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Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 41-48

Rationale for the treatment of unilateral cleft lip – GC4 protocol

Guwahati Comprehensive Cleft Care Centre (GC4), Mission Smile, Mahendra Mohan Houdhary Hospital, Guwahati, Assam, India

Date of Submission18-Sep-2020
Date of Acceptance24-Nov-2020
Date of Web Publication13-Jan-2021

Correspondence Address:
Dr. Anhad Mehra
Guwahati Comprehensive Cleft Care Centre (GC4), Mission Smile, Mahendra Mohan Houdhary Hospital, M.G Road, Fancy Bazaar, Guwahati, Assam
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_30_20

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Introduction: The aim of this study is to retrospectively analyze the surgical outcomes of 200 patients who were treated for unilateral cleft lip (UCL) over a period of 4 months in our cleft care center. Materials and Methods: This is a retrospective audit of all the patients who had undergone UCL repair from January to April 2019. The patients were stratified based on the cleft severity. Fisher technique was employed for the correction of incomplete cleft lip while modified Mohler technique was the choice of repair for complete cleft lip. Clinical records including each patient's preoperative and postoperative photographs were taken into consideration. Results: Of the 200 patients who had undergone lip repair, 56% were male and 44% were female. The average age of the patients treated was 10.5 months. Visual Analog Scale (VAS) and Scar Assessment Scale were used to evaluate the scar, taking into account pigmentation, vascularity, acceptability, parent comfort, and contour. The results ranged from “excellent” and “good” in the case of incomplete cleft lip repair to “good” and “acceptable” in the case of complete cleft lip repair. Postoperative follow-up revealed that 5 of them had complications related to dehiscence and bleeding. Conclusion: Fisher's method in patients with unilateral incomplete cleft lip proved the effectiveness in improving the esthetic results with good symmetry while the Mohler modification of Millard technique helped achieve optimal lip length with acceptable esthetics.

Keywords: Cleft, complete, Fisher, incomplete, Mohler, protocol, unilateral

How to cite this article:
Mehra A, Sarma H. Rationale for the treatment of unilateral cleft lip – GC4 protocol. J Cleft Lip Palate Craniofac Anomal 2021;8:41-8

How to cite this URL:
Mehra A, Sarma H. Rationale for the treatment of unilateral cleft lip – GC4 protocol. J Cleft Lip Palate Craniofac Anomal [serial online] 2021 [cited 2021 Apr 11];8:41-8. Available from: https://www.jclpca.org/text.asp?2021/8/1/41/306772

  Introduction Top

Unilateral cleft lip (UCL) is a deformity, which has drawn the attention of several plastic and maxillofacial surgeons over the years. The multidisciplinary approach for the correction of this midface defect has appealed to clinicians to consider several key elements for the intervention and carry out surgical techniques, which would help bring out desired postoperative results. The aim of each cleft surgeon is to always achieve exemplary symmetry and balance with minimum scarring and reduced requirement for secondary corrective procedures. Nasal involvement with UCL is an association, which is pervasive and should be addressed at the time of primary lip surgery.[1] Cleft care centers should have protocols for a comprehensive approach to the correction of the deformity, involving nutritionists, cleft surgeons, anesthesiologists, pediatricians, orthodontists, child care and patient care teams, speech pathologists (if palate is involved), dentists, etc. The augmentation of our protocols with techniques such as Fisher technique and modified Mohler technique has helped enhance surgical outcomes to exceptional and desirable levels. In this study, we have also been successful in comparing the effectiveness of anatomic subunit technique in incomplete cleft lip over complete cleft lip repair and the preference of modified Mohler rotation and advancement flap technique for the complete cleft lip. The acceptance of our protocol suggests that Fisher technique for mild-to-moderate unilateral clefts produces a more desirable outcome than rotation and advancement flap techniques, which provide suboptimal results for the same.

Fisher's technique for the closure of wide complete cleft lips is a highly cumbersome and technique-sensitive method unless carried out after nasoalveolar molding (NAM). Presurgical NAM is not regularly possible in our center as patient compliance and accessibility is difficult to achieve in the distant and poverty-stricken regions of the Northeast.

