ORIGINAL ARTICLE
Anatomical Reconstruction in Bilateral Cleft Lip With
Mendoza Technique
Araceli Pérez González, MD and Rigoberto Arámburo-Garcı́a, MDy
The bilateral cleft lip (BCL) is the most severe manifestation of
orofacial clefts. Multiple techniques have been described to recon-
struct BCL to obtain good aesthetic and functional results with
minimal complications.
Objective: Description of surgical technique for BCL
reconstruction and present the postoperative results obtained.
Methods: Patients with BCL of the cleft lip and palate at ABC
Medical Center from June 2013 to June 2017 operated with
Mendoza bilateral cheiloplasty were included. The procedure
includes an anatomical reconstruction of the lip with minimal
resection of tissue, alignment of the orbicularis muscle, vestibule
creation, and complete use of the prolabium. The evaluation was
carried out by photographs analyzing parameters of quality,
symmetry, and alignment of lip and nose structures.
Results: The authors included 36 patients, 15 women and 16 men.
The average procedure time was 57 minutes. Photographs were
evaluated 1 year postoperatively, symmetry in lip was observed in
91.6% of the patients, muscle continuity in 100%, deep
gingivolabial sulcus in 94.5% of cases, closed nasal floor in
100% with no presence of nasovestibular fistulas.
Conclusions: This technique allows an anatomical BCL
reconstruction with good aesthetic and functional results.
Key Words: Bilateral cleft lip, cleft lip and palate, nasal floor
closure
(J Craniofac Surg 2018;29: 1452–1456)
B ilateral cleft lip (BCL) is the most severe manifestation of
orofacial clefts. Multiple procedures for bilateral cleft lip
reconstruction have been described because of the complexity to
obtain good aesthetic and functional results.1,2
Previously, radical methods like the resection or the retroposi-
tion of the premaxilla with osteotomies were used. However,
knowledge of the embryology and vascularity of the lip, as well
as the introduction of preoperative orthopedics, less invasive, and
better surgical strategies has been established.3– 5
From the PMG American British Cowdray Medical Center, Cleft Lip and
Palate Clinic, Plastic and Reconstructive Surgery; and yPlastic and
Reconstructive Surgery, Hospital General ‘‘Dr. Manuel Gea González,’’
Tlalpan, Ciudad de México, Mexico.
Received December 27, 2017.
Accepted for publication June 1, 2018.
Address correspondence and reprint requests to Araceli Pérez González,
MD, Plastic Surgery, Centro Medico ABC, Mexico City, Mexico;
E-mail: dra.araceliperez@yahoo.com.mx
The authors report no conflicts of interest.
Copyright # 2018 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000004785
1452 The Journal of Craniofacial Surgery  Volume 29, Number 6, September 2018
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
One of the most widespread techniques used is the Mulliken
procedure, it describes that the challenge of BCL surgery is the
reconstruction of the nasolabial complex in 3 dimensions, and
anticipates a fourth dimension given by time to predict the facial
growth.6 This technique was described in 1983 and emphasizes the
use of preoperative orthopedics, primary nasal repair, and the
symmetrical closure of the lip without using the whole prolabium.7
The author considers the vermilion resection, because the tissue is
thin, insufficient and causes ‘‘whistle deformity.’’8,9
Manchester described a technique in 1965, the prolabium is used
to recreate the Cupid bow and the tubercle.10,11
Mexico has a high prevalence and incidence of cleft lip and
palate, the refinement of surgical techniques has shown an excep-
tional growth. Dr. Mario Mendoza, plastic and reconstructive
surgeon of the Hospital General ‘‘Dr. Manuel Gea González’’,
was one of the exponents in this field.
This article aims to describe the Mendoza technique for bilateral
cleft lip reconstruction to be reproduced in other centers with
interest in the disease and present the postoperative results obtained.
METHODS
All patients with diagnosis of bilateral cleft lip operated with the
Mendoza technique from June 2013 to June 2017 at the Clinic of
Cleft Lip and Palate of the ABC Medical Center were included. The
procedure was performed by a single surgeon (AP-G) with 20 years
of experience in bilateral cleft lip reconstruction. Preoperative
orthopedics were performed by nasal-alveolar molding and Latham
device (in cases with fissure greater than 1 cm and with prominent
premaxilla).
