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. 2025 Sep 23;13(9):e7107. doi: 10.1097/GOX.0000000000007107

Revisiting the Boot Flap for Secondary Repair of the Free Border in Cleft Lip

Koichi Ueda *,✉, Yuka Hirota *, Hiromi Kino *, Chizuru Umeda *, Daisuke Nishioka †
PMCID: PMC12456503  PMID: 40995577

Abstract

Background:

Deficiency of the free border of the lip and “whistling lip” deformity are encountered in secondary repairs of unilateral and bilateral cleft lip. We have reported the use of the de-epithelialized oral vestibular flap (boot flap) for secondary cleft lip repair. We experienced more cases using this method and analyzed them.

Methods:

Fifty-nine patients with a cleft lip underwent secondary repair using this method. In unilateral cases, total scores were determined by evaluating the height of the notch, the volume of the upper lip tubercle, and the upper lip volume of the cleft side. In bilateral cases, total scores were determined by evaluating the height of the notch and the volume of the median lip tubercle.

Results:

Of the 46 patients with a unilateral cleft lip, 3 patients underwent a second boot flap operation due to undercorrection, and 1 patient underwent boot flap revision. Of the 12 patients with a bilateral cleft lip, 1 patient underwent a second boot flap operation due to flap atrophy. The second operation could be performed without any difficulty in either unilateral or bilateral cases. Compared with the preoperative scores, the postoperative scores improved significantly in both unilateral and bilateral cases.

Conclusions:

We experienced a recurrent notch deformity after direct suturing in a patient with a unilateral cleft lip. This was thought to be caused by scar contracture. To prevent a recurrent deformity, it is important to interrupt the plane where scar contracture occurs by incorporating a boot flap and augmenting the volume.

Takeaways

Question: What were the follow-up results of secondary repair of the free border using the boot flap in cleft lip cases?

Findings: Of 46 patients with a unilateral cleft, 3 patients underwent a second boot flap operation, and 1 patient underwent boot flap revision. Of the 12 patients with a bilateral cleft lip, 1 patient underwent a second boot flap operation. Compared with the preoperative scores, the postoperative scores improved significantly in both unilateral and bilateral cases.

Meaning: The boot flap prevents a recurrent deformity by interrupting scar contracture and augmenting the volume.

INTRODUCTION

Malalignment of the red line can be corrected by Z-plasty or by advancement of the vermilion from the lateral lip.1 Deficiency of the free border of the lip is encountered in secondary unilateral cleft lip deformities. Other deformities can be corrected by Z-plasty on the free border of the lip, V-Y advancement of the labial mucosa,2 scar flap,3 and submucosal back-flipped flap.4 “Whistling lip” is a characteristic deformity observed after primary surgery for bilateral cleft lip. To treat the deformity, a double V-Y procedure,5 Kapetansky double-pendulum island flap,6 vermilion border transposition flap,7 de-epithelialized mucosal-submucosal flap,8 propeller flap,9 and lateral vermilion border transposition flap10 have been reported.

A shortage of subcutaneous tissue and orbicularis oris muscle requires other tissues or materials to obtain good results. For such tissues or materials, free dermis-fat graft,11 temporoparietal fascia,12 free tongue graft,13 and acellular human dermis14 have been reported. However, for absolute shortage of vermilion or tissue deficiency, a cross-lip vermilion flap,15 Abbe flap,16 or tongue flap17 should be considered.

We reported a de-epithelialized oral vestibular flap (boot flap) for the treatment of free border deformities after unilateral cleft lip surgery and to correct whistling lip deformity after bilateral cleft lip surgery in Viewpoint articles published in Plastic and Reconstructive Surgery in 201218 and 2013,19 respectively. The merit of this simple method is that it leaves no additional donor-site scar in either unilateral or bilateral cleft lip cases, and it can also be applied as a treatment for mild defects of the median tubercle in bilateral cleft lip. Since the first report, we have experienced more cases of secondary repair of the free border of the cleft lip using this boot flap method with long-term follow-up and have analyzed and described them here.