  Materials and Methods Top

A retrospective analysis of 200 patients was carried out who were treated for UCL in our cleft care center over a period of 4 months. An equal sample size was taken into account for both Fisher and modified Mohler techniques (100 patients each). Clinical preoperative and postoperative records were taken into consideration for this study.

The patients were stratified based on the severity of their clefts (degree of tissue deficiency).

Our cleft center surgical protocol spans over a specific time period to accommodate the child's developing years [Table 1].
Table 1 – GC4 Surgical protocol

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Group 1

Mild deficiency of <3 mm was noted between cleft and noncleft lip heights. Incomplete UCLs were included in this group. The Fisher technique was employed for the treatment in this group.

Group 2

Moderate-to-severe deficiency was defined as a 3–6 mm difference and beyond between the cleft and noncleft lip heights. All of these patients had complete UCLs. The modified Mohler technique was employed for this group.

The rotation-advancement repair was the initial technique of choice by the surgeons of our center over the years. However, due to recurring suboptimal esthetic results, the choice was transitioned to the anatomic subunit repair for mild-to-moderate cleft lip. Photographic comparison of 10 patients was carried out to analyze the postoperative results of incomplete cleft lip repair done using rotation-advancement technique (5 patients) and Fisher's technique (5 patients).

The inclusion criteria for this study involved (a) patients who were treated between January and April 2019 (4 months) in our center, (b) nonsyndromic cleft patients, and (c) operated upon post 6 months of age (as per our surgical protocol). The exclusion criteria involved (a) patients who were syndromic, (b) patients without any preoperative photographs or records, (c) malnourished or underage patients (<6 months of age) who were deemed not fit for surgery, and (d) patients with underlying systemic conditions.

Postoperative assessment of the results and complications was carried out using Scar Assessment Scale – Manchester Scar Scale adjunct with Visual Analog Scale (VAS). This Scar Assessment Scale was selected because it covers a wider range of scars and uses descriptors related to clinical significance instead of physical measurement alone. VAS also has an advantage of intra- and inter-rater reliability and is easy to conduct [Table 2].
Table 2 – Manchester scar scale in adjunct with Visual Analog Scale assessment tool

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Postoperative follow-ups were carried out at time periods of 1 week, 3 months, 6–8 months, and 1.5 years.

Qualitative analyses of cleft lip repair were evaluated for cutaneous roll symmetry, vermillion symmetry, scar appearance, Cupid's bow symmetry, lip length, nostril symmetry, alar dome symmetry, and alar base symmetry according to the Steffensen grading criteria[2] [Table 3].
Table 3 - Steffensen Grading Criteria

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Ethical clearance

“For this type of study, formal consent has been taken from parents/guardians of the babies.” “This article does not contain any studies with human participants or animals performed by any of the authors.” The manuscript was reviewed by the Institutional Review Board for publication.


The Fisher technique

The Fisher technique employs anatomical subunit principles to guide repair. Markings included the medial lip, lateral lip, and the nasal floor markings. The Fisher anatomical subunit approach was performed strictly, as described in detail by David Fisher.[3] The exception to the rule was keeping the base of cutaneous triangle on the lateral segment up to 2 mm. The cleft-side lip shortening was lengthened in this technique by (a) the curvilinear Rose-Thompson effect and (b) the cutaneous back-cut [Figure 1]a.
Figure 1: Key landmarks and markings of Fisher technique and modified Mohler technique. (a) Key landmarks and markings of Fisher technique. (b) Key landmarks and markings of modified Mohler technique

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The modified Mohler technique

The Mohler technique is one of the most popular methods to repair UCL among the modified Millard methods. Markings on the medial lip, lateral lip, and nasal floors were carried out based on the modification of Mohler technique by Cutting and Mulliken.[4] The GC4 approach is devoid of the perialar incision and includes Mohler columellar back-cut of 1 mm up on the columella and 3/5th the width of columella. Placing a triangle on the vermillion augments the vermillion deficiency on the lateral segment. The cleft-side lip shortening was lengthened in this technique by (a) Mohler columellar back-cut, (b) the curvilinear Rose-Thompson effect, and (c) the cutaneous back-cut [Figure 1]b.

