ORIGINAL ARTICLE

Unilateral Microform Cleft Lip Repair: Application

of Muscle Tension Line Group Theory
Ningbei Yin, MD, Tao Song, MD, Jiajun Wu, MD, Bo Chen, MD, Hengyuan Ma, MD, Zhenmin Zhao, MD,
Yongqian Wang, MD, Haidong Li, MD, and Di Wu, MD
Background: In microform cleft lip repair, reconstructing the elaborate
structures is difficult. We describe a new technique of unilateral microform cleft lip repair that is based on the muscle tension line group theory.
Methods: According to the shape of Cupid bow, a different small incision is used without creating an obvious cutaneous scar. First, the
nasolabial muscle around the nasal floor (the first auxiliary tension
line group) is reconstructed, and then the orbicularis oris muscle around
the philtrum (the second auxiliary tension line group) is reconstructed
based on the muscle tension line group theory.
Results: From June 2006 to June 2012, the technique was used in 263
unilateral microform cleft lip repairs. For 18 months, 212 patients were
followed up. The appearance of the nasal alar, nasal sill, philtrum, and
Cupid bow peak improved. Most patients had a satisfactory appearance.
Conclusions: Based on the muscle tension line group theory, using
this technique offers the ability to adduct the nasal alar effectively to
form a good nasal sill and philtrum.
Key Words: Lip muscle, nasal muscle, nasolabial muscle complex,
muscle tension line, microform cleft lip
(J Craniofac Surg 2015;26: 343346)

linical manifestations of microform cleft lip include disruption of

the Cupid bow, elevated Cupid bow peak, deformity of the philtrum, deficiency of the orbicularis oris muscle, and nasal deformity.
What Is This Box?
A QR Code is a matrix barcode readable by
QR scanners, mobile phones with cameras,
and smartphones. The QR Code links to
the online version of the article.

From the Center for Cleft Lip and Palate Treatment, Plastic Surgery Hospital,
Chinese Academy of Medical Sciences and Peking Union Medical College,
Beijing, Peoples Republic of China.
Received October 21, 2014.
Accepted for publication December 1, 2014.
Address correspondence and reprint requests to Ningbei Yin, MD, Center for
Cleft Lip and Palate Treatment, Plastic and Surgery Hospital, Chinese
Academy of Medical Science, Peking Union Medical College, No. 33,
Ba-Da-Chu Rd, Shi Jing Shan District, Beijing 100144, Peoples Republic
of China; E-mail: ningbeiyin@126.com
This work was supported by the Capital Medical Development Fund of China
(grant 20093012).
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journals Web site (www.jcraniofacialsurgery.com).
Copyright 2015 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000001460

Patients or their parents usually have a high expectation because the

deformities look mild.
Traditionally, an incision was made on the upper lip and sometimes even on the nasal floor. An obvious scar was left.1 Recently, some
surgeons reported making a small incision on the mucosa to repair unilateral microform cleft lip.2,3 However, the operative field was insufficient. With this technique, it is difficult to suture the muscle accurately
and to reconstruct the elaborate structures, such as the position of the nasal alar, nasal sill, and philtral column. Reconstructing these structures effectively poses a dilemma when repairing unilateral microform cleft lip.
Since 2006, we have studied the anatomy of the nasolabial
muscle and have performed microcomputed tomography scanning
of nasolabial tissues.4 The results are shown. The pars peripheralis
has a flat-fan shape and is located in the deep level of the upper lip.
It originates from one side of the modiolus and diffuses outward like
a fan. We found that it was divided into 3 different branches with
different directions (A1, A2, A3). A1 terminated at the tissue below
the ipsilateral anterior nasal spine, continued with the depressor septi
muscle, and was relevant to the lip movements. A2 crossed the midline
and continued with the alar part of nasalis, which originated from the
lateral crus of alar cartilage at the contralateral nasal bottom. A2 is related to the shape of the nasal bottom and nasal alar. The fibers of A3
went across the same group of muscle fibers from the opposite side in
the midline. Most of the fibers terminated at the skin of the contralateral philtrum ridge region. Moreover, some of the muscle fibers terminated at the lateral skin of the contralateral philtrum ridge region,
which is relevant to the shape of the philtrum. The connected muscle
fibers in bundles are called the tension line. Because of the involvement of the levator labii superioris alaeque nasi, the tension lines in
decussation are called the tension line group. We divide the orbicularis
oris muscle tension of the upper lip into 3 tension line groups: main
tension line group, first auxiliary tension line group, and second auxiliary tension line group (Fig. 1). The shape of the nose and lip relies
on the tension line groups. We believe that the microform cleft lip deformity is related to the first auxiliary tension line group and second
auxiliary tension line group.
It is commonly known that it is nearly impossible to repair the abnormal orbicularis oris muscle anatomy to the same appearance as a normal human, but it is possible to restore the muscle tension line to the
normal level. To repair the deformities of the unilateral microform cleft
lip, including the philtrum, depressed nasal floor, deformity of the nasal
alar, discontinuity of the orbicularis oris muscle, misplacement of the
Cupid bow, and the notch of vermillion, without obvious skin incisions,
we used the concept of the tension line groups and applied a new method
for reconstructing the tension line. The unilateral microform cleft lip is
repaired through small incisions on the Cupid bow and mucosa to reconstruct the nasolabial muscle. The results have been favorable.