MATERIALS AND METHODS

Operation Method

Secondary Repair of Unilateral Cleft Lip

The operation was performed under general anesthesia. The boot flap was designed on the oral vestibule along the primary suture line. (See Video [online], which displays the operation methods of the boot flap.) Generally, the flap was made on the cleft side, but it can also be made on the contralateral side (Fig. 1). A subcutaneous pocket was dissected over the muscle through the primary suture line at the tissue-deficient site. The pocket was designed to be 1 mm wider than the actual depressed area. The surface mucosa can be easily de-epithelialized before flap elevation. The volume of the flap was slightly larger than required because atrophy did not occur in almost all cases. The flap contained subcutaneous tissue. A small portion of the orbicularis oris muscle can be contained if the volume is necessary. The flap was turned over, inserted into the subcutaneous pocket, and fixed at the base of the space using absorbable sutures. The mucosal defect of the donor site was closed by advancing the lateral wound edge forward. Finally, all incisions were closed using 6-0 nylon and absorbable sutures.

Fig. 1.

Fig. 1.

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Boot flap schema for tissue deficiency on the free border of the unilateral cleft lip. A, The flap was designed along the primary suture line. The surface mucosa was de-epithelialized before flap elevation. B, The flap was elevated and contained subcutaneous tissue; however, a small part of the orbicularis oris muscle may be included. C, A subcutaneous pocket was dissected, and the boot flap was inserted into the pocket. D, The mucosal deficiency was corrected by advancing the flap.

Video 1. This video displays the incision lines. In this case of the right complete cleft lip, we found a deficiency on the free border of the lip. To correct this deficiency, we designed the flap on the oral vestibule along the primary suture line. This flap looks like a boot so we called it the boot flap. We made a subcutaneous pocket under the deficient area. Then we raised the boot flap and de-epithelialized it. Finally, we secured this de-epithelialized boot flap to the subcutaneous pocket. The mucosal deficiency was also corrected by advancement.
Download video file (55.1MB, mp4)
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Secondary Repair of Bilateral Cleft Lip

For whistling lip deformities, the flap was designed bilaterally in the oral vestibule along the median suture line of the primary cleft lip (Fig. 2). A subcutaneous pocket was dissected over the muscle on the bilateral tissue of the deficient site, as in the unilateral case. The flap volume may be 10%–20% larger than required because mild atrophy of the flap can occur postoperatively, as happened in in 1 case, which is different from the unilateral cases. The flap was turned over, inserted into the subcutaneous pockets bilaterally, and fixed. The mucosal defect was closed by advancing the lateral wound edge forward. In this manner, the notch or depressed site was reconstructed, and the upper lip could be advanced slightly forward.

Fig. 2.

Fig. 2.

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Boot flap schema for tissue deficiency on the free border of the bilateral cleft lip. A, The flap was bilaterally designed on the oral vestibule. B, The flap was elevated over the orbicularis oris muscle and connected to the lateral lips via its bilateral subcutaneous pedicles. C and D, Mucosal deficiency was corrected by advancing bilateral flaps.

Patients

This study was performed in the Department of Plastic and Reconstructive Surgery at Osaka Medical and Pharmaceutical University from July 2005 to December 2023. Fifty-nine patients with a cleft lip underwent secondary repair of free border deformity using this method. The ethical committee of the hospital approved this study (institutional review board no. 2024-123).

Evaluation Methods

Two photographs of the patients from 2 angles (frontal and submental) were evaluated.

Evaluation for Unilateral Cleft Lip

The score was determined using 3 aspects: the height of the notch, the volume of the upper lip tubercle, and the upper lip volume of the cleft side. The final score was determined by adding three scores (Fig. 3):

Fig. 3.

Fig. 3.

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Evaluation methods for unilateral cleft lip. Using 3 aspects, the height of the notch, volume of the upper lip tubercle, and upper lip volume on the cleft side, the total unilateral score was determined.

