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  • Cleft lip with or without cleft palate is the most common congenital malformation of the head and neck occurring in 1:1000 live births.

  • Each patient should be evaluated for congenital anomalies, developmental delay, neurologic disorders, and psychosocial concerns.

  • A multidisciplinary team is recommended to ensure that every aspect of care is appropriately coordinated among providers.

  • A fundamental understanding by the surgeon of each step of care is warranted.


  • Lip (Figure 52-1)

    1. Primary muscle: orbicularis oris (innervated by CN VII)—creates a sphincter around the mouth

    2. Primary blood supply: superior labial artery—runs deep to the orbicularis oris muscle

    3. Vermillion border (white roll): mucoepithelial junction between the cutaneous lip and mucosal lip—a 1-mm discrepancy in reapproximation is easily visible

    4. Philtral ridges: paramedian columns formed at embryonic fusion plane between maxillary and frontonasal prominences—elevation of the vermillion at the junction with the philtrum forms the peak of cupid’s bow

    5. Philtral dimple: midline dimple above central portion of cupid’s bow formed by decussation of muscles to contralateral philtral column and attachment of orbicularis oris to dermis

  • Palate

    1. Primary palate: anterior to the incisive foramen and includes alveolar ridge

    2. Secondary palate: posterior to the incisive foramen

      • Hard palate: posterior to incisive foramen but anterior to Levator veli palitini muscle

      • Soft palate: posterior to hard palate, comprised of Levator veli palitini, Tensor veli palitini, Musculus uvula

    3. Bony anatomy: the hard palate consists of the premaxilla (anteriorly) and vertical segments of the palatine bone (posteriorly) which contain the greater palatine foramina and the lesser palatine foramina

    4. Greater palatine foramen: contents included the greater palatine vessels and greater palatine nerve

    5. Lesser palatine foramen: lesser palatine nerves

    6. Muscles: are all innervated by CN X except tensor veli palatini (innervated by V3)

      • Levator veli palatini

      • Tensor veli palatini

      • Palatoglossus

      • Palatopharyngeus

      • Musculus uvula

    7. Primary blood supply

      • Hard palate: greater palatine artery

      • Soft palate: descending palatine branch of the facial artery, palatine branch of the ascending pharyngeal artery, and lesser palatine artery

Figure 52-1

Anatomy of the lip. (Reproduced with permission from Lee KJ: Essential Otolaryngology. 7th ed. Stamford, CN: Appleton & Lange; 1999.)


  • Lip (Figure 52-2)

    1. Gestational week 4: paired maxillary prominences begin to appear from the first pharyngeal arches and frontonasal prominence (only unpaired prominence) from mesenchyme ventral to forebrain

    2. Gestational week 5: nasal placodes invaginate forming medial and lateral nasal prominences

    3. Gestational weeks 6-7: medial growth of paired maxillary prominences meet paired medial nasal prominences and frontonasal prominence forming upper lip

  • Palate

    1. Gestational weeks 5-12: maxillary prominences push medial nasal prominences medially and fuse by 12 weeks; intermaxillary segment (with 4 incisor teeth buds) is formed by fusion of the paired medial nasal prominences; disruption in this process leads to clefting of the primary palate

    2. Gestational weeks 5-6: soft palate musculature migrates toward midline from both ...

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