PATIENTS AND METHODS

From June 2006 to June 2012, the technique was used in 263
unilateral microform cleft lip repairs (158 male and 105 female). The
patients ages ranged from 3 months to 36 years. The average age

The Journal of Craniofacial Surgery Volume 26, Number 2, March 2015

Copyright 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

343

The Journal of Craniofacial Surgery Volume 26, Number 2, March 2015

Yin et al

FIGURE 1. The orbicularis oris muscle tension of the upper lip is divided into
3 tension line groups. Purple line: main tension line group; red line: first auxiliary
tension line group; green line: second auxiliary tension line group.

was 37.8 months. There were 148 patients on the left side, and 117
patients on the right side. The surgical technique is described as follows:

Design of Incision
The incision was designed according to the shape of the Cupid
bow, vermillion, and tubercle. If the Cupid bow was jagged, Z-plasty
was used to restore the continuity of Cupid bow and descend the ipsilateral Cupid bow peak. If some skin was inserted into the vermillion,
we performed a fusiform excision of the extra skin to restore the continuity of the Cupid bow. If the ipsilateral Cupid bow peak was much
higher than the unaffected Cupid bow peak, a small triangle skin flap
was inserted medially, or a curved incision was made to restore the
continuity of the Cupid bow and descend the ipsilateral Cupid bow
peak. Simultaneously, a mucosal incision was made to expose the
orbicularis oris muscle. The skin of the upper lip was intact.

Reconstruction of the Nasolabial Muscle Around

the Nasal Floor (Reconstruction of the First
Auxiliary Tension Line Group
The orbicularis oris muscle was dissected from the mucosa and
skin. The abnormal muscular attachments from the inferior and lateral
margins of the piriform aperture and the anterior segment of the maxilla were released. According to the direction of the muscle fiber, the
lateral muscle was divided into 2 parts: the alar part of the nasalis flap
and orbicularis oris muscle flap. The medial orbicularis oris muscle
flap at the root of the columella was elevated and sutured with the lateral alar part of the nasalis flap. The lateral orbicularis oris muscle flap
covered the 2 muscle flaps mentioned above and was fixed at the anterior nasal spine. We believe that the alar part of the nasalis originates
from the lateral part of the lateral crus of alar cartilage, runs along the
edge of the piriform aperture from the deep to the superficial layer,

FIGURE 2. Reconstruction of the first auxiliary tension line group. A, A medial

orbicularis oris muscle flap at the root of the columella is elevated and sutured with
the lateral alar part of the nasalis flap. B, Tension line L2 is reconstructed.
C, The lateral orbicularis oris muscle flap covers the 2 muscle flaps mentioned above
and is fixed at the anterior nasal spine. D, The first auxiliary tension line group is
reconstructed.