  1. Height of the notch: The score was determined by comparing the height of the notch to the normal height of the red lip. A score of 3 was assigned when no notch existed. A score of 2 was assigned when the height of the notch was less than one-third of the normal height of the red lip. A score of 1 was assigned when the height of the notch was one-third or more or two-thirds or less of the normal side. A score of 0 was assigned when the height of the notch was two-thirds or more of the normal side.

  2. Volume of the upper lip tubercle: The upper lip tubercle volume was divided into 3 stages: good, fair, and poor. They were assigned scores of 3, 2, and 1, respectively.

  3. Upper lip volume of the cleft side: The score was determined by comparing the volume of the red lip on the cleft side with that of the normal side. A score of 3 was assigned when it had the same volume as that of the normal side. A score of 2 was assigned when the volume was more than half of the normal side. A score of 1 was assigned when the volume was less than half of the normal side.

  4. Total scores: The total score was then determined by adding the 3 aforementioned scores.

Evaluation for Bilateral Cleft Lip

The scores were determined using 3 points: the bilateral notch height and the median lip tubercle volume. The final score was determined by adding two scores (Fig. 4).

Fig. 4.

Fig. 4.

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Evaluation methods for bilateral cleft lip. Using 2 aspects, the height of the notch and the volume of the median lip tubercle, the bilateral total score was determined.

  1. Height of the notch: The same scoring method for the notch was used as in the unilateral method. However, it was difficult to compare the normal side in patients with a bilateral cleft lip. The line was determined by prolonging the upper lip marginal line, and the normal height of the upper lip was decided. The score was determined bilaterally.

  2. Volume of median lip tubercle: The median lip tubercle volume was divided into 3 stages: good, fair, and poor. They were assigned scores of 3, 2, and 1, respectively.

  3. Total scores: The total score was then determined by adding the abovementioned 2 scores together.

Statistical Analysis

Two consultant plastic surgeons evaluated the data using the aforementioned scoring scale. The total scores were analyzed. The Wilcoxon signed-rank test was used to compare preoperative scores with postoperative scores in patients with both unilateral and bilateral cleft lips. The Mann-Whitney U test was used to evaluate the preoperative and postoperative scores between patients with unilateral and bilateral cleft lips.

RESULTS

Between 2005 and 2023, 59 patients underwent secondary repair using this method. Of these, 46 patients exhibited a unilateral cleft lip, 12 patients had a bilateral cleft lip, and 1 patient had a median cleft lip. The follow-up periods ranged from 6 months to 12 years (mean 5 y 2.3 mo). Of the 59 patients, 47 underwent primary repair in our department. There were 34 male and 25 female patients, with ages ranging from 6 to 21 years.

Of the 46 patients with a unilateral cleft lip, 3 underwent a second boot flap operation due to undercorrection, and 1 patient underwent a boot flap revision. Of the 12 patients with a bilateral cleft lip, 1 underwent a second boot flap operation due to flap atrophy. The second operation could be performed without any difficulty in either unilateral or bilateral cases. A mucus cyst complication was noted in 1 bilateral patient 2 years postoperatively. No other complications were recognized.

Evaluation for Unilateral Cleft Lip

Comparison Between Preoperative and Postoperative Scores in Unilateral Cleft Lip

When comparing preoperative and postoperative scores in patients with a unilateral cleft lip, significant differences were observed in the total score D according to the Wilcoxon signed-rank test (P < 0.001). Postoperative scores improved significantly in patients with a unilateral cleft lip (Fig. 5).

Fig. 5.

Fig. 5.

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Comparison between preoperative and postoperative scores in unilateral cleft lips. Postoperative scores improved significantly.

Comparison of Preoperative Scores Between Incomplete and Complete Unilateral Cleft Lips

On comparing the preoperative scores between patients with incomplete and complete unilateral cleft lips, no significant differences were found in the total score D according to the Mann-Whitney U test (Fig. 6).

Fig. 6.

Fig. 6.

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Comparison of preoperative scores between incomplete and complete unilateral cleft lips. There were no significant differences in the total score D according to the Mann-Whitney U test.

