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 after bilateral cleft lip repair. This deformity represents a significant aesthetic stigma after bilateral cleft lip repair and is challenging to correct. In severe cases, the whistle deformity can lead to functional speech issues due to a resultant inability to seal the lips while creating 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 for bilateral cleft lip repair, although some techniques may predispose to this deformity more than others. The authors 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 autoaugmentation 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. The PAUL flap-an effective adjunct to prevent a whistle deformity-can be used with any skin pattern technique designed for the prolabial skin flap in primary bilateral cleft lip repair.