344

continues to the secondary branch of the pars peripheralis (A2) from

the contralateral modiolus at the nasal floor, and makes the strength
transfer backward, called tension line L2. A1 originates from the
modiolus, terminates at the tissue below the ipsilateral anterior nasal
spine, and continues with the depressor septi muscle, called tension
line L1. These 2 tension lines from different directions and the alar
cartilage are connected into a whole ring structure and form a crisscross structure at the nasal floor, called the first auxiliary tension line
group. Thus, this step is called the reconstruction of the first auxiliary
tension line group (Fig. 2).

Reconstruction of the Orbicularis Oris Muscle

Around the Philtrum (Reconstruction of the
Second Auxiliary Tension Line Group
The medial orbicularis oris muscle was sutured with the deep
layer of the lateral orbicularis oris muscle. The superficial layer of
the lateral orbicularis oris muscle was sutured to the deep dermis of
the philtrum to form a philtral dimple and philtral ridge. We believe
that the third branch of pars peripheralis (A3) originates from one side
of the modiolus, runs upward and medially, crosses the midline, and
inserts into the skin of the philtrum and its lateral areas. The first
branch of the levator labii superioris alaeque nasi (B1) enters the upper lip from the lateral and top directions, moves inward, and inserts
into the dermis inside of the ipsilateral philtrum ridge. In the axial
plane of the upper lip, the directions of A3 and B1 cross each other,
and their muscle fibers interact with each other, which is known as
the second auxiliary tension line group (Fig. 3). Thus, this step is called
reconstruction of the second auxiliary tension line group (see Supplemental Digital Content, Video, http://links.lww.com/SCS/A104, which
demonstrates the complete procedure). We repaired the deformity of
the nasal alar when patients were older than 6 years.

Assessment
Two plastic surgeons, who were not part of our team, assessed
the nasal floor fullness, abduction of the nasal alar, and shape of the
nasal sill and philtrum using a 3-point visual analog scale. If the shape
of the nasal floor, nasal alar, nasal sill, and philtrum were similar to
normal, the result was rated as 3; if the shape was improved, but not
as good as normal, it was rated as 2; if the shape was not improved,
it was rated as 1.

RESULTS
All the patients healed well. After the surgery, the fullness of
the nasal floor was attained; the nasal alar was symmetrical; the

FIGURE 3. Reconstruction of the secondary auxiliary tension line group. A,

The medial orbicularis oris muscle is sutured with the deep layer of the lateral
orbicularis oris muscle. The superficial layer of the lateral orbicularis oris muscle
is sutured to the deep dermis of the philtrum. B, The philtral ridge is
reconstructed using mechanical traction. C, The second auxiliary tension line
group is reconstructed.

2015 Mutaz B. Habal, MD

Copyright 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery Volume 26, Number 2, March 2015

Application of Muscle Tension Line Group Theory

TABLE 1. Long-term Results of Microform Cleft Lip Repair

Assessment
Fullness of nasal floor
Nasal sill
Abduction of nasal alar
Height of cleft-side philtral ridge

132
122
139
175

74
73
64
33

6
17
9
4

deviation of the columella was improved; the nasal sill was similar
to normal; the tubercle was obvious; and the philtrum was not obviously twisted.
For 18 months, 212 patients were followed up. None of the
patients had obvious scars. In 37 patients, they had a thicker vermillion than the unaffected side. Secondary revision was performed on
33 patients. In 27 patients, the lateral lips were bulging, and in 25 of
those, the lips improved obviously after 18 months. The other 2 patients
refused further treatment. After 18 months, 16 patients had philtrums
that became shallow. The appearance of the nasal alar, nasal sill,
philtrum, and Cupid bow peak improved (Table 1) (Figs. 46). Most
patients had a satisfactory appearance.

