The pars superficialis is located under the skin of the lip and is related to other facial muscles of expression (levator labii superioris, alaeque nasi, and zygomaticus minor), and these retract the upper lip as a group. The pars superficialis consists of an upper and lower bundle.

The deep portion of the pars marginalis muscle is responsible for sphincteric action of the mouth and runs under the vermilion from one modiolus to the other.

The relationship of the lower lateral cartilage to the septum is normal; however, the septum itself is deformed, thereby tilting the base of the nose toward the noncleft side and the tip of the nose toward the cleft side.

The columella is shorter on the cleft side with its footplate displaced and tethered inferiorly.

The base of columella is deviated to the noncleft side.

The medial crus of the alar cartilage is shorter on the cleft side.

The lateral crus of the alar cartilage on the cleft side is longer and, together with the adherent skin, is drawn to an S-shaped fold.

The alar cartilage on the cleft side is displaced in the backward and downward planes.

The nasal tip is displaced and asymmetric, with loss of the defining point on the cleft side.

The dome on the cleft side is obtuse.

The flattened ala results in horizontal orientation of the nostril on the cleft side, and it is usually larger than the opposite side.

The entire nostril is retropositioned.

The base of the ala is displaced posterior and inferiorly where it is tethered to the displaced underlying bone on the cleft side.

The nasal floor is lower or absent on the cleft side.

The caudal septum and anterior nasal spine are deflected to the noncleft vestibule (FIG 2).

Septal deviation of varying degrees leads to posterior nasal obstruction on the cleft side due to the deviation of the septum and, often, the narrowing of the internal nasal valve.

The lower turbinate on the cleft side is hypertrophic.

Nasolabial fistula may be present.

The lesser maxillary segment is hypoplastic and displaced on the cleft side.

The nasal pyramid is asymmetric.

Preoperative passive appliance: Hotz of Zurich introduced the use of an appliance placed preoperatively to control the greater and lesser segments, providing guidance for positioning the segments after lip/nose closure. This is left in place to prevent arch collapse until palatoplasty is performed.

Preoperative active appliance: Nasoalveolar molding (NAM) with active preoperative segmental positioning has become internationally popular and used by many centers and teams. It provides better positioning of the maxillary segments while expanding and positioning the nasal soft tissues. It makes the surgery easier, particularly for the inexperienced surgeon.

Latham’s earlier techniques using active forces were proven to be detrimental to maxillary growth and alignment. Adverse effects on growth need further scientific investigation before the final outcome of all active techniques is known.

In my experience, excellent results can consistently be obtained without adding nasoalveolar molding in the unilateral cleft lip and palate patient. The technique can be labor intensive requiring family compliance and frequent visits to the orthodontist.

With NAM, the molding of the nose must be done carefully to prevent creating a mega nostril through the potential tissue expansion effect, rather than just the desired reshaping of the nostril.

After three decades of cleft surgery, we believe that the skin incision is not very important in and of itself. The final aesthetic and functional outcome is determined by the extended dissection that allows the surgeon to free all the anatomic elements of the lip and nose that were displaced by the cleft in order to achieve complete repositioning of these elements.

The concept of the Salyer lip/nose repair is one of totally freeing all elements of the lip and nose in a plane above the periosteum, so they are floating free above the abnormal skeletal base.¹

The lip and nose elements are then placed in the proper position, visualizing the 3D reconstruction and attempting to make form and function as normal as possible. The aesthetic result always remains foremost.

Repositioning the muscle is one of the keys to achieving a good and stable result, as this provides the foundation and support of the repair, maintaining alar base and nasal tip projection and symmetry. Lining up the muscle is the single most important maneuver in the repair, and it should be vigilantly aligned.

Various techniques today put emphasis on exact preoperative markings, which commits the surgeon. The repair should be fluid, allowing for improvisation and artistry by the surgeon, especially with respect to the nose.

For the first 20 years, I believed that an incision around the alar base was necessary to reshape the ala; however, today, this incision has been entirely eliminated, and we feel it only adds an unnecessary scar.²

The surgeon sits at the head of the table operating upside down with the infant’s head almost in the surgeon’s sterile lap slightly hyperextended to provide complete visualization of the infant’s face.