The PAUL flap: “Prolabial Augmentation of the Upper Lip” In Primary Bilateral Cleft Lip Repair

A whistle deformity is a common secondary deformity of upper lip volume deficiency in the tubercle following bilateral cleft lip repair. The whistle deformity is a significant aesthetic stigma of bilateral cleft lip repair and challenging to correct. In the most severe situations, it can also lead to functional speech issues due to the inability to seal the lips during plosive consonant sounds. Various secondary surgical methods have been proposed to address secondary tubercle deformities requiring revision surgery. Volume deficiency can occur in the tubercle with any surgical technique used, with some being more prone than others. We present a novel fibroadipose tissue flap to improve tubercle fullness during primary bilateral cleft lip repair using tissue that is otherwise normally discarded. The prolabial augmentation of the upper lip (PAUL) flap is a random pattern fibroadipose flap distally based off the undersurface of the prolabial skin flap. The fibroadipose tissue in the premaxillary segment is preserved, dissected and everted for auto-augmentation of the tubercle. The PAUL flap is inset into a submucosal pocket in the vermilion over the orbicularis muscle repair as one of the final steps of repair. This is an effective adjunct to prevent a whistle deformity and can be used with any skin pattern technique designed for the prolabial skin flap in the primary bilateral cleft lip repair.