DISCUSSION
With years of clinical experience, methods of repairing microform cleft lip have greatly improved. The high expectations of patients
have driven the need for a more minimally invasive technique.
Mulliken5 designed a double unilimb Z-plasty to correct the
vertical asymmetry and notch of vermillion while limiting the scar
to the lower one-half of the lip. When the distance from the cleft side
peak of the Cupid bow to the midline is shorter than on that from the
noncleft side, using a conventional cheiloplasty approach results in an
asymmetrical Cupid bow with an unnatural philtrum that is difficult
to correct. Koh et al6 modified the design of the cleft-side Cupid
bow to avoid causing this secondary deformity. Oyama et al7 modified
Mullikens method to maintain the natural curve and obtained a symmetrical and natural-looking Cupid bow. Oyama et al7 emphasized the
importance of preserving the remaining normal structure, particularly
the curve of the white roll on the lateral lip, and suggested that the
peak of the curve should be defined as the Cupid bow peak of the cleft
side. In fact, the Cupid bow in microform cleft lip was various. Only 1

FIGURE 4. Typical case: A 5-month-old boy with right microform cleft lip. 1A, 1B,
1C, The clinical manifestation included asymmetrical nostril, right depressed nasal
floor and nasal alar, a notch of vermillion, and a jagged Cupid bow. The right
Cupid bow peak was 1.5 mm higher than the left peak. 2A, 2B, 2C: Six months
after surgery, the bilateral nasal alar was symmetrical; the right nasal floor was
slightly higher; the right upper lip was bulging, and the philtral dimple was very
depressed. The philtral ridge was obvious. The right vermillion was thick. 3A, 3B,
3C: Two years later, the bilateral nasal alar, nasal floor, and upper lip were
symmetrical. The philtrum was natural. The right vermillion was a little thick.

FIGURE 5. Typical case: A 3-year-old girl with left microform cleft lip. 1A, 1B, 1C:
The clinical manifestation included asymmetrical nostril, left depressed nasal floor
and nasal alar, and a jagged Cupid bow. 2A, 2B, 2C: Twelve months after surgery ,
the philtral dimple was very depressed. The philtral ridge was obvious. The right
vermillion was thick.

method was difficult to meet the clinical requirements. A different

method should be used based on the different appearances of the
Cupid bow. The surgeon should use caution when making an incision
in the upper lip. When we started to repair microform cleft lip, we
chose small incision only to reduce scar of lip. Now, we believe small
incision is an inevitable choice, if the second auxiliary tension line
group is reconstructed. When the abnormal skin of microform cleft
lip is removed, the upper lip is too tight to form philtral ridge.
Some authors reported that the nasal floor of the cleft lip is
repaired by a skin flap or mucosa flap.8 When the nasal floor is reconstructed with a flap, which is only a layer of skin or mucous membrane
cover, and its bottom is hollow, the postoperative result may be stable,
but the deformity easily relapses.
We believe that the alar part of the nasalis originates from the
lateral part of the lateral crus of the alar cartilage, runs along the edge
of the piriform aperture from the deep to the superficial layer, continues to the secondary branch of the pars peripheralis (A2) from
the contralateral modiolus at the nasal floor, and makes the strength
transfer backward, called tension line L2. A1 originates from the
modiolus, terminates at the tissue below the ipsilateral anterior nasal
spine, and continues with the depressor septi muscle, called tension
line L1. These 2 tension lines from different directions in combination
with the alar cartilage are connected in a whole ring structure and form
a crisscross structure at the nasal floor, which is called the first auxiliary tension line group.
Using this technique, we advocate restoring the continuity of
the nasolabial muscle complex. A medial orbicularis oris muscle flap
at the root of columella is elevated and sutured with the lateral alar part
of the nasalis flap. The lateral orbicularis oris muscle flap covers the

FIGURE 6. Typical case: A 13-month-old girl with left microform cleft lip. 1A, 1B,
1C: The clinical manifestation included asymmetrical nostril, left depressed nasal
floor and nasal alar, and a notch of vermillion. 2A, 2B, 2C: Eighteen months after
surgery, the philtral dimple was depressed. The philtral ridge was obvious. The
right vermillion was a little thick.

