craniofacial defects are rare , disfiguring facial anomalies , with an incidence of about 1.4 to 4.9 cases per 100,000 live births . craniofacial clefts may be caused by failure of the maxillary processes to fuse , external pressure , amniotic bands , oligohydramnios , central disorganization of the neural crest , and hematomas . in 1973 , the median cleft of the upper lip , or tessier 0 class , has a variety of presentations , ranging from a minimal notching of the lip , vermilion , and nose to a wide cleft that divides craniofacial structures . tessier 0 clefts result from failure of the two medial nasal processes to fuse at midline . median clefts are broadly classified into true and false ; false clefts are due to agenesis of the medial nasal process , while true clefts are due to failure of the medial nasal process to fuse . treatment of median clefts depends on the clinical presentation and may vary from simple alignment of orbicularis oris and vermilion , to reconstruction of the cupid 's bow and philtrum for true median clefts , and complex craniofacial procedures in case of false median clefts . various techniques have been described to repair mild or moderate true median cleft lips . here we report using a pfeifer incision to correct a moderate true median cleft of the upper lip . pfeifer incision includes wavy lines , which elongate the incised tissues as the waves are straightened to close in a straight line , and also provide extra tissue for a tension free closure . a five - year - old boy with a facial cleft presented to our clinic . on examination , there was a median cleft of the upper lip involving the white roll , with no bony involvements . the highest- ( points a , a ) , and the deepest - points ( points b , b ) of the white roll were marked on both sides . subsequently , a wavy incision line was made starting from the deepest point and extending over the philtrum just above the cleft ( fig . a diamond incision was made over the vermilion and the labial mucosa , intra - orally extending just beyond the cleft margin . incision was made and the mucosal tissue covering the area medial to the incision site ( sterile zone ) was removed . undermining of the orbicularis oris muscle was performed and it was approximated using 4 - 0 vicryl . the cupid 's bow was properly aligned , with equal height on both sides ( fig . vermilion form was satisfactory and the fullness and continuity of the orbicularis oris were maintained . incision marking for pfeifer technique ( a , a : highest points on white roll ; b , b : deepest points on white roll ) postoperative result after suture removal a median cleft can also be called midline cleft or vertical cleft through the centre of the upper lip , and is a rare anomaly , the exact developmental origin of which is not clear . tessier 0 clefts occur during the third week of gestation due to failure of the two medial nasal processes to close in midline . it can occur in isolation or be a part of a syndrome such as orofacial - digital syndrome . false clefts are associated with abnormalities of the forebrain and are categorized under the category of holoprosencephaly . in 1937 , veau   categorized median clefts to notch of the lip , median cleft extending to the columella , and defects due to atrophy of the midline facial structures . median cleft face syndrome , frontonasal dysplasia , and tessier 0 clefts are various terms used to describe abnormalities associated with true median clefts that are not accompanied by forebrain abnormalities . the tessier 0 anomaly may present as a small notch in the soft tissue , or in association with hypertelorism , midline craniofacial osseous defects , and hairline abnormalities . various treatment options are present for mild deformities which do not involve the white roll . when developing the treatment plan , reconstruction of the cupid 's bow , labial philtrum , vermillion , and buccal mucosa should be kept in mind . urata and kawamoto   described using a v - y flap , while weimer et al ,   used a diamond incision to repair these anomalies . da silva frietas and colleagues   described a mucosal z transposition technique to treat mild cases . for moderate defects involving the philtrum , these waves are subsequently approximated in a straight line , which help expanding the length and width of the tissue . this incision has previously been used to correct other tessier clefts with a high success rate . the above - mentioned studies prove the versatility of the pfeifer incision . in our case we were able to achieve adequate symmetry of the philtrum and the cupid 's bow , which is important in cases like this . the postoperative results were excellent and proper approximation of the orbicularis oris muscle and the vermilion was achieved with a symmetrical cupid 's bow and philtrum . the only disadvantage of this technique is that the final closure line is placed directly over the philtrum . since the presentation of midline cleft deformities varies widely , each case should be individually considered and treated . pfeifer incisions can successfully provide mucosal length , vermilion fullness , and lip symmetry in patients with moderate median cleft lip .
median cleft is the midline cleft of the lip . 
 it develops due to incomplete or failed fusion of the median nasal prominence . 
 it can present with minimal deformities such as involvement of the vermilion border , or complex clefting of the midline structures and brain . 
 median clefts are broadly classified as true and false clefts . 
 this case report describes a rare case of median cleft of the upper lip involving the white roll , which was not associated with any other deformities . 
 treatment included reconstruction of the philtrum and the cupid 's bow while maintaining vermilion fullness and continuity , and minimizing scar formation . 
 various techniques have been advocated for treatment of this type of median upper lip cleft . here 
 we describe a technique using pfeifer incision to correct our patient 's defect . 
 pfeifer incision consists of wavy lines and its use has been advocated for correction of various craniofacial abnormalities .