The patients were photographed in preoperative and at the 3, 6,
and 12 postsurgical months. The photographs were collected digi-
tally and in .jpg format. One-year postoperative photographs were
analyzed, measuring parameters by an external certified plastic
surgeon with experience in reconstruction of cleft lip and palate.
Quality parameters, symmetry and alignment of lip and nose
structures were analyzed12,13 (Table 1). The muscle continuity,
the gingivolabial sulcus, and the presence of nasovestibular fistulas
were clinically evaluated14 (Table 2).
SURGICAL TECHNIQUE: BILATERAL
CHEILOPLASTY MENDOZA
This technique repositions anatomical structures with minimal
resection of tissue. It begins with the anatomical closure of the
bilateral nasal floor and then the reconstruction of the lip
is performed.
Marking
The marking points are as follows (Fig. 1):
 A1 and A2: at the nasolabial angle level on both sides of
the columnella.
 B1 and B2: at the mucocutaneous ridge of the prolabium,
drawing a straight line from A1 and A2 and the point is placed
1 mm lateral.
The Journal of Craniofacial Surgery  Volume 29, Number 6, September 2018
TABLE 1. Photographic Evaluation Parameters12,13
Quality of the scar
Good: not visible.
Regular: Widened scar.
Bad: Scar with deformity.
Symmetry in the length of the scar: measurement in millimeters from
the base of the nostril to the mucocutaneous ridge. Both results were
compared and it was determined whether it was symmetric or asymmetric.
Alignment of the mucocutaneous ridge: the continuity of the mucocutaneous ridge
was assessed at the site of the scars. From this it was determined whether
it was aligned or not aligned.
Symmetry in nostrils: The length of the horizontal and vertical axes of each
nostril was compared.
Closed nasal floor: Absence of nasovestibular fistulas.
TABLE 2. Clinical Evaluation14
Muscle continuity: the patient was asked to make a whistle position and the continuity
in the thickness of the lip was observed.
Gingivolabial sulcus: it was considered sufficient when the lip covers the entire
alveolus.
FIGURE 1. Markings of Mendoza technique.
 C1 and C2: in the mucocutaneous ridge lateral to A point.
 D1 and D2: at the most prominent point of the red lip in the
mucocutaneous ridge in lateral segments.
 E1 and E2: at the level of the alar base.
 F1 and F2: at the junction of the alveolus with the
nasal mucosa.
Points A, B, and C are joined in a triangular shape in the
prolabium. Subsequently, points D, E, F are joined in the lateral
segment. Finally, from C and F points a line is drawing in the union
between nasal and oral mucosa, this is called ‘‘Mendoza line’’ and
defines the mucoperiostical flaps used to anatomical closure of
nasal floor (Fig. 2).
FIGURE 2. Marking lines of Mendoza technique.
# 2018 Mutaz B. Habal, MD
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Anatomical Reconstruction in BCL
FIGURE 3. Lip dissection. (A) Mucosal dissection of the lip. (B) Muscle
dissection. (C) Mucosal incision parallel to alveolar ridge.
Lip Dissection
The first step is the tattoo of points B and D with methylene blue
and infiltration with lidocaine and epinephrine is performed to
control hemostasis (Fig. 3). The dissection begins in the lateral
segment, the first cut begins medially to point D, with the scalpel
outward impacting the entire thickness of the lip. Then, the skin is
cut from point D on the mucocutaneous ridge to point F, obtaining a
flap of lateral mucosa.
Then, mucosa is removed from the orbicularis muscle with a
depth of 3 to 4 mm throughout its circumference, trying to keep
mucosa intact. The orbicularis muscle is removed from the anoma-
lous fixations and nasal wing base to allow free advancement and
rotation of the flap. In the alveolar ridge the incision is continued in
oral mucosa toward lateral and parallel to the vestibule.
