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Macrostomia, also called a transverse or horizontal facial cleft, is a relatively rare malformation. 1,2 It is often associated with the first branchial arch syndrome 3 and the first and second branchial arch syndrome, 4 especially with the former type. Many plastic surgeons have developed surgical procedures for repair of this malformation. 5–17 The purposes of those procedures involve (1) the formation of symmetric lips and symmetric commissure of the mouth, (2) reconstruction of the orbicularis muscle of the mouth to restore labial function, and (3) reconstruction of the natural-looking commissure of the mouth to produce a natural contour. 1,2 Although many surgical procedures have been introduced to achieve these therapeutic goals, the procedures are controversial 13–16 and no gold standard has yet been established. Therefore, plastic surgeons select the most appropriate procedure for individual patients. We devised a surgical method to achieve the above therapeutic goals and to allow us to adjust intraoperatively the position of the commissure according to the degree of deformation of macrostomia. We obtained relatively satisfactory clinical results by using this technique, and here we describe our technique and present clinical cases.In macrostomia, the commissure of the mouth on the affected side is expanded and displaced inferolaterally in a cleft-like form. Disruption of facial expression muscles, including the orbicularis muscle, and cleft of the oral mucosa are also present. These disruptions should be repaired in a manner that is rational both anatomically and functionally. From an aesthetic point of view, a treatment method should be selected very carefully so as to provide a natural look when the patient changes facial expression. Therefore, we consider that every surgical procedure for macrostomia repair should be devised and performed by using the same levels of techniques and concepts as for cleft lip repair.The details of our surgical procedure are as follows. First, the distance from the commissure of the mouth on the unaffected side up to the inferior edge of the philtral column, i.e., the intersection between the philtral column and the white roll (highest point of Cupid’s bow), is measured. 1,16 Point A is placed at a point apart from the contralateral highest point of Cupid’s bow, and this measured distance is transposed on the contralateral white roll of the upper lip. At that time, because a protrusion formed by the stump of the orbicularis muscle usually exists on the vermilion just lateral to point A, as mentioned by Kaplan, 9 by using this stump as a landmark, we confirm a design. Next, point B, which is the commissure of the mouth on the lower lip corresponding to point A, is defined in the same manner by reference to the distance between the midpoint of the lower vermilion and the commissure of the mouth on the unaffected side. Although the protrusion of the orbicularis muscle in the lower lip may be less apparent than that in the upper lip, we select point B by considering that the thickness of the vermilion is usually narrowed abruptly in the cleft region. Then point C, which is equally distant from points A and B, is selected. This point C is at the apex of a triangular tissue, which is thought to provide the least conspicuous dog-ear after resection. The distance from point A or B to point C is generally about 20 to 40 mm, although it may differ according to the length and severity of the cleft and naturally also depends on the age of the patients.