Comparison of Postoperative Scores Between Incomplete and Complete Unilateral Cleft Lips

On comparing the postoperative scores between patients with incomplete and complete unilateral cleft lips, significant differences were observed in the total score D according to the Mann-Whitney U test (P = 0.031). The postoperative scores in patients with incomplete cleft lip were higher than those in patients with complete cleft lip (Fig. 7).

Fig. 7.

Fig. 7.

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Comparison of postoperative scores between incomplete and complete unilateral cleft lips. There were significant differences in the total score D according to the Mann-Whitney U test.

Comparison Between Preoperative and Postoperative Scores in Bilateral Cleft Lip

When comparing preoperative and postoperative scores in patients with a bilateral cleft lip, significant differences were found in the total score D according to the Wilcoxon signed-rank test (P < 0.003). Postoperative scores improved significantly in the bilateral cleft lip group (Fig. 8).

Fig. 8.

Fig. 8.

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Comparison between preoperative and postoperative scores in bilateral cleft lips. There were significant differences in the total score D, as shown by analysis using the Wilcoxon signed-rank test.

Case Reports

Case 1

The patient underwent primary repair of a left incomplete cleft lip at 3 months of age at our hospital, followed by rhinoplasty using reverse-U incision at 5 years of age. As deformity of the free border of the lip manifested at 17 years of age, the patient underwent a boot flap operation (Fig. 9). (See figure, Supplemental Digital Content 1, which displays case 1. A, Design of the boot flap. B, Postoperative image, https://links.lww.com/PRSGO/E314.) The patient’s postoperative clinical course was uneventful.

Fig. 9.

Fig. 9.

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Case 1: A 17-year-old male patient with tissue deficiency on the free border of the upper lip. A, Preoperative frontal and submental images. B, Three years after the boot flap.

Case 2

The patient underwent primary repair at 4 months of age at our hospital, followed by bilateral rhinoplasty using a reverse-U incision at 7 years of age. A left alveolar bone graft using iliac cancellous bone was performed at 9 years of age. The palatal fistula was closed at 11 years of age. Because deformity of the free border of the lip manifested at 14 years of age, the patient underwent bilateral boot flap surgery (Fig. 10). The patient’s postoperative clinical course was uneventful.

Fig. 10.

Fig. 10.

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Case 2: A 14-year-old female patient with whistling deformity of the upper lip. A, Preoperative frontal and submental images. B, Four years after the boot flap.

Case 3

The patient underwent primary repair at 3 months of age at our hospital, cleft palate repair at 1 year of age, and bilateral rhinoplasty using a reverse-U incision at 4 years of age.

An alveolar bone graft was performed bilaterally using the iliac cancellous bone at 8–9 years of age. The patient underwent bilateral boot flap surgery at 12 years of age (Fig. 11). Le Fort I osteotomy and distraction were performed; 3 months later, mandibular sagittal splitting was performed at 18 years of age. The patient’s postoperative clinical course was uneventful. (See figure, Supplemental Digital Content 2, which displays case 3: 12 years after the boot flap and 6 years after Le Fort I osteotomy, https://links.lww.com/PRSGO/E315.)

Fig. 11.

Fig. 11.

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Case 3: A 12-year-old male patient with whistling deformity of the upper lip due to bilateral cleft lip. A, Preoperative frontal and submental images. B, Three years after the boot flap.19

DISCUSSION

Many surgeons have reported revision rates in patients with a unilateral complete cleft lip.20–25 In the unilateral complete forms, 21% of patients had or required a labial revision.26 The most common labial revisions were unilimb Z-plasty at the vermilion–cutaneous junction (13%) and adjustment of the mucosal free border (10%). In 136 patients with unilateral incomplete cleft lip treated by 1 surgeon with 28 years of experience, 57% required revision of the mucosal free margin.4

The boot flap yields good results in the secondary repair of the free border in patients with unilateral and bilateral cleft lips. Our analysis revealed that in both unilateral and bilateral cases, the postoperative scores improved significantly compared with the preoperative scores.

