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GRAND ROUNDSGRAND ROUNDSRowena Abante M.D.

February 11, 2010


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CLEFT LIP

Cleft lip


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CLEFT LIP


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CLEFT LIP

Incidence

1/1000 live births

By race:

American Indians 3.6:1000

Japanese 2.1:1000

Chinese 1.7:1000

Caucasians 1:1000

Blacks 0.7:1000

14% are associated with syndromes

2/3 occur in males

80% unilateral; 20% bilateral

2/3 left-sided


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CLEFT LIP

Etiology Genetic

Is heterogenous

+/- environmentalinsults Fetal alcohol exposure Smoking

Folic aciddef/antagonists

Phenytoin

Retinoic acidderivatives

Amniotic band syndrome

Maternaldiabetes

Cleft lip +/-

Palate (%)

Cleft Palate

(%)

Parents Normal, first child affected,

no affected relatives

Affected relatives

Parents normal,

2 affected relatives

One parent, no affected children

One parent, one affected child

4

4

9

4

17

2

7

10

6

15


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CLEFT LIP

Embryology

Criticalperiod ofPalataldevt: 8-12 wks

Criticalperiod for CL +/- Pdevt: 4-6wks

5 facialprimordia appear around the

stomodeum (primitive mouth) early in the 4th

week

Frontonasal prominence Paired maxillary prominence

Paired mandibular prominences


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CLEFT LIP

EmbryologyAt 6-7 wks, the medial nasalprominences merge with each other and the maxillary

processes to form the intermaxillary segment which give rise to:

Philtrum

Premaxilla

Primary palate (median palatine process)

NasalTip


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CLEFT LIP

Embryology

The lateral maxillary prominences

form the

Laterallip

Lateral maxilla

Secondary palate

Lateral nasal ala


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CLEFT LIP

Embryology

Failure of fusion of the

medial nasal

prominences with themaxillary prominences

Failure of fusion of the lateral

palatine process

Cleft Lip +/- Palate

cleft palate


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CLEFT LIP

Classification


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CLEFT LIP

Characteristics

Nasal ala on cleft side is inferiorly, posteriorly, and

laterally displaced

Orbicularis muscle is

oriented upward, parallel

to cleft margins,

orbicularis sphincter

disruptedMaxilla is hypoplastic on

cleft side


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CLEFT LIP

CharacteristicsColumella is displaced to the non-cleft side

Medial crus is

shorter, and the

lateral crus is longer

on the cleft lowerlateral cartilage

Dome on cleft side is

lower, resulting in alar

flattening and horizontal

nostril shapeAlveolar defect passes

Nasal floor is absent


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CLEFT LIP

Goals of Treatment

full thickness of the vermillon

restoration ofCupids bow at the proper

level

recreation of the missing philtral line

restoration of the vermillion tubercle

adequate liplength andprojection inrelation to the lower lip

Improvement in:

closure and elevation of the nostril floor

restoration of normal nostril size and

symmetry

straightening of the tilted columella

proper positing of the ala on the cleft side


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CLEFT LIP

the rule of tens - 10 wks, 10 lbs, Hgb 10

Cleft lip repair is commonly performed between 3-6months of age

Cleft palate repair is frequently performed between 6-

18 months.

Timing of Surgical Repair


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CLEFT LIP

Rose-Thompson Straight Line Closure

TennisonTriangular Flap (Randall Modification)

Quadrilateral Flap (Wang Modification ofLeMesurier

Techniques)

Millard Rotation Advancement Technique

Techniques


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CLEFT LIP


The first documentation of cleft lip repair occurred in the fourth century AD inChina.

This simple technique involved freshening and approximation of the cut cleft

edges, and remained the standard of care until 1825 when von Graefe proposed

the use of curved incisions to allow lengthening of the lip.


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CLEFT LIP


His work provided the foundation for the Rose-Thompson technique and other

straight-line closure repairs introduced in the early 1900s.

The straight-line closures, however, had the disadvantage of vertical scar contracture

leading to notching of the lip


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CLEFT LIP

Indication: Linear closure of a minimaldefect with

no distortion of the nostril floor



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The mediallip element is lengthened by introducing a triangular flap from the inferior

portion of the laterallip element

TennisonTriangular Flap (Randall Modification)

Advantage:

Adds length to the medial

lip element

Rebuilds a good floor of

the nostril

Preserves cupids bow

Adds tissue in the lower

one-third of the lip

Disadvantage: The Z in the lip crosses the

philtral line

Confusing technique

Vermillion contour is

deficient in midline

Tendency to increase lip

height on the repaired side

Decreasing the discrepancyin liplength


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Quadrilateral Flap (Wang Modification ofLeMesurierTechniques)The mediallip element is lengthened by introducing a quadrilateral flapdeveloped from the lateral

lip element

Advantage:

The major and minordistance of the flap are

vertical and horizontal

Provides more tissue at

he mucocutaneous line

to provide a pouting lip

Easy and

straightforward

Disadvantage:

More tissue is lost inthe flap creation


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CLEFT LIP

Millard Rotation Advancement Technique

for repair of both incomplete and complete cleft

lip

Most accepted method for single cleft lipdefect

cut as you go technique advances a mucocutaneous flap from the laterallip

element into the gap of the upper portion of the lip

resulting from the inferior downward rotation of the

mediallip element

The repair attempts to place the lip scars along

anatomic lines of the philtral column and nasal sill


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CLEFT LIP

Millard Rotation Advancement TechniqueAdvantages:

Minimal or no tissue discarded

suture line is camouflaged

flexible and adaptable

normallooking cupids bow provides good access to the nose

alar base and nasal floor are easily reconstructed

Disadvantages:

frequent contracture of the vertical scar

gap on the noncleft side created by the downward rotation of the flap may be too extensive for the lateral

advancement flap sometimes a mismatch in the vermillion

increases scarring of the lip

sight method


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Post-operative CarePost-operative Care

MonitorigVS

Suctioning the mouth

Monitoring the airway

Applying elbow restraints

Post-operative feeding

Asepto syringe

Boiled water that has returned to room

temperature is given first, later formula feeding is

resumed


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CLEFT LIP

Complication ofLip Repair

insufficient rotation of the flap

vermilion-cutaneous mismatch vermilion notching and a tight-appearing lateral

lip element,

a lateral muscle bulge,

a laterally displaced ala,

a constricted-appearing nostril

dehiscence of the repair (more common

if the repair is delayed until the childislearning to walk and falls) and

excessive scar formation and/or

contracture oflip scars


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CLEFT LIP

Feeding

encourage uninterrupted breastfeeding after

surgery.

soft catheter-tip syringe for 10 days and then

resuming normal nipple bottle feeding


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CLEFT LIP

PLAN

Cheiloplasty using Millard Rotation Advancement Flap

Uranoplasty at 18 months


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Thank youThank you


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CLEFT LIP

Cleft lip


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CLEFT LIP

Cleft lip

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