The major differences between the various techniques for UCL repair lie within the boundaries of their markings and the associated incisions. The surgical procedure is more or less similar for both Fisher and modified Mohler technique [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d,[Figure 2]e.
Figure 2: Surgical procedure of cleft repair. (a) Incision along the markings. (b) Raising of C flap and inferior turbinate flap exposing the septum. (c) Dissection of lateral segment and release of muscle. (d) Mucosal closure using 5-0 vicryl. (e) muscle closure using 5-0 prolene

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  Results Top

A total of 200 patients were operated for UCL repair from the month of January to April 2019. The male patients occupied 56% (112 patients) of the sample size while female patients occupied 44% (88 patients) of the same. The average age of the patients treated for the defect was 10.5 months.

The preoperative selection of the sample size was done using random selection of 200 patients irrespective of the surgeons who had operated on them from January to April 2019. The analysis of the operated cases was done using postoperative photographs and comprehensive scar assessment scales. Blind assessments were carried out to eradicate bias from this study.

VAS and Scar Assessment Scale were used to evaluate the postoperative scar. The Manchester Scar Scale was adjunct with VAS scar assessment to produce a bias-free investigation.

The preoperative, postoperative, and follow-up records and photographs were assessed for the results. Scoring for the same was done in accordance with the Manchester Scar Scale, VAS, and Steffensen grading criteria.

Under Group 1, the results majorly ranged from “excellent” to “good” under VAS assessment (45% and 32%) and had a score range of 5–8 under the Manchester Scale at the end of 1.5 years, while under Group 2, the results ranged from “excellent” to “acceptable” under the VAS (36% and 32%) and had a score range of 6–9 under the Manchester Scale at the end of 1.5 years [Figure 3]a,[Figure 3]b,[Figure 3]c,[Figure 3]d,[Figure 3]e and [Figure 4]a,[Figure 4]b,[Figure 4]c,[Figure 4]d,[Figure 4]e.
Figure 3: Preoperative and postoperative assessment of incomplete cleft lip patient. (a) Preoperative photograph of the incomplete cleft lip patient. (b) Postoperative photograph with skin closure using 6-0 vicryl (1-week follow-up). (c) Postoperative photograph after 3 months. (d) Postoperative photograph after 8 months. (e) Postoperative photograph after 1.5 years

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Figure 4: Pre- and postoperative assessment of complete cleft lip patient. (a) Preoperative photograph of the complete cleft lip patient. (b) Postoperative photograph with skin closure using 6-0 vicryl (1-week follow-up). (c) Postoperative photograph after 3 months. (d) Postoperative photograph after 8 months. (e) Postoperative photograph after 1.5 years

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Comparison between Modified Mohler and Fisher technique for incomplete cleft lip revealed a higher incidence of scar shortening/contraction, hypertrophy, and widening seen with the rotation-advancement repair, which were more visible and more challenging to correct. Suboptimal results and scarring of the columella was evident in Modified Mohler technique in mild cleft lip deformity. The results were majorly suboptimal under VAS assessment and had a score range of 12 to 14 under Manchester scale. [Figure 5]a, [Figure 5]b and [Figure 6]a, [Figure 6]b.
Figure 5: (a and b) Suboptimal results following the modified Mohler rotation-advancement repair in two different patients

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Figure 6: (a and b) Satisfactory results following Fisher anatomic subunit repair in two different patients

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The complication rate for Group 1 was 3%, while the complication rate for Group 2 was 2%. The complications majorly included bleeding from the surgical site (3 patients) and dehiscence (2 patients) during their 1-week follow-up [Figure 7] and [Figure 8].
Figure 7: Graphic representation of postoperative assessment of incomplete cleft lip repair using Fisher technique

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Figure 8: Graphic representation of postoperative assessment of complete cleft lip repair using modified Mohler technique

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  Discussion Top

UCL is a common congenital deformity of the maxillofacial region that has detrimental and dilapidating effects on the appearance and function of newborn babies.[5] Delayed intervention due to taboos associated with this disfiguration leads to devastating influence on the confidence and self-esteem of the growing child.

All the techniques are derived from three basic “methods” for UCL repair: (a) the straight-line technique, (b) the triangular flap technique, and (c) the rotation-advancement technique.[6] However, there is no individual technique, which is universal and superior. Any technique, which is promoted for the correction of UCL, should have the following features: (a) establish a symmetric, balanced Cupid's bow, (b) construct a philtral column with the same shape and height as the philtral column on the noncleft lip side, (c) reorient and repair the orbicularis oris muscular sling, and (d) atraumatic, non linear skin closure.[6],[7]

The widely accepted surgical protocol of selecting a cleft patient for surgery is the “rule of tens.”[8] However, this rule is difficult to apply for northeast Indian demographics as most of the people belong to a lower socioeconomic status and are unaware of the nutritional requirements of cleft children. Hence, we operate on patients who have attained a minimum of 6 kg at 6 months of age. Malnourished or underweight babies are referred to our in-house nutritionist as healthy dietary intake plays a very important role in the developing milestones of cleft children and also provides them with optimum support for postoperative recovery. Often, the delivery method of breast milk or formula can be altered in order to require less effort by the infant and decrease caloric output, thereby increasing the calories ingested to facilitate weight gain and growth.[9]

Presurgical orthopedics in the form of NAM was introduced by Grayson BH et al. in 1993[10] and modified by him in 2009.[11] The main aim of presurgical orthopedics is to use an acrylic appliance with nasal stents to reduce the severity of cleft deformity by molding the immature nasal cartilages and reducing the necessity of surgical revisions for excessive scar tissue, formation of oronasal fistulas, and nasal and labial deformities. However, NAM holds good for correction before 3 months of age due to excess amount of maternal estrogen present in the baby, which leads to increased levels of hyaluronic acid causing the intracellular matrix of the nasal cartilages to loosen and be easily molded.[12] The adoption of Fisher and modified Mohler techniques has helped us achieve desirable results without presurgical orthopedics. Expense and patient compliance are also factors to be taken into account.[13]

Today, a cleft surgeon can choose from a variety of techniques for the correction of UCL. Most of them have advantages and limitations, and the surgical outcome mostly depends on the surgeon's expertise and experience.[6] The earliest publications on cleft lip repair were by Rose and Thompson who modified the conventional straight-line repair to reduce the shortening of the upper lip due to contracture.[14],[15] However, the limitation of this method was creation of a short upper lip with a notch at the vermillion-cutaneous junction and nasal asymmetry. Triangular flap methods were popularized by Tennison, Randall, and Skoog, who created variations of this technique to reduce the complication of lip shortening.[16],[17],[18] The unilimb Z-plasty technique is one such modification, which helps to elongate the medial segment by placing a triangular flap high in the philtral column. However, the limitation of this technique is an unnatural scar, which crosses the philtrum over the visible portion of the lip. Dr. Ralph Millard revolutionized the field of cleft lip surgeries when he introduced the rotation-advancement flap or “cut as you go” technique in 1957. Over the years, various modifications have been introduced for this technique, but it still remains a highly popular method.[19] Sitzman et al.[20] conducted a recent survey in the USA and Canada, where it was observed that 84% of surgeons perform rotation-advancement techniques for complete UCL. This technique involves the rotation of the medial cleft element, increasing its length and advancement of the lateral cleft element into the back-cut near the columellar-labial junction. In 1995, Fisher introduced a technique based on anatomic subunits, which helped achieve exemplary results with minimum postoperative scar formation.[3],[6]