This step is repeated on the contralateral side, before proceeding
with the closure of the nasal floor.
Anatomic Closure of Nasal Floor15
Once the lip dissection is performed, the lowest portion of the
nasal floor is identified and the F point is continued, delimiting the
Mendoza line and the nasal mucoperiostic flap for the anatomical
closure of the nasal floor (Fig. 4). In the medial portion the point C is
continued and the mucoperiostic flap of the nasal septum is
obtained. Once both flaps are dissected, the nasal floor is closed
with inverted points of Vycril from posterior to anterior in 2 layers.
Prolabium Unfolding
The triangle (delimited by points A, B, and C) is desepitalizated
on both sides of the prolabium (Fig. 5). The prolabium is dissected
from the premaxilla in the distal portion and advances until the
prolabium has the adequate length, but with a good vascularity.
FIGURE 4. Final result of the closure of nasal floor with mucoperiostic flaps.
1453
González and Garcı́a The Journal of Craniofacial Surgery
FIGURE 5. Prolabium cleavage.
FIGURE 6. Gingivolabial sulcus creation. It must be deep to recreate a more
anatomical vestibule.
Gingivolabial Sulcus Creation
Subsequently, the previously dissected lateral mucosa flaps are
attached from lateral to medial on the premaxilla until a deep
gingivolabial sulcus is obtained (Fig. 6).
Orbiculary Muscle Miorraphy
The lateral portion of the lip is fixed to prolabium in a partial
coaptation of the muscular fibers, generating a ‘‘Vycril hammock’’
(Fig. 7). The miorraphy is performance from distal to proximal until
nasogenian sulcus is marked (Fig. 6).
Close the Lip
Once both sides are reconstructed the prolabium adapts over the
orbicularis muscle (Fig. 8A). B and D points are fixed recreating the
mucocutaneous ridge with an inverted point and an external point.
Straight incisions are created and excess skin is removed from the
nasal floor. The closure is obtained from the skin coaptation of lines
A–B and D–F. Finally, the distal portion of the prolabium is
attached to the labial mucosa.
FIGURE 7. Orbicularis muscle miorraphy.
1454 # 2018 Mutaz B. Habal, MD
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 29, Number 6, September 2018
FIGURE 8. (A) Final reconstruction. (B, C) Female patient with bilateral cleft lip
operated with Mendoza technique. Preoperative and 1-year postoperative
photos in antero-posterior y lateral view.
RESULTS
Thirty-six patients were included, 15 women and 16 men. The
average procedure time was 57 minutes (Tables 3 and 4). There
were no postoperative complications. Some of the patients have
been followed for more than 2 years and do not require
additional procedures.
In the first 6 months the scars were hyperemic and indicated
massage. Photographs were evaluated 1 year postoperatively.
83.3% (n ¼ 30) of the patients had symmetry in length 91.6%
TABLE 3. Preoperative Characteristics of Patients
Age (Mean) 5 Mo
Genre Men: 16
Women: 15
Preoperative orthodontics NAM: 33 (91.6%)
Latham device: 3
NAM, nasoalveolar molding.
The Journal of Craniofacial Surgery  Volume 29, Number 6, September 2018 Anatomical Reconstruction in BCL

TABLE 4. Transoperative vestibular fistulas.15,18 The wide dissection of the lateral lip mucosa
and its union with the premaxilla mucosa and the prolabium allows
Surgical time 57 min
achieving a deep gingivolabial sulcus, recreating a more anatomical
Anatomical nasal floor closure 36 (100%)
vestibule.19 The orbicular muscle dissects in both lateral segments
Gingivolabial sulcus creation 36 (100%)
and approaches the midline without coaptation, but leaving a
Whole prolabium use. 36 (100%)
‘‘Vycril hammock ’’ this prevents tension and widening of the
Orbicular muscle continuity 36 (100%)
scar, and allows more movement of the lip.20 The orbicularis
muscle reconstruction is made from distal to proximal until the
nasal floor and the nasogenian sulcus are marked bilaterally.
