, M.D. Medical University of South Carolina 135 Rutledge Avenue Charleston, S.C clin@musc.edu CODING PERSPECTIVE This information provided by Dr. Raymond Janevicius is intended to provide coding guidance Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral Code is global and includes all components of the soft tissue unilateral cleft lip repair. All flaps elevated in the course of the cleft lip repair are included in code Reporting code (adjacent tissue transfer, lip) in addition to code would be unbundling. Code is reported for the repair of partial as well as complete cleft lips. This code is used for all methods of unilateral cleft lip repair. Thus, it is reported for both the rotation-advancement and philtral ridge techniques. The code descriptor includes the term nasal deformity, which sometimes causes confusion. In the course of cleft lip repair, the nostril is narrowed and the nostril sill is reconstructed. It is the soft-tissue nasal deformity correction that is included in code Surgery on the nasal cartilage is not included in code and is reported with codes or PATIENT CONSENT Parents or guardians provided written consent for the use of patients images. references 1. Tanaka SA, Mahabir RC, Jupiter DC, Menezes JM. Updating the epidemiology of cleft lip with or without cleft palate. Plast Reconstr Surg. 2012;129:511e 518e. 2. Zeytinoglu S, Davey MP. It s a privilege to smile: Impact of cleft lip palate on families. Fam Syst Health 2012;30: Murray L, Arteche A, Bingley C, et al.; Cleft Lip and Palate Study Team. The effect of cleft lip on socio-emotional functioning in school-aged children. J Child Psychol Psychiatry 2010;51: Stal S, Brown RH, Higuera S, et al. Fifty years of the Millard rotation-advancement: Looking back and moving forward. Plast Reconstr Surg. 2009;123: Sitzman TJ, Girotto JA, Marcus JR. Current surgical practices in cleft care: Unilateral cleft lip repair. Plast Reconstr Surg. 2008;121:261e 270e. 6. Sykes JM, Tollefson TT. Management of the cleft lip deformity. Facial Plast Surg Clin North Am. 2005;13: Burt JD, Byrd HS. Cleft lip: Unilateral primary deformities. Plast Reconstr Surg. 2000;105: ; quiz Sykes JM. Management of the cleft lip deformity. Facial Plast Surg Clin North Am. 2001;9: Zaleckas L, Linkevičienė L, Olekas J, Kutra N. The comparison of different surgical techniques used for repair of complete unilateral cleft lip. Medicina (Kaunas) 2011;47: Horswell BB, Pospisil OA. Nasal symmetry after primary cleft lip repair: Comparison between Delaire cheilorhinoplasty and modified rotation-advancement. J Oral Maxillofac Surg. 1995;53: ; discussion Amaratunga NA. A comparison of Millard s and LeMesurier s methods of repair of the complete unilateral cleft lip using a new symmetry index. J Oral Maxillofac Surg. 1988;46: Mulliken JB, Martínez-Pérez D. The principle of rotation advancement for repair of unilateral complete cleft lip and nasal deformity: Technical variations and analysis of results. Plast Reconstr Surg. 1999;104: Reddy SG, Reddy RR, Bronkhorst EM, Prasad R, Kuijpers Jagtman AM, Bergé S. Comparison of three incisions to repair complete unilateral cleft lip. Plast Reconstr Surg. 2010;125: Reddy GS, Webb RM, Reddy RR, Reddy LV, Thomas P, Markus AF. Choice of incision for primary repair of unilateral complete cleft lip: A comparative study of outcomes in 796 patients. Plast Reconstr Surg. 2008;121: Lazarus DD, Hudson DA, van Zyl JE, Fleming AN, Fernandes D. Repair of unilateral cleft lip: A comparison of five techniques. Ann Plast Surg. 1998;41: Jan SN, Khan FA, Ansari HH, Hanif A, Bajwa A. Reducing the vermilion notch in primary lip repairs: Z-plasty versus the Noordhoff triangular flap. J Coll Physicians Surg Pak. 2012;22: