Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair [1st ed.] 9783030446802, 9783030446819

Table of contents :
Front Matter ....Pages i-xxi
Anatomy (Percy Rossell-Perry)....Pages 1-25
Classification (Percy Rossell-Perry)....Pages 27-45
Protocol (Percy Rossell-Perry)....Pages 47-62
Preoperative Considerations (Percy Rossell-Perry)....Pages 63-70
Unilateral Cleft Lip Repair (Percy Rossell-Perry)....Pages 71-161
Bilateral Cleft Lip Repair (Percy Rossell-Perry)....Pages 163-276
Cleft Palate Repair (Percy Rossell-Perry)....Pages 277-394
Back Matter ....Pages 395-400

Citation preview

Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair Percy Rossell-Perry

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Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair

Percy Rossell-Perry

Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair

Percy Rossell-Perry Plastic surgery Edgardo Rebagliati Hospital ESSALUD of Lima Peru Lima Peru

ISBN 978-3-030-44680-2    ISBN 978-3-030-44681-9 (eBook) https://doi.org/10.1007/978-3-030-44681-9 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

I wish to dedicate this book to my Lord Jesus Crist who guides all my works. To my understanding wife Patti and my parents Blanca and Percy. To my friend, Dr. William Carter, in gratitude to his generous help as surgeon and professor, giving his best for the benefit of poor children of Peru. To my professors, Drs. Daniel and Claudio Kirschbaum who made my professional development in plastic surgery possible. Finally, this book is dedicated to all my patients and their parents who taught me a lot about love for others.

Foreword

My relationship with Dr. Percy Rossell-Perry dates back to 2006 when he visited the UCLA Craniofacial Clinic as the American Society of Plastic Surgeons Educational Foundation’s Visiting Professor. Although he had extended his 3 months’ stay by a month, it was clearly not to teach more about the repair of cleft lips and palates, as is well attested by this book, but to extend his knowledge about craniofacial surgery. Dr. Rossell-Perry’s experience in the management of clefts of the lip and palate is extensive. He has already written “Tratamiento de la Fisura Labio Palatina,” “Cirugia de la Fisura Labial Unilateral,” “Cirugía de la Fisura Labial Bilateral” (with an English translation on a disc), “Cirugia de la Fisura Palatina,” and “Malos Resultados y Complicaciones en la Cirugía de Fisura Labio Palatina.” Now comes this seventh book with its comprehensive coverage of the primary treatment of cleft lip and palate malformations. This volume is extremely well illustrated and covers every variation of the malformations. Rationale and detailed description of the technique used to address the defects are well described. Thus, surgeons beginning their adventure into the field as well seasoned veterans will profit by reading this book. Henry K. Kawamoto Jr, MD, DDS UCLA School of Medicine Division of Plastic Surgery Los Angeles, CA, USA

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Foreword

I am happy to write this foreword for Professor Rossell-Perry, a dedicated surgeon, teacher, and major contributor to the cleft literature. I do not know Dr. Rossell-Perry personally. I have been asked to write this because of my international reputation based on 50  years of publishing extensively on cleft lip, palate and craniofacial surgery, developing a premier center for the treatment of patients in Dallas, Texas, USA, and performing over 16,000 operations. I have dedicated my career to teaching, traveling, lecturing, and initiating or supporting teams in the developing world through the World Craniofacial Foundation, which has treated thousands of complex charity cases from 75 countries. This continues to be my passion. The author has achieved outstanding results in Lima, Peru, where I know the basic systems necessary to support sophisticated teams may be seriously absent or flawed, making it very difficult to improve outcomes. This atlas represents the author’s 25 years of experience, his very well-thought-­ out protocol, and excellent results. The protocol was developed working in Lima in a number of different hospital settings. Since 2016, Dr. Percy Rossell-Perry has served as a plastic surgery assistant at the Edgardo Rebagliatti Martín Hospital of ESSALUD, where he performs pediatric reconstructive plastic surgery focused on cleft care. The author has spent his professional career working with cleft lip and palate patients crafting his approach “standing on the shoulders of the giants in cleft care before him.” He is a professor of post-graduate studies of the faculty of Human Medicine of San Martín de Porres University in Lima. In addition to his own practice, he has worked and taught in multiple hospitals in Lima. As medical director of the Outreach Surgical Center Program in Lima, a cleft program supported by ReSurg International and Smile Train, he has treated more than 3000 patients with clefts in Peru and other countries from 1994 to 2019. Few surgeons in the developing world match Dr. Rossell-Perry’s achievements. The classification, protocol, and techniques he has developed and modified are now compiled in this atlas with pleasant, detailed color illustrations. This book should be of interest to all cleft surgeons as well as those studying this field, such as medical students, residents, and fellows interested in learning these proven techniques. The atlas demonstrates how one dedicated man can create a well-documented ix

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Foreword

and thoughtful approach to all variations and degrees of deformity in cleft patients in the developing world. This detailed atlas of his life’s surgical experience is now available in one place for the first time. Much of the atlas’s content is based on Dr. Rossell-Perry’s previously published articles on classification, diagnosis, and detailed treatment for each variation of cleft lip and palate deformity. It is a very nice composite of his experience and should be a welcome addition to the library of anyone who is serious about surgical cleft care and wants to expand their knowledge. Keep it available as a handbook for studying his approach and methods before or during operations. A critique and discussion of some methods and technical details of his approach in this atlas seem appropriate. The triangular flap is one of the technical foundations for the author’s approach to unilateral cleft lip repair, which is used by few surgeons today. The most popular approach is some variation of rotation advancement. The author uses the triangular flap in various unique and successful ways when it is placed a few millimeters above the vermillion to lengthen the medial cleft lip element but also simultaneously lengthen the lateral lip element when needed in severe unilateral deformity of the lip. His detailed description of the all-important muscle reconstruction in the lip repair is well illustrated. He also uses a vermillion triangular flap to correct the wet line in the manner of Noordhoff. The triangular flap technique originated by Tennyson, which was first published in 1946 then modified by Randall in 1959, is the foundation of the author’s approach. The author, “standing on the shoulders of the giants before him,” modified their technique, as well as incorporating concepts of Pool based on the rotation-­ advancement operation, to arrive at his operation. It is interesting that the author used a rotation advancement technique for his first 10  years in practice but was unhappy with scarring when using this procedure. He started using the triangular flap technique, which is well-known to me because my colleague and co-author in multiple books was Janusz Bardach, M.D., a very dear friend and superb cleft scholar and surgeon. Dr. Bardach started using a single or double triangular flap, depending on the deformity, in the 1960s in Poland before he immigrated to the USA. He continued to have superb results with the triangular flap technique throughout his career. I have great personal respect for those who successfully use these techniques. Most surgeons are able to achieve satisfactory results using almost any technique when they are adept and experienced in unilateral cleft lip repair. However, consistently achieving good or excellent primary nasal reconstruction is rare in the hands of most surgeons. I was happy to see that the author addresses the primary nose in unilateral and bilateral cases using the V-Y-Z technique, which he developed. It is a combination of Potter’s and Berkeley’s concepts of lateral Z-plasty. He has refined this to achieve good results using an alar cartilage rotational composite flap. Primary nasal reconstruction at the time of the lip repair has been my primary focus from the beginning of my career. I developed the Salyer primary lip-nose complex procedure in the 1970s and have used modifications of it to the present day with consistently good to excellent results. Kudos to the author for developing his own successful primary nose operation.