The introduction of anatomical subunit approximation technique by Fisher has enabled surgeons to place the scar within the ideal lines of repair and mirror the contralateral noncleft-side philtral column. This is based on the principle of subunit approximation.[3],[21] Our center prefers to accept the Fisher technique for the correction of incomplete cleft lip or minor clefts because the line of repair extends from the peak of the Cupid's bow on the cleft side, mirrors the noncleft philtral column, and then extends superolaterally to a point where the closure takes place in the nasal sill region. A study put forth by Mbuyi-Musanzayi et al.[22] in 2017 suggested that Fisher technique helps in improving the medial and lateral lip height and is not dependent on the severity of the cleft. Nevertheless, the experience of our center in this field for over 10 years has helped us realize that wide clefts do require some form of augmentation of the medial height deficiency from the lateral element. Hence, we restrict Fisher technique to incomplete cleft lip and go ahead with modified Mohler technique for complete clefts. Rose-Thompson lengthening occurs as the sloped incisions crossing the cutaneous roll of the medial and lateral lip elements approximate in the vertical. This allows for placing a back-cut in the incision line of the medial segment[23] and a smaller triangle above the cutaneous roll of the lateral segment, as suggested by Nordoff.[24] The base width of the inferior triangle can be measured by the following method:[3]

(Lesser lip height = [Total lip height] - [greater lip height] - 1 mm = Base width of the small inferior triangle).

However, we prefer to keep the base width within 2 mm. The lateral lip markings will vary according to the vertical height of the lateral segment. The point of proposed closure of nostril sill (point 19) is a point of convenience and arbitrary and can be placed relative to the height of the lip at the site of proposed closure in the nostril sill (noncleft side) to accommodate for the variation in the vertical height.[3] Primary rhinoplasty can also be carried out, however, minor incomplete clefts hardly have any nasal asymmetry. The advantages of Fisher technique include: (a) allows for approximation of the medial and lateral lip elements almost entirely along the seams of anatomical subunits of the lip and nose, (b) under rotation is rare using this technique despite using such a small triangle, (c) can almost always accommodate the available height of the lateral lip, and (d) the cutaneous scar on the nose is minimized and is essentially limited to the cleft-side nostril sill. The limitations of this technique are small: (a) steep learning curve and (b) it is a “measure twice, cut once” style of repair. The design relies upon 25 landmarks and can be time-consuming.[7]

In 1987, Lester Mohler published his modification of Millard's rotation and advancement technique to counter the shortcomings of the latter procedure.[25] Rotation and advancement techniques have limited effectiveness in the correction of complete cleft lips as they fail to lengthen the lateral segment and also produce a scar which is symmetric to the noncleft philtral column only in the lower two-third region, hence leading to scar contracture and visible asymmetry.[25],[26] The limitations of this technique involved: (a) deficient and narrow nasal sill, (b) incision crossed the midline at the philtrum superiorly, (c) disruption of the white roll due to peaked appearance of the vermillion roll, and (d) malposition of the alar base with lack of contour.[5]

Mohler's modification required placement of small C-flaps to fill the entire downward rotation defect of medial lip element while the correction of the ala on the cleft side was carried out using a perialar incision. However, this restricted the amount of rotation possible due to a small back-cut.[4] Extended Mohler technique by Cutting and Dayan helped to extend the back-cut and reduce the extension of the alar base incision to allow closure and rotation of significant medial rotation defects.[4],[25] Another advantage of this technique was restriction of only one horizontal incision crossing the Langer's lines unlike Millard's technique, where two tips of the advancement flap crossed the lines. The perialar incision was unnecessary, and as supported by Nordoff and Salyer, it should be avoided to prevent an unsightly scar. The extended or modified Mohler technique also helped to achieve primary columellar elongation. The elongation of the lip height was achieved by (a) Mohler columellar back-cut, (b) the curvilinear Rose-Thompson effect, and (c) the cutaneous back-cut.

The authors used to prefer Modified Mohler technique for incomplete cleft lip repair for a long time but started noticing unacceptable occurrence of suboptimal aesthetic results, such as scar contraction, hypertrophy, and widening, especially at the junction of vertical and horizontal scar lines just below the columellar base. These outcomes led the authors to explore alternate techniques and eventually adopt anatomical subunit repair a few years ago.