TABLE 5. Lip Evaluation at One Year Postoperatively Finally, the vermilion of the prolabium is used integrally, providing
a suitable central volume and harmony of the lateral segments.
Scar of the lip. Quality Good: 30 (83.3%)
Regular: 3 (8.35%) Preoperative orthopedics is a basic element in reconstruction. A
Bad: 3 (8.35%) prominent premaxilla does not allow a free closure of muscle and
Scar of the lip. Length Symmetrical: 33 (91.6%) skin tension.21,22 The objective, regardless of the method used, is to
Asymmetrical: 3 (8.4%) establish the symmetry, to reduce the alveolar gap, to align the
Mucocutaneous ridge Aligned: 33 (91.6%) alveolar arch, and to facilitate the closure of the lip.
No aligned: 3 (8.4%) In our center, nasal repair differs up to 15 years of age when the
Muscular union Continuity: 36 (100%) growth in face is completed. The anatomical closure of the nasal
No continuity: 0
floor during the cheiloplasty generates acceptable results in the
Gingivolabial sulcus Deep: 34 (94.4%)
No deep: 2 (5.6%) nose.23,24
Photometry is a useful tool to evaluate results in cleft lip and
palate surgeries. There are a lot of methods described, Mulliken has
created photometric measures to evaluate postsurgical results.6,25,26
TABLE 6. Nose Evaluation at the One Year Postoperatively However, this evaluation cannot be used to our patients because the
markings, lines, and use of vermillion in the technique modify the
Symmetry in shape Symmetrical: 33 (91.6%)
Asymmetrical: 3 (8.4%) final result. There is no photometric evaluation specifically to
Nasal floor Close: 36 (100%) Manchester or Mendoza technique.
Open: 0 At 2 years of follow-up none of our patients has required
Nasovestibular fistulae Yes: 0 sequential correction surgeries. With adequate planning and the
No: 36 (100%) execution of the critical points of reconstruction with the Mendoza
technique in this type of patients, the need for a nasolabial correc-
tion is unlikely. Mulliken, in 2013, published a series of 50 patients
(n ¼ 33), a mucocutaneous ridge aligned in 91.6% (n ¼ 33), 100% in whom 33% required corrective surgery and 8% required 2
(n ¼ 36) and sufficient sulcus in 94.4% (n ¼ 34) (Table 5). revision surgeries. The main causes were insufficient gingivolabial
In nose, symmetry in the form was present in 91.6% (n ¼ 33), sulcus, presence or deficiency tissue in tubercle, and nonaligned
nasovestibular fistulas 0% and nasal floor closed in 100% (n ¼ 36) mucocutaneous ridge.26
(Table 6). Good aesthetic results and functional results like absence of
nasovestibular fistulae and indirectly more hygiene and better
DISCUSSION conditions to posterior procedures, validate the use of this tech-
Bilateral lip repair techniques have been perfected in the last nique.
30 years, the most commonly used are those described by Mulliken The procedure described has been used for 30 years, but has not
and Manchester. The technique of Mulliken is considered the most been described in the literature. This accomplishes the contempo-
validated technique by the Medical Education Council of the United rary principles of bilateral cleft lip reconstruction: maintains sym-
States, the vermillion is not used, the conservation of this structure metry, use of presurgical orthopedics for premaxilla management,
to give a central volume to the lip is primordial for the facial allows building a lip with an adequate volume, generates a gingi-
characteristics of our meztizo population.16,17 Manchester used the volabial sulcus, establishes muscle continuity, and modifies nasal
whole prolabium, the technique does not describe the creation of a deformity27,28 (Fig. 9).
deep gingivolabial sulcus. Anatomical closure of the nasal floor is
not described in either technique10,11 (Fig. 8B and C). CONCLUSION
The Mendoza technique generates a more anatomical and This technique allows a functional and aesthetic reconstruction of
aesthetic lip (Fig. 9A and B). It is based on the following principles: bilateral cleft lip with good results and with less corrective surgeries
the anatomical closure of the nasal floor with mucoperiostic flaps in the evolution of the patient.
allows having a symmetrical nasal base and reduces the incidence of
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