Foreword

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Depending on the degree of deformity, bilateral primary lip and nose repair remain a difficult problem that has not been completely solved. The author’s approach is a variation of a bilateral straight-line closure, utilizing the tissue present as much as possible. Small variations, such as a triangular flap and other methods, balance and lengthen the lip. Dr. Rossell-Perry consistently closes both sides of the lip simultaneously, whether with lip adhesion or definitive repair tailoring, and using the prolabium that is present. Depending on the degree of deficiency of the columella in bilateral closure of the lip (especially with a prolabium less than 6 millimeters in height), this procedure will pull the nose down and deform it more severely at the expense of the lip. I like closing one side of the lip at a time when no presurgical orthodontics or nasoalveolar molding is available. The premaxilla is rotated back one side at a time, preventing the need for surgically doing a setback, which I think should be avoided at all costs. The author does not mention or use this technique. The primary goal for cleft palate repair remains good speech. My preferred procedure is a two flap palatoplasty, which Bardach and I developed together. It remains the best procedure available for wide cleft palate. Dr. Rossell-Perry’s protocol, which is demonstrated nicely in this atlas, is a one-stage procedure based on non-­ radical intravelar veloplasty but with variations depending on the degree of tissue deficiency in an attempt to limit elevating mucoperiosteum flaps, which may adversely affect growth of the maxillae. This is the reason for his single flap palatoplasty. The key to good speech is a good levator veli palatini muscle closure, as the author demonstrates, and that it does not need to be radical. I would agree. The speech results are presented in a chart that demonstrates results comparable to the best outcomes by other expert cleft surgeons. Speech evaluations need to be continued over years with documented criteria by expert speech pathologists. Professor Rossell-Perry has produced an excellent atlas based on one surgeon’s experience demonstrating very clearly his techniques. I suggest that long-term outcomes with photographic documentation after years of growth—and ideally after completion of treatment—should be included in the atlas’s second edition. The single most important factor in achieving excellent outcomes in primary cleft surgery is the “surgeon,” not the technique. There are few internationally accomplished cleft surgeons. The author is one of those surgeons. Congratulations to him on his expert surgery and this atlas. Kenneth E. Salyer, MD, FACS, FAAP Founder & Chairman of the Board World Craniofacial Foundation Dallas, USA

Acknowledgments

I would like to express my gratitude to my brother Luis Rossell-Perry for his contribution with the excellent designs of this book.

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Introduction

The Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair is my seventh book and represents a lifetime dedication to this field supported by 25 years of experience and more than 3000 operated patients. This book, based on illustrative images of primary cleft lip and palate repair, is a useful educational tool for any resident or surgeon with interest in cleft surgery. Used techniques are well designed and presented with long-term outcomes. The preoperative evaluation of a patient with cleft lip and/or palate must consider a carefully identification of the cleft deformity and its degree of severity. There is a wide spectrum of cleft lip nose and palate deformities, from occult forms to severe deficiencies associated with median facial dysplasia. Better understanding of the primary deformity and refined surgical technique have resulted in decreased secondary deformities and stigmata of the repaired cleft. An adequate classification system is necessary to establish an objective evaluation of the preoperative patient’s condition. The author uses his cleft lip and palate classification based on degree of severity with this purpose in this textbook. The selection of a proper strategy (surgical technique) to address the lip, nose, and/or palate deformity and surgeon’s skills and experience are equally important. Both are key points to improve surgeon’s outcomes. Appropriate supportive treatment must consider an interdisciplinary management including orthodontic and speech therapy. A team work will achieve a more consistent and satisfactory result. The surgical techniques presented here have evolved over a period of 25 years. The Triple Unilimb Z plasty for unilateral cleft lip repair is a good example. This is more than a simple modification (in my personal understand); this is a true technique. Their utility and efficacy have been evaluated and demonstrated through different scientific researches developed by the author and published in high-impact indexed journals. Other personal contributions to the field of the cleft lip and palate treatment, such as the rotational composite and V-Y-Z rhinoplasties and the surgical nasoalveolar molding concept, are presented in this book. I feel grateful for the life-changing experience I had during my international fellowship at the Institute of Reconstructive Plastic Surgery of the New York University

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Introduction

and University of California Los Angeles under the direction of Dr. Joseph Mc Carthy and Dr. Henry Kawamoto Jr., respectively. I owe a special thanks to Dr. William Carter, MD, for his lessons during my first years of sharing surgical campaigns in Peru, and I am deeply grateful to my brother Luis Rossell-Perry who did the beautiful illustrations in this book. Percy Rossell-Perry Edgardo Rebagliatti Martins Hospital ESSALUD Lima, Peru

Contents

1 Anatomy������������������������������������������������������������������������������������������������������    1 1.1 Upper Lip and Nose ����������������������������������������������������������������������������    1 1.2 Anatomy of the Palate ������������������������������������������������������������������������   18 References����������������������������������������������������������������������������������������������������   25 2 Classification����������������������������������������������������������������������������������������������   27 2.1 Classification of Severity��������������������������������������������������������������������   27 2.2 The Clock Diagram ����������������������������������������������������������������������������   43 2.3 The Cleft Code������������������������������������������������������������������������������������   44 References����������������������������������������������������������������������������������������������������   45 3 Protocol ������������������������������������������������������������������������������������������������������   47 3.1 Cleft Lip and Palate: General Protocol of Management����������������������   48 References����������������������������������������������������������������������������������������������������   61 4 Preoperative Considerations��������������������������������������������������������������������   63 4.1 Cleft Lip and Palate Preoperative Considerations ������������������������������   63 References����������������������������������������������������������������������������������������������������   70 5 Unilateral Cleft Lip Repair ����������������������������������������������������������������������   71 5.1 Unilateral Cleft Lip Surgical Techniques��������������������������������������������   71 5.2 Author’s Surgical Technique ��������������������������������������������������������������   73 5.3 Presurgical Considerations������������������������������������������������������������������   74 5.4 Unilateral Cleft Lip Surgical Protocol������������������������������������������������   74 5.4.1 Mild Unilateral Cleft Lip��������������������������������������������������������   74 5.4.2 Moderate Unilateral Cleft Lip������������������������������������������������   96 5.4.3 Severe Unilateral Cleft Lip ����������������������������������������������������  110 5.5 Unilateral Cleft Lip Primary Rhinoplasty: The Surgical Nasal Molding Concept ������������������������������������������������  124 5.5.1 Mild Unilateral Cleft Lip Nose ����������������������������������������������  128 5.5.2 Moderate and Severe Unilateral Cleft Lip Nose ��������������������  134 5.5.3 Nasal Floor Reconstruction����������������������������������������������������  146

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Contents

5.6 Skeletal Reconstruction ����������������������������������������������������������������������  148 5.7 Postoperative Care ������������������������������������������������������������������������������  155 5.8 Case Studies����������������������������������������������������������������������������������������  157 References����������������������������������������������������������������������������������������������������  160 6 Bilateral Cleft Lip Repair ������������������������������������������������������������������������  163 6.1 Presurgical Orthopedics����������������������������������������������������������������������  163 6.2 Bilateral Cleft Lip Surgical Techniques����������������������������������������������  165 6.3 Author’s Surgical Technique ��������������������������������������������������������������  166 6.4 Presurgical Considerations������������������������������������������������������������������  166 6.5 Bilateral Cleft Lip Surgical Protocol ��������������������������������������������������  168 6.5.1 Surgical Orthopedics��������������������������������������������������������������  168 6.5.2 Primary Bilateral Cleft Lip Repair������������������������������������������  178 6.6 Bilateral Cleft Lip Primary Rhinoplasty: The Surgical Nasal Molding Concept ������������������������������������������������  248 6.7 Skeletal Reconstruction ����������������������������������������������������������������������  265 6.8 Postoperatory Care������������������������������������������������������������������������������  270 6.9 Case Studies����������������������������������������������������������������������������������������  271 References����������������������������������������������������������������������������������������������������  276 7 Cleft Palate Repair������������������������������������������������������������������������������������  277 7.1 Cleft Palate Surgical Techniques ��������������������������������������������������������  277 7.2 Author’s Surgical Technique ��������������������������������������������������������������  279 7.3 Presurgical Considerations������������������������������������������������������������������  281 7.4 The Lima Cleft Palate Surgical Protocol ��������������������������������������������  282 7.4.1 Submucous Cleft Palate����������������������������������������������������������  282 7.4.2 Incomplete Cleft Palate ����������������������������������������������������������  289 7.4.3 Unilateral Cleft Palate ������������������������������������������������������������  312 7.4.4 Bilateral Cleft Palate ��������������������������������������������������������������  339 7.5 Use of Buccal Fat Pad in Primary Cleft Palate Repair������������������������  370 7.6 Muscular Reconstruction: The Non-radical Intravelar Veloplasty����������������������������������������������������������������������������  372 7.7 Uvular Repair: The Unilateral Uvuloplasty����������������������������������������  380 7.8 Postoperative Care ������������������������������������������������������������������������������  383 7.9 Case Studies����������������������������������������������������������������������������������������  385 References����������������������������������������������������������������������������������������������������  393 Index������������������������������������������������������������������������������������������������������������������  395

About the Author

Percy  Rossell-Perry,  born in Lima, studied human medicine at San Marcos University of Lima completing in 1993. Then, he took up plastic surgery training at Kirschbaum Institute between 1993 and 1996 and Militar Central Hospital between 1996 and 1999 supported by San Marcos University of Lima. Dr. RossellPerry did his Visiting Scholar Fellowship at Emori University, Atlanta, in 2004 and UCLA and New York University in 2006 (Drs. Henry Kawamoto and Joseph Mc Carthy). His teaching experience began in 1987  in the Department of Human Anatomy of the School of Human Medicine at the University of San Marcos and he continued teaching there until the year 2000. Dr. Rossell-Perry taught specialty courses at the University of San Marcos, Cayetano Heredia University, and the Peruvian Society of Plastic Surgery. At present, he is professor of Post Graduate Studies of the Faculty of Human Medicine of San Martin de Porres University in Lima, Peru. Although involved in many aspects of plastic surgery, his main activity now is centered on surgery for patients with cleft lip and palate. Since 2016, Dr. Rossell-­Perry is plastic surgeon assistant of the Edgardo Rebagliatti Martins Hospital of ESSALUD where he performs pediatric reconstructive plastic surgery. He was a Consultant Plastic Surgeon at the Casimiro Ulloa Hospital (2004–2008), Cayetano Heredia Hospital (2009), and San Bartolome Hospital of Lima (since 2010). In addition, during the past few years he has worked as a consultant plastic surgeon in other hospitals of Lima, such as Alberto Sabogal and Guillermo Almenara Hospitals of ESSALUD. In 2011, he obtained a master’s degree in Teaching University and a doctorate (PhD) in Human Medicine from San Marcos University of Lima in 2014. xix