Of the 46 patients with a unilateral cleft lip, 3 underwent a second boot flap due to undercorrection of the initial flap. In unilateral cases, boot flap atrophy did not occur; however, flap revision via volume reduction was performed. Of the 12 patients with bilateral cleft lips, 1 patient underwent a second boot flap operation due to flap atrophy. Various types of nonvascularized free grafts, such as free dermis fat grafts,11 temporoparietal fascia grafts,12 free tongue grafts,13 and acellular human dermis14 have been reported. However, graft atrophy has not been reported in these studies. There is a low possibility of atrophy because the upper lip is well vascularized and the volume of the graft is small. Although the boot flap is thought to be a vascularized pedicle flap, the extent of the blood supply is unclear. During the operation, we aimed to slightly increase the volume in the unilateral cleft lip cases and by 10%–20% in the bilateral cleft cases. A second operation can be performed without any difficulty. This may be due to the gradual loosening of the tension of the mucosa at the donor site after the operation.

One bilateral patient developed a mucus cyst complication 2 years postoperatively. The cause was thought to be the mucus membrane remaining after de-epithelialization of the boot flap. Although the frequency is thought to be low, 1 of 59 or 1.7%, the de-epithelialization procedure in the oral mucosa should be performed carefully.

The boot flap is very useful in patients with mild-to-moderate deficiency of the free border of the lip. The boot flap offers the following advantages:

  1. The flap can be used to increase the volume of the vermilion.

  2. Additional operative scars did not appear because the boot flap was designed along the previous operative scars from the primary cleft lip repair.

  3. Donor-site scars are inconspicuous because almost all scars are located on the upper lip mucosa of the oral vestibule.

  4. The additional advantage of advancing the red lip can be obtained by closing the donor site.

  5. The flap can be easily inserted into the pocket in which it is placed from the operative wound edge.

  6. There is minimal flap resorption, and the softness can be maintained after the operation.

  7. The second operation of the boot flap can be performed easily after several years.

In our experience, direct suturing for correcting notch deformities of the free margin in incomplete unilateral cleft lip resulted in the occurrence of the same deformity.27 This was thought to be caused by scar contracture. To prevent recurrent deformity, it is important to interrupt the plane where scar contracture occurs by incorporating a boot flap and augmenting the volume. In this analysis, the postoperative scores were significantly better than the preoperative scores in both patients with unilateral and bilateral cleft lips. The results revealed that the boot flap was effective in preventing scar contractures.

Postoperative scores in patients with an incomplete cleft lip were significantly higher than those in patients with a complete cleft lip, although preoperative scores showed no significant difference between patients with incomplete and complete unilateral cleft lips. Based on this analysis, the boot flap is thought to yield better results in incomplete cases than in complete cases of unilateral cleft lip. The reason for this finding remains unknown. Tan et al postulated that patients with incomplete cleft lip would require fewer revisions than those with more severe cleft lip phenotypes.4 Previous studies supporting this presumption show a higher number of labial revisions in bilateral complete versus unilateral complete cleft lip and palate cases.20,23

CONCLUSIONS

The boot flap yields good results in secondary repair of the free border in patients with unilateral and bilateral cleft lips. Our analysis revealed postoperative score improvement after long-term follow-up in both the unilateral and bilateral cases. Additional scars did not appear because the boot flap was designed along the previous operative scars from the primary cleft lip repair. The boot flap has many advantages and is very useful in patients with mild-to-moderate deficiency of the free border of the lip.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

Patients provided written consent for the use of their images.

Supplementary Material

gox-13-e7107-s002.pdf (4.7MB, pdf)
gox-13-e7107-s003.pdf (11.8MB, pdf)

Footnotes

Published online 23 September 2025.

Presented at the 16th World Congress of the International Cleft Lip and Palate Foundation, July 17–19, 2024, Tokyo, Japan.

Disclosure statements are at the end of this article, following the correspondence information.

Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.

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Associated Data

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Supplementary Materials

gox-13-e7107-s002.pdf (4.7MB, pdf)
gox-13-e7107-s003.pdf (11.8MB, pdf)

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