2015 Mutaz B. Habal, MD

Copyright 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

345

Yin et al

The Journal of Craniofacial Surgery Volume 26, Number 2, March 2015

2 muscle flaps mentioned above and is fixed at the anterior nasal

spine. The technique simulates the physical structure to adduct the nasal alar, elevate the nasal floor, form a nasal sill, and correct the deviation of the columella. The medial orbicularis oris musclelateral alar
part of the nasalis structure supports the skin-like bridge-building with
the tension to simulate the nasal sill. Fixation of the lateral orbicularis
oris muscle flap is involved in the formation of the nasal sill and prevents the lateral vermillion from ptosis. A stable nasal sill can be maintained. The balanced muscle strength can restore the dislocated nasal
septum to the middle position. Because the patients received the full
nasal floor, raised nasal sill, columella in the middle, and arched nose,
they were often very satisfied with the operations results.
The philtrum should be reconstructed using the orbicularis oris
muscle. To repair microform cleft lip, Desrosiers et al9 combined the
following 3 techniques: the Mulliken microform cleft lip repair with
no cutaneous scar, the Furlow complete cleft lip repair with interdigitating muscle, and the Cutting cleft nose repair. With Desrosiers and
colleagues9 technique, the orbicularis oris muscle was divided into
some bundles and sutured together to form the philtral ridge. Cho and
Baik10 split the medial and lateral muscle flaps into 2 leaves. The 2
leaves of each muscle flap were sutured together to create a vertical interdigitation to form the philtral ridge. In Kim and colleagues11 report,
the abnormally inserted orbicularis muscle was freed and realigned in a
normal horizontal orientation. The muscle was vertically incised and
repaired with vertical mattress sutures, spreading out the muscle to increase the thickness of the philtral ridge. The philtral ridge was accentuated by deepening the dimple with a dermal suture at the midline.
We believe that the third branch of the pars peripheralis (A3)
originates from 1 side of the modiolus, runs upward and medially,
crosses the midline and inserts into the skin of the philtrum and its lateral areas. The first branch of the levator labii superioris alaeque nasi
(B1) enters the upper lip from the lateral and top directions, moves inward, and inserts into the dermis inside of the ipsilateral philtrum
ridge. In the axial plane of the upper lip, the directions of A3 and
B1 cross each other, and their muscle fibers interact with each other.
It is known as the second auxiliary tension line group. Because the
strength of the muscle fibers of B1 and A3 pulls the skin on both
sides of the philtral ridge in opposite directions, the bevels perpendicular to the direction of the muscle fibers on both sides are formed,
which constitute the contour of the philtral ridge. With our technique,
the orbicularis oris muscle on the lateral side of the cleft is divided into
2 layers. The muscle fibers of the deep layer are sutured obliquely to
the muscle fibers on the medial side of the cleft to simulate the muscle
strength of A3. The muscle fibers of the superficial layer are sutured
obliquely to subcutaneous tissue on the medial side of the cleft to simulate the strength of B1. Then, the orbicularis oris muscle on both sides
of the philtral ridge forms a cross structure in the 3-dimensional space,
and under the influence of its strength, the philtral dimple is formed
with a narrow top and wide bottom, and the philtral ridge is raised.
We advocate the adoption of mechanical traction rather than the volume accumulation to reconstruct the cleft lip patients philtral ridge.12,13
Haddock et al14 observed the long-term effect of primary cleft
rhinoplasty in patients with unilateral cleft lip and believed that primary nasal reconstruction performed with cleft lip repair made the nasal tip more symmetric and required less complex intervention at the
time of definitive secondary rhinoplasty. Guyuron15 stated that primary rhinoplasty could not reduce the ratio and difficulty of secondary
rhinoplasty. Yuzuriha and Mulliken16 performed primary rhinoplasty in
severe microform cleft lip patients. We repaired the nasal alar deformity when patients were older than 6 years. We believe that the nasal
deformity becomes increasingly more severe because of the abnormal
mechanical traction from the muscle. With our technique, the first
auxiliary tension line group is built, which simulates the physical