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About the Author

Dr. Rossell-Perry has a diploma in Clinical Research from Harvard University, USA. During his professional career, Dr. Rossell-Perry has been awarded several times. In 2002, he was awarded with the KAELIN National Award for scientific research from ESSALUD. Later, he received the Humanitarian Award from the Interplast Foundation, USA, in 2003. Then, in 2005 he won the Plastic Surgery Educational Foundation Scholarship granted by the Pierr Foundation, USA.  In Perú, Dr. Rossell-­ Perry received twice the Hipolito Unanue National Award for the Best Scientific Edition in 2013 and 2019 for the books: Basic management of chronic cutaneous lesions based on scientific evidence and Bad results and complications in cleft lip and palate surgery, respectively. He has written many books and scientific articles. Dr. Rossell-Perry is the main author of the following books: Cleft Lip and Palate Treatment (2009), Unilateral Cleft Lip Surgery (2011), Basic management of chronic cutaneous lesions based on scientific evidence (2012), Bilateral Cleft Lip Surgery (2013), Cleft Palate Surgery (2015), and Bad results and complications in Cleft Lip and Palate Surgery (2018)as well as author’s chapter Principles of Cleft Palate Repair in Global Cleft Care in Low-Resource Settings textbook. Since 2006 he has authored 40 scientific articles published in high-impact indexed journals. Dr. RossellPerry is Editorial Board Member of the Plastic and Reconstructive Surgery GO Journal and Journal of Craniofacial Surgery. He is reviewer of some of the most important plastic surgery journals of the world, such as Plastic Reconstructive Surgery Journal, Aesthetic Plastic Surgery Journal, Journal of Plastic Surgery and Hand Surgery, and Journal of Craniofacial Surgery. Dr. Rossell-Perry is a well-known international lecturer presenting his experience in countries such as Chile, Brazil, Mexico, and The USA and elected as Member of the Scientific Committee of the IX and X International Cleft Lip and Palate Foundation Congress (CLEFT 2009 in Brazil) and (2013 in the USA). He has

About the Author

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been Chair of the Symposium “Cleft Surgery in developing countries” during CLEFT 2013  in Orlando, USA. Dr. Rossell Perry is a Fellow of American College of Surgeons and member of the American Society of Plastic Surgery, American Cleft Palate Association, and other international medical associations. Currently has been elected President of the Latin American Craniofacial Association (LATICFA) for 2018–2020 period. Dr. Rossell-Perry was Medical Director of the Outreach Surgical Center Program Lima, a cleft program supported by ReSurge International and Smile Train Foundations from the USA, which attended to more than 3000 patients with clefts in Peru and other countries for 25 years, since 1994 until 2019. Recently has been elected Scientific Director of the South American Medical Advisory Council of the Smile Train Foundation, USA.

Chapter 1

Anatomy

1.1  Upper Lip and Nose A detailed knowledge of the upper lip and nose anatomy is required for a better understanding of the anatomy of the cleft. Understanding the normal lip and nasal anatomy is essential for any surgeon managing cleft lip deformities. This is presented in Figs. 1.1 and 1.2. There is a broad spectrum of variations in the clinical presentation of unilateral and bilateral cleft lip involving the upper lip, nose, alveolus, and palate (Figs. 1.3, 1.4, 1.5, 1.6, 1.7, and 1.8). We may consider the following types for surgical protocol purposes: (a) Mild unilateral cleft lip (includes microform and incomplete cleft lips) (b) Moderate unilateral cleft lip (c) Severe unilateral cleft lip This is an anatomical classification based on the degree of severity as the author described in the respective chapter. Moderate and severe cases are mostly a complete type of cleft lip.

© Springer Nature Switzerland AG 2020 P. Rossell-Perry, Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair, https://doi.org/10.1007/978-3-030-44681-9_1

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1 Anatomy

Fig. 1.1  Upper lip surface anatomy. 1. Nasal tip. 2. Columellar base. 3. Columellar base (lateral point). 4. Alar base. 5 Philtral column. 6. Cupid’s bow (middle point). 7. Cupid’s bow (lateral point). 8. White roll. 9. Red roll. a: Supralabium. b: Infralabium

 he Microform Unilateral Cleft Lip Microform (Fig. 1.3) T This type is characterized by partial or total clefting of the upper lip muscles. A minimal discrepancy between the heights of cleft and non-cleft side lip may be observed. The difference between these two distances is less than 3 mm.

1.1  Upper Lip and Nose

3

Fig. 1.2  Upper lip anatomical landmarks. A and B: Alar bases. 1-2-3: Cupid’s bow. 4: Point between supra- and infralabium. 6-5-7: Columellar base. 6-A and 7-B: Nasal sill. 1-6 and 3-7: Philtral column height. 1-A and 3-B: Distance from alar base to cupid’s bow (lateral point). C and D: Oral commissure. 6-A and 7-B: Nasal floor 1-6, 2-5 and 3-7: Upper lip height 1-C and 3-D: Upper lip lateral width. 1-1′, 2-2’and 3-3′: Vermilion height

 he Incomplete Unilateral Cleft Lip (Fig. 1.4) T This type is characterized by a partial or total clefting of the skin, muscle, and mucosa of the upper lip sparing the underlying skeletal structures. Sometimes a notch may be observed affecting the primary palate. Soft tissue band located at the nasal sill named as Simonart’s band may be present. Both microform and incomplete forms represent a mild degree of severity according to the author’s classification [1].

4 Fig. 1.3 Microform Unilateral Cleft Lip

Fig. 1.4 Incomplete Unilateral Cleft Lip

1 Anatomy

1.1  Upper Lip and Nose

5

 he Complete Unilateral Cleft Lip (Fig. 1.5) T This type is characterized by a clefting of the skin, muscle, mucosa, and underlying skeletal framework (primary and/or secondary palate). Narrow bands of upper lip soft tissue may be present in this type of cleft lip. Depending on the lip’s asymmetry, the degree of severity of complete cleft lip deformity is considered moderate or severe according to the author’s classification [1]. Variations in clinical presentation of bilateral cleft lip involve the upper lip, nose, alveolus and palate (Figs. 1.6, 1.7, and 1.8). We may consider the following types for surgical protocol purposes: (a) Mild bilateral cleft lip (Includes microform and incomplete cleft lips). (b) Moderate bilateral cleft lip. (c) Severe bilateral cleft lip. This is an anatomical classification based on degree of severity as the author described in the respective chapter. The microform bilateral cleft lip (Fig. 1.6). This type is characterized by partial clefting of the upper lip muscles. A minimal lip height discrepancy between both sides may be observed. The differences between these two distances is less than 3 mm. The incomplete bilateral cleft lip (Fig. 1.7). This type is characterized by a partial clefting of the skin, muscle and mucosa of the upper lip sparing the underlying skeletal structures. Simonart’s band may be present. This type of cleft may affects one or both sides of the bilateral cleft lip.

Fig. 1.5 Complete Unilateral Cleft Lip

6 Fig. 1.6  Microform + incomplete bilateral cleft lip

Fig. 1.7 Incomplete bilateral cleft lip

1 Anatomy

1.1  Upper Lip and Nose

7

Fig. 1.8  Complete bilateral cleft lip

Both microform and incomplete forms represent the mild degree of severity under author’s classification [1]. The complete bilateral cleft lip (Fig. 1.8). This type is characterized by a clefting of the skin, muscle, mucosa and underlying skeletal framework (primary and/or secondary palate). The cleft may affects one or both sides of the bilateral cleft lip. Combination of these types may be observed in bilateral cleft lips. The anatomy of the nose includes both its cartilaginous structure and the soft tissues that make it up. The anatomical subunits of the external nose are nasal dorsum, nasal tip, alae, columella, and nostril sill (Figs. 1.9, 1.10, and 1.11). The cartilaginous anatomy of the nose includes lower lateral cartilages (medial and lateral crus and domes), the upper lateral cartilages, and nasal septum (Fig. 1.12). The internal anatomy of the nose is constituted by lateral wall (turbinates), medial wall (nasal septum), and nasal floor. Its most anterior portion represents a functional area named as nasal vestibule. This is an area located between the external and internal nasal valves. It is the most anterior part of the nasal cavity. This is enclosed by the cartilages of the nose (alar cartilages superiorly and nasal septum medially), the nostril sill inferiorly, and the ala and lower turbinate laterally (Fig. 1.13). The nasal vestibule and the primary and secondary palates constitute the nasal floor and roof of the mouth (Fig. 1.14). This is composed of the nostril sill, alveolus (primary palate), and hard palate (secondary palate). The nose and upper lip muscles associated with the primary cleft lip repair are as follows (Figs. 1.15, 1.16, and 1.17):

8

1 Anatomy

Fig. 1.9  Normal anatomy of the external nose. 1. Domes (nasal tip) 2. Supra alar crease. 3. Nostril. 4. Columella. 5. Soft tissue triangles. 6. Alae. 7. Medial crura footplate. 8. Nostril sill. 9. Lip columellar crease. 10. Subalar crease

Nasolabial muscles (a) Orbicularis oris muscle Narirn [2] described that this muscle contains 2 segments: marginal and peripheral. The marginal segment includes fibers from levator labii superioris, levator labii superioris alaeque nasi, and zygomaticus. It runs below the skin and closes the oral opening. The peripheral segment runs between the angles of the mouth (modiolus). This segment pushes the lip forward. (b) Levator labii superioris alaeque nasi This is a muscle of facial expression that widens the nostrils and elevates the upper lip and alae. This muscle is inserted at the frontal process of the maxilla and then is inserted into the skin of the alae and upper lip (orbicularis oris complex) [3]. The alar

1.1  Upper Lip and Nose

9

Fig. 1.10  Anatomy of the unilateral cleft lip nose. 1. Domes (nasal tip) 2. Supra alar crease. 3. Nostril. 4. Columella. 5. Soft tissue triangles. 6. Alae. 7. Medial crura footplate. 8. Nostril sill. 9. Lip columellar crease. 10. Subalar crease

division is inserted into the alae through a fibrous tendon at the level of the alar base. It is easily identified during primary cleft lip surgery. The arterial supply of the upper lip and nose in normal and cleft patients is provided by the following arteries (Figs. 1.18, 1.19, and 1.20): (a) Facial artery. A branch of the external carotid artery that supplies structures of the superficial face. (b) Angular artery. The final branch of the facial artery. Runs alongside the nose and goes up to the medial canthus. (c) Medial nasal artery (dorsal nasal branch). A terminal branch from the ophthalmic artery through the anterior ethmoidal artery.

10

1 Anatomy

Fig. 1.11  Anatomy of the bilateral cleft lip nose. 1. Domes (nasal tip) 2. Supra alar crease. 3. Nostril. 4. Columella. 5. Soft tissue triangles. 6. Alae. 7. Medial crura footplate. 8. Nostril sill. 9. Lip columellar crease. 10. Subalar crease

(d) Lateral nasal artery. This artery supplies the alae and dorsum of the nose anastomosing with the medial nasal branch. (e) Superior labial artery. This artery supplies the upper lip and gives off three main branches: septal, alar, and terminal.

1.1  Upper Lip and Nose

a

11

b

Fig. 1.12 (a) Unilateral cleft lip nose. (b) Bilateral cleft lip nose. 1. Nasal bone. 2. Maxilla. 3. Nasal septum. 4. Upper lateral cartilages. 5. Lower lateral cartilages

Fig. 1.13  Nasal vestibule. 1. Alar margin. 2. Nasal columella. 3. Caudal septum. 4. Nasal tip. 5. Intercartilaginous border (limen nassi). 6. Alar cartilage (skyblue area). 7. Nostril sill. 8. Internal nasal valve angle. 9. Nostril

12

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Fig. 1.14  Nasal floor anatomy. A. Nostril sill. B. Primary palate (alveolus). C. Secondary palate (hard palate). D. Soft palate. E. Nasal septum

Fig. 1.15  Facial muscles. 1. Levator labii superioris alaeque nasi muscle. 2. Labial division of this muscle. 3. Nasal division of this muscle. 4. Orbicularis oris muscle (marginal muscle). 5. Orbicular oris muscle (peripheral muscle). 6. Levator labii superioris. 7. Nasalis. 8. Zigomaticus minor. 9. Zigomaticus major. 10. Depressor anguli oris. 11. Depressor labii inferiores. 12. Mentalis

1.1  Upper Lip and Nose

13

Fig. 1.16  Unilateral cleft lip facial muscles. 1. Levator labii superioris alaeque nasi muscle. 2. Labial division of this muscle. 3. Nasal division of this muscle. 4.Orbicularis oris muscle (marginal muscle). 5. Orbicular oris muscle (peripheral muscle). 6. Levator labii superioris. 7. Nasalis. 8. Zigomaticus minor. 9. Zigomaticus major. 10. Depressor anguli oris. 11. Depressor labii inferiores. 12. Mentalis

14

1 Anatomy

Fig. 1.17  Bilateral cleft lip facial muscles. 1. Levator labii superioris alaeque nasi muscle. 2. Labial division of this muscle. 3. Nasal division of this muscle. 4.Orbicularis oris muscle (marginal muscle). 5. Orbicular oris muscle (peripheral muscle). 6. Levator labii superioris. 7. Nasalis. 8. Zigomaticus minor. 9. Zigomaticus major. 10. Depressor anguli oris. 11. Depressor labii inferiores. 12. Mentalis

1.1  Upper Lip and Nose

15

Fig. 1.18  Upper lip and nose vascularization in normal person. 1. Medial nasal artery. 2. Angular artery. 3. Lateral nasal artery. 4. Columellar branches. 5. Superior labial artery. 6. Inferior labial artery. 7. Facial artery

16

1 Anatomy

Fig. 1.19  Upper lip and nose vascularization in unilateral cleft lip. 1. Medial nasal artery. 2. Angular artery. 3. Lateral nasal artery. 4. Columellar branches. 5. Superior labial artery. 6. Inferior labial artery. 7. Facial artery

1.1  Upper Lip and Nose

17

Fig. 1.20  Upper lip and nose vascularization in bilateral cleft lip. 1. Medial nasal artery. 2. Angular artery. 3. Lateral nasal artery. 4. Columellar branches. 5. Superior labial artery. 6. Inferior labial artery. 7. Facial artery

18

1 Anatomy

1.2  Anatomy of the Palate (a) Surface anatomy of the cleft palate Presurgical analysis of the surface anatomy of the cleft palate identifying the relevant structures is mandatory. Most important structures to be considered before the cleft palate surgery planning are presented in Figs. 1.21, 1.22, 1.23, and 1.24. I must emphasize the location of the greater palatine vascular bundle in order to

a

b

Fig. 1.21  Surface anatomy of the unilateral cleft palate. 1. Alveolar cleft. 2. Vermilion. 3. Alveolar ridge (gum). 4. Lateral edge of the hard palate. 5. Maxillary tuberosity. 6. Oral mucosa. 7. Hard palate mucosa. 8. Vomer. 9. Soft palate pit. 10. Soft palate. 11. Hemiuvula. 12. Adenoids. x: Greater palatine foramen location. Left: A. Cleft segment. B: Non-cleft segment. Right: A. Non-cleft segment. B: Cleft segment. a. Upper frenulum. b. Gingival sulcus

a

b

Fig. 1.22  Surface anatomy of the bilateral cleft palate. 1. Premaxilla. 2. Vermilion. 3. Alveolar ridge (gum). 4. Lateral edge of the hard palate. 5. Maxillary tuberosity. 6. Oral mucosa. 7. Hard palate mucosa. 8. Vomer. 9. Soft palate pit. 10. Soft palate. 11. Hemiuvula. 12. Adenoids. x: Greater palatine foramen location. Right: a. Alveolar cleft. b. Gingival sulcus

1.2  Anatomy of the Palate

a

19

b

Fig. 1.23  Surface anatomy of the incomplete cleft palate. 1. Primary palate. 2. Vermilion. 3. Alveolar ridge (gum). 4. Lateral edge of the hard palate. 5. Maxillary tuberosity. 6. Oral mucosa. 7. Hard palate mucosa. 8. Adenoids. 9. Soft palate. 10. Hemiuvula. x: Greater palatine foramen location

Fig. 1.24  Surface anatomy of the submucous cleft palate. 1. Primary palate. 2. Vermilion. 3. Alveolar ridge (gum). 4. Lateral edge of the hard palate. 5. Maxillary tuberosity. 6. Oral mucosa. 7. Hard palate mucosa. 8. Translucent zone in soft palate. 9. Soft palate pits. 10. Soft palate. 11. Hemiuvula. x: Greater palatine foramen

20

1 Anatomy

prevent its damage during the cleft palate repair. Vascularization of the mucoperiosteum of the hard palate comes mainly from the greater palatine vessels which emerge from the greater palatine foramen. Important structures to be identified during the observation of the surface anatomy of the cleft palate are the posterior border of the palatine bone which presents in the lateral segment the posterior alveolar ridge dimple (useful for identifying the position of the greater palatine foramen) and the soft palate pit (Figs.  1.21, 1.22, 1.23, and 1.24). The posterior alveolar ridge dimple is caused by the action of the tensor aponeurosis over the oral mucosa. The soft palate pit (or fold) is a depression of the palatal mucosa that is located immediately behind the hard palate and caused by traction of the palatal muscles as described by Tse et al. [4]. At this level, the oral submucosa is thinner and the surgical dissection of the oral mucosa may injure its integrity with consequent development of palatal fistulas. (b) Soft palate muscles The soft palate consists of muscle fibers sheathed in mucous membrane. There are five paired muscles of the soft palate [5] (Fig. 1.25). Musculus uvulae  This muscle lies entirely within the uvula. It originates at the level of the posterior nasal spine and is inserted into the uvula. This muscle shortens and broadens the uvula. The uvula is used to articulate a range of consonant sounds [6]. Levator veli palatini  Its function is to elevate the soft palate closing the velopharyngeal space. It arises from the petrous portion of the temporal bone and cartilaginous segment of the auditory tube. After passing above the superior pharyngeal constrictor muscle, its fibers spread out into the velum [7]. Tensor veli palatini  This muscle is providing tension to the soft palate and to open during the swallowing of the Eustachian tube. This muscle is made up of two segments. It arises from the scaphoid fossa at the base of the medial pterygoid plate and the lateral wall of the auditory tube. Then the fibers of this muscle descend and end as a tendon which winds around the hamulus [8]. Medially, this tendon is inserted into the palatine aponeurosis and behind the posterior border of the palatine bone together with the levator muscle. Palatopharyngeus muscle  This muscle pulls the pharynx upward during swallowing. It is composed by two fasciculi: the anterior fasciculus which lies in the soft palate between the levator and tensor veli palatini and joins in the middle line, and the posterior fasciculus which joins with the opposite muscle in the midline. Palatoglossus muscle  This muscle closes the oropharyngeal isthmus and initiates the function of swallowing. The palatoglossus arises from the palatine aponeurosis passing then downward in front of the palatine tonsil and inserted into the side of the tongue.

1.2  Anatomy of the Palate

21

Fig. 1.25  Abnormal insertion of the velar muscles in an incomplete cleft palate patient. 1. Hard palate. 2. Palatine process of maxilla. 3. Palatal aponeurosis. 4. Greater palatine artery. 5. Tendon of the tensor veli palatini. 6. Hamulus. 7. Tensor veli palatini muscle. 8. Levator veli palatini. 9. Palatopharyngeous and palatoglossus muscles. 10. Uvularis muscle

(c) Arterial supply of the cleft palate (Figs. 1.26, 1.27, and 1.28) Few studies about the vascular supply of the cleft palate have been done. One of the most important researches related to the vascularization of the cleft palate have been developed by Maher [9]. Maher described variations of the arteries of the palate in cleft patients and observed in cleft and non-cleft fetuses arterial anastomoses between the greater palatine artery and the following arteries: infraorbital, superior

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1 Anatomy

Fig. 1.26  Unilateral cleft palate vascularization. 1. Greater palatine artery. 2. Descending palatine artery. 3. Ascending palatine artery. 4. Anterior palatine artery. 5. Branches from infraorbital artery. 6. Superior alveolar artery. 7. Superior labial artery. A: Vascular anastomoses between descending palatine artery and ascending palatine artery through lesser palatine vessels. B: Vascular anastomoses between greater palatine artery and anterior palatine artery

alveolar, sphenopalatine branches from the maxillary artery, and superior labial branches from the facial artery. Main blood supply of the palate is provided by the greater palatine artery (branch of descending palatine artery from the maxillary artery). This artery reaches the mucoperiosteum of the hard palate and runs anteriorly (continuing its pathway into an osseous groove until it reaches the retroincisive zone) in the lateral portion of the palate near its junction with the alveoli. In cleft palate patients, additional vascularization is provided by multiple branches passing both medially from the nasal mucosa (connecting nasal and palatal mucosa) and laterally toward the alveolus [10].

1.2  Anatomy of the Palate

23

Fig. 1.27  Bilateral cleft palate vascularization. 1. Greater palatine artery. 2. Descending palatine artery. 3. Ascending palatine artery. 4. Anterior palatine artery (absent). 5. Branches from infraorbital artery. 6. Superior alveolar artery. 7. Superior labial artery. 8. Dorsal nasal artery. A: Vascular anastomoses between descending palatine artery and ascending palatine artery through lesser palatine vessels

Descending palatine artery provides the lesser palatine branches which enters to the soft palate through the lesser palatine foramens. The blood supply of the soft palate is provided in addition by the following arteries: ascending palatine (from the facial artery), tonsillar (branch of the ascending palatine artery), and ascending and

24

1 Anatomy

Fig. 1.28  Incomplete cleft palate vascularization. 1. Greater palatine artery. 2. Descending palatine artery. 3. Ascending palatine artery. 4. Anterior palatine artery (absent). 5. Branches from infraorbital artery. 6. Superior alveolar artery. 7. Superior labial artery. 8. Dorsal nasal artery. A: Vascular anastomoses between descending palatine artery and ascending palatine artery through lesser palatine vessels

References

25

recurrent pharyngeal (both from external carotid artery). There is a large network of anastomoses between the vessels that supply the hard palate and soft palate (Figs. 1.26, 1.27, and 1.28). One of the most important is the anastomoses between the ascending palatine branch and lesser palatine arteries (in variable number). This vascular connection acquires importance when the greater palatine artery is sectioned during the cleft palate surgery. Gauthier et al. (2002) published a study performing ligation of both descending palatine arteries and observed perfusion of the hard palate mucosa via anastomoses between the greater palatine and ascending palatine arteries mainly through the lesser palatine arteries [11]. This study demonstrates the existence of vascular anastomoses between hard and soft palates and confirms that the section of the vascular pedicle of the flap is not necessarily related to flap necrosis [11]. These findings support the concept described by Wardill and Dorrance in their techniques which include the section of both greater palatine pedicles in order to obtain proper length of the palate, without any report of palatal necrosis. Another vascular anastomosis is present between the anterior palatine artery (from the sphenopalatine artery which comes through the incisive foramen) and the greater palatine artery. However, this anastomosis is observed only in the unilateral cleft palate at the non-cleft side (Fig. 1.26). Important differences exist between the arterial supply of different types of cleft palate (Figs. 1.26, 1.27, and 1.28). This anatomical consideration supports the proposed cleft palate surgical protocol in this book.

References 1. Rossell-Perry P.  New diagram for cleft lip and palate description: the clock diagram. Cleft Palate Craniofac J. 2009;46(3):305–13. 2. Nairn R. The circumoral musculature structure and function. Br Dent J. 1975;138:49. 3. Hur M, Hu K, Park J, Youn K, Kim H. New anatomical insight of the levator labii superioris alaeque nasi and the transverse part of the nasalis. Surg Radiol Anat. 2010;32(8):753–6. 4. Tse R, Siebold B. Cleft palate repair: description of an approach, its evolution and analysis of postoperative fistulas. Plast Reconstr Surg. 2018;141(5):1201–14. 5. Cutting C, Rosenbaum J, Rovati L. The technique of muscle repair in the cleft soft palate. Oper Tech Plast Reconstr Surg. 1995;2(4):215–22. 6. Finkelstein Y, Meshorer A, Talmi Y, Brenner J, et al. The riddle of the uvula. Otolaryn Head Neck Surg. 1992;107(3):444–50. 7. Finkelstein Y, Talmi Y, Nachmani A, Hauben D. Levator veli palatini muscle and Eustachian tube function. Plast Reconstr Surg J. 1990;85(5):684–92. 8. Matsune S, Sando I, Takahashi H. Insertion of the tensor veli palatini muscle into the Eustachian tube cartilage in cleft palate cases. Ann Otol Rhinol Laryngol. 1991;100(6):439–46. 9. Maher W. Distribution of palatal and other arteries in cleft and non-cleft human palates. Cleft Palate J. 1977;14(1):1–12. 10. Cho J, Kim J, Park H, Suh J, Kim J, et al. Arterial supply of the human soft palate. Surg Radiol Anat. 2017;39(7):731–4. 11. Gauthier A, Lezy Z, Vacher C. Vascularization of the palate in maxillary osteotomies: anatomical study. Surg Radiol Anat. 2002;24(1):13–7.

Chapter 2

Classification

2.1  Classification of Severity Current classifications based on anatomical features of the cleft are not enough for proper diagnosis and management of the patient. Therefore, there is a need for a new classification and descriptive diagram that will allow for the most complete cleft deformity illustration based on its severity. The widely used classifications (like Kernahan’s or Veau’s) are descriptions of the components involved in the cleft, but they do not consider the severity of its distortion [1]. In addition, current diagrams for cleft description show which segment is compromised but not how severely it is affected. The severity of the cleft is probably the most important element to be considered in surgical planning. The use of presurgical orthopedics, lip adhesion, and modification of surgical techniques are good examples of individualized management of the cleft lip and palate. Based on the previous publications by the author, four basic components are considered for cleft lip and palate description [2]: (A) upper lip, (B) nose, (C) primary palate, and (D) secondary palate. Following are the descriptions of some of the modifications. (A) Upper Lip The upper lip description involves the medial and lateral segments in unilateral cleft lips and right and left segments in bilateral cleft lips (Figs. 2.1, 2.2, 2.3, 2.4, 2.5, and 2.6). The more the discrepancy of the lip height between the segments, the more severe is the lip deformity, since the main objective of the surgery is the lip’s symmetry. In unilateral cleft lips, the soft tissue deficiency is determined by the difference in the upper lip height between the non-cleft segment and cleft segment. This discrepancy illustrates the lateral segment hypoplasia and upper lip asymmetry. The non-cleft lip height is measured from the peak of the cupid’s bow to a line tangent to the base of the columella at the medial segment. This distance is measured from the end of the cupid’s bow to