A similar approach was promoted by Mittermiller et al (2000). However, though their study experienced reduced postoperative cutaneous scars and revisions with Fisher's technique, they presented with a high incidence of excessive vermillion fullness. Our study did not experience similar issues because we recruited less sulcus from the lateral segment and placed the Nordoff point slightly medial to the actual point to make a smaller red triangular flap.[27]

Also, Mohler repair required a 4 point closure where the C-flap met the lateral segments and nasal sil region, which increased the instances of wound dehiscence and scar contraction in mild to moderate lip defects.While, Fisher technique majorly brought two flaps of skin together and avoided the formation of a horizontal scar under the nasal sil.[27]

On the other hand, Modified Mohler rotation and advancement flap technique is preferred for complete unilateral lip repair in our centre because even though wide clefts can be repaired with Fisher technique, they have to be majorly associated with NAM and our centre does not perform NAM regularly due to poor patient compliance. Columellar back-cut in rotation-advancement method also helps in achieving appropriate lip length in severe cleft lip deformities and at the same time the technique is not as landmark sensitive and time consuming as Fisher's technique.[28]

Our surgical protocol agrees with the study put forth by Losee et al. regarding the preservation of lip width along with achieving the lip height. Losee et. al suggests marking the lip height of the Cupid's Bow on the lateral lip segment just before attenuation of lip fullness and not before where the white roll ends.[29]

Our center adopted the extended Mohler technique and modified it according to our own requirements. The columellar back-cut was extended up to the columella and subtracted the alar base incision from the procedure. The small inferior triangle concept was adopted on the lateral segment above the white roll, and a large triangle was placed in the vermillion of the cleft side to augment the deficient portion of the lip. Primary rhinoplasty is also conducted based on the requirement. The advantages of this modification are as follows: (a) widely applicable, accurate markings, and more flexible; (b) prevents scar formation over the upper third region of the philtrum; (c) uses the columella to lengthen the lip; (d) the rotation incision is designed to mirror the normal philtral column and extends onto the columella, and (e) C-flap is used to fill both the columellar defect and abut the rotated lip segment.

  Conclusion Top

This retrospective analysis describes our center's experience performing correction of UCLs using Fisher technique and modified Mohler technique. It could be recorded that both the techniques were responsible for bringing about significant changes in the lip height and vermilion asymmetries, along with symmetrical nasal reconstructions. We could conclude that the techniques should be chosen based on the severity of the cleft defect as Fisher technique is the one, which allows for approximation of the medial and lateral lip elements almost entirely along the seams of anatomical subunits while modified Mohler technique allows adequate rotation and advancement of the cleft lip segments to achieve improved symmetry and balance with less scarring.


The authors would like to thank Guwahati Comprehensive Cleft Care Centre, Mission Smile, and our team for the encouragement and facilities provided.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Salyer K, Rozen S, Genecov E, Genecov D. Unilateral cleft lip-approach and technique. Semin Plast Surg 2005;19:313-28.  Back to cited text no. 1
Kuna SK, Srinath N, Naveen BS, Hasan K. Comparison of outcome of modified Millard's incision and Delaire's functional method in primary repair of unilateral cleft lip: A prospective study. J Maxillofac Oral Surg 2016;15:221-8.  Back to cited text no. 2
Fisher DM. Unilateral cleft lip repair: An anatomical subunit approximation technique. Plast Reconstr Surg 2005;116:61-71.  Back to cited text no. 3
Cutting CB, Dayan JH. Lip height and lip width after extended Mohler unilateral cleft lip repair. Plast Reconstr Surg 2003;111:17-23.  Back to cited text no. 4
Patel TA, Patel KG. Comparison of the fisher anatomical subunit and modified millard rotation-advancement cleft lip repairs. Plast Reconstr Surg 2019;144:238e-45.  Back to cited text no. 5
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Mbuyi-Musanzayi S, Katombe FT, Tshilobo PL, Kayamba PK, Devriendt K, Reychler H. Anthropometric and aesthetic outcomes for the nasolabial region in 101 consecutive African children with unilateral cleft lip one year after repair using the anatomical subunit approximation technique. Int J Oral Maxillofac Surg 2017;46:1338-45.  Back to cited text no. 22
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1], [Table 2], [Table 3]


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