346

structure. Over time, the nose may develop properly under normal
permanent mechanical traction. So, we recommend allowing the natural development of the cleft lip nose until the patient is 6 years old.
After surgery, 17.5% of patients had thick vermillion. Possible
reasons are scar, edema of vermillion flap, and prolapse of vermillion,
which is caused by dissection and detachment of vermillion from
orbicularis oris muscle. We think the main reason of permanent thick
vermillion is prolapse of vermillion. So we reattached the dissected
vermillion and mucosa to orbicularis oris muscle recently. And the results were better than before. There is more skin of the upper lips than
normal in some cases. After reconstruction of the second auxiliary
tension line group, lateral lip is bulging because of extra skin. Usually,
extra skin shrinks, and bulging lip becomes normal in 1 year.
We believe that the shape of the lip depends on the balanced
muscle tension on both sides instead of upon the muscle volume. Once
the muscle tension line is disrupted, the deformity occurs. Here, we
repaired unilateral microform cleft lip according to the muscle tension
line group theory and obtained favorable results.

REFERENCES
1. Onizuka T, Hosaka Y, Aoyama R, et al. Operations for microforms of cleft
lip. Cleft Palate Craniofac J 1991;28:293300; discussion 300
2. Akita S, Hirano A. Surgical modifications for microform cleft lip repairs.
J Craniofac Surg 2005;16:11061110
3. Cho BC. New technique for correction of the microform cleft lip using
vertical interdigitation of the orbicularis oris muscle through the intraoral
incision. Plast Reconstr Surg 2004;114:10321041
4. Bo C, Ningbei Y. Reconstruction of upper lip muscle system by anatomy,
magnetic resonance imaging, and serial histological sections. J Craniofac
Surg 2014;25:4854
5. Mulliken JB. Double unilimb Z-plastic repair of microform cleft lip. Plast
Reconstr Surg 2005;116:16231632
6. Koh KS, Hwang CH, Kim EK. Modified design of Cupids bow in the
repair of unilateral microform cleft lip: in case of deficient distance
between the midline and the cleft side Cupids bow peak. J Craniofac Surg
2009;20:13671369
7. Oyama A, Funayama E, Furukawa H, et al. Minor-form/microform cleft lip
repair: the importance of identification and utilization of Cupid bow peak
on the lateral lip. Ann Plast Surg 2014;72:4749
8. Mendoza M, Perez A. Anatomical closure technique of the nasal floor for
patients with complete unilateral cleft lip and palate. J Plast Surg Hand
Surg 2013;47:196199
9. Desrosiers AE 3rd, Kawamoto HK, Katchikian HV, et al. Microform cleft lip
repair with intraoral muscle interdigitation. Ann Plast Surg 2009;62:640644
10. Cho BC, Baik BS. Formation of philtral column using vertical
interdigitation of orbicularis oris muscle flaps in secondary cleft lip. Plast
Reconstr Surg 2000;106:980986
11. Kim SW, Oh M, Park JL, et al. Functional reconstruction of the
philtral ridge and dimple in the repaired cleft lip. J Craniofac Surg
2007;18:13431348
12. Wu J, Yin N. Anatomy research of nasolabial muscle structure in fetus with
cleft lip: an iodine staining technique based on microcomputed
tomography. J Craniofac Surg 2014;25:10561061
13. Wu J, Yin N. Detailed anatomy of the nasolabial muscle in human
fetuses as determined by micro-CT combined with iodine staining.
Ann Plast Surg [published ahead of print July 4, 2014]
doi: 10.1097/SAP.0000000000000219
14. Haddock NT, McRae MH, Cutting CB. Long-term effect of primary cleft
rhinoplasty on secondary cleft rhinoplasty in patients with unilateral
cleft lipcleft palate. Plast Reconstr Surg 2012;129:740748
15. Guyuron B. MOC-PS(SM) CME article: late cleft lip nasal deformity. Plast
Reconstr Surg 2008;121:111
16. Yuzuriha S, Mulliken JB. Minor-form, microform, and mini-microform
cleft lip: anatomical features, operative techniques, and revisions. Plast
Reconstr Surg 2008;122:14851493

2015 Mutaz B. Habal, MD

Copyright 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.