© Springer Nature Switzerland AG 2020 P. Rossell-Perry, Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair, https://doi.org/10.1007/978-3-030-44681-9_2

27

28 Fig. 2.1  Mild unilateral cleft lip

Fig. 2.2 Moderate unilateral cleft lip

Fig. 2.3  Severe unilateral cleft lip

2 Classification

2.1  Classification of Severity

29

Fig. 2.4  Mild bilateral cleft lip

Fig. 2.5 Moderate bilateral cleft lip

the subnasal depression at the lateral segment of the cleft. Both measurements are done at 3 months of age. Initially the cupid’s bow rotation has been used to evaluate the medial segment soft tissue deficiency. However, there is not any correlation with the surgical management and, therefore, it was abandoned. In bilateral cleft lips, the soft tissue deficiency is determined by the difference in the lip height between the right segment and left segment. This discrepancy illustrates the degree of asymmetry of the soft tissue of the upper lip. This distance is measured on both sides from the end of the white roll to the subnasal depression following the cleft margin.

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2 Classification

Fig. 2.6  Severe bilateral cleft lip

The three forms of unilateral cleft lip deformity based on lip component are as follows. • Mild  Difference between the non-cleft and cleft segment lip height is less than 3 mm. • Moderate  Difference between the non-cleft and cleft segment lip height is between 3 and 6 mm. • Severe  Difference between the non-cleft and cleft segment lip height is more than 6 mm. The three forms of bilateral cleft lip deformity based on lip component are as follows. • Mild  Difference between the right and left segment lip height is less than 3 mm. • Moderate  Difference between the right and left segment lip height is between 3 and 6 mm. • Severe  Difference between the right and left segment lip height is more than 6 mm. (B) Nose The degree of nose deformity is used in our hospital to select the surgical technique but not for presurgical management due to the limited use of presurgical nasal molding by us.

2.1  Classification of Severity

31

Fig. 2.7  Unilateral cleft lip. Nasal septum deviation for unilateral cleft lip nose estimation

Fig. 2.8  Bilateral cleft lip. Columellar height (x) for bilateral cleft lip nose estimation

In unilateral cleft lips, the nose deformity is measured by the angle of the nasal septum deviation (columellar angle) based on initial description published by Fisher [3]. The nasal septum deviation or columellar angle is measured considering the columellar axis and its intersection with the horizontal plane across the columellar’s base (Fig. 2.7). In bilateral cleft lips, the degree of nose deformity is measured using the columellar height. This distance is measured from the columellar peak to the subnasale point (Fig. 2.8). Measurements are done at 3 months of age in both types of clefts.

32

2 Classification

The three forms of unilateral cleft lip deformity based on nose component are (Figs. 2.9, 2.10, and 2.11) as follows. • Mild  Columellar angle is greater than 60 degrees. • Moderate  Columellar angle between 30 and 60 degrees. • Severe  Columellar angle is less than 30 degrees. Fig. 2.9  Mild unilateral cleft lip nose

Fig. 2.10 Moderate unilateral cleft lip nose

2.1  Classification of Severity

33

Fig. 2.11  Severe unilateral cleft lip nose

Fig. 2.12  Mild bilateral cleft lip nose

The three forms of bilateral cleft lip deformity based on nose component are (Figs. 2.12, 2.13, and 2.14) as follows: • Mild  Columellar height is equal or greater than 4 mm. • Moderate  Columellar height is between 2 and 4 mm. • Severe  Columellar height is equal or less than 2 mm.

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2 Classification

Fig. 2.13 Moderate bilateral cleft lip nose

Fig. 2.14  Severe bilateral cleft lip nose

(C) Primary palate I use the cleft width to determine the severity grade for cleft lip and palates. In unilateral cleft lip and palate, the width of the alveolar gap between the medial and lateral segments determines the severity of the cleft (Fig. 2.15). Actually, there is not any correlation between the primary palate degree of severity and surgical protocol for unilateral cleft lip and palates. For bilateral cleft lip and palate deformity, the type of cleft is determined by the more severely affected side (based on cleft’s width) (Fig. 2.16). The width of the alveolar gap is an important element to determine presurgical and surgical management of bilateral cleft lip and palate. It is measured at 1 year of age before cleft palate surgery.

2.1  Classification of Severity

35

Fig. 2.15  Unilateral cleft lip. x: Width of the alveolar gap for evaluation of primary palate

Fig. 2.16  Bilateral cleft lip. x: Width of the alveolar gap for evaluation of the primary palate

(D) Secondary palate Estimation of the cleft palate is done by comparing the cleft’s width and the sum of the width of both palatal segments. This proportion is named as cleft palate index [4]. The same parameter is used for incomplete, unilateral, and bilateral cleft palates. The cleft’s width is measured at the posterior border of the palatine bone between the hard and soft palates from the maxillary tuberosity to the posterior nasal spine (Fig. 2.17). X: Cleft width measured at the hard palate posterior border level. Y: Palatal segment diameter (right and left) measured at the same level as X.

Index : X / Y 1 + Y 2



36

2 Classification

The three forms of cleft palate deformity based on secondary palate component are: • Mild  Cleft palate index is less than 0.20. • Moderate  Cleft palate index is between 0.20 to 0.40. • Severe  Cleft palate index is greater than 0.40. The three forms of unilateral cleft lip and palate deformity based on primary palate component are (Figs. 2.18, 2.19, and 2.20) as follows. • Mild  Cleft width less than 5 mm. • Moderate  Cleft width between 5 and 10 mm. • Severe  Cleft width greater than 10 mm. Fig. 2.17  The clef palate index: X/Y1 + Y2

Fig. 2.18  Mild unilateral cleft lip and palate (primary palate component)

2.1  Classification of Severity

37

Fig. 2.19 Moderate unilateral cleft lip and palate (primary palate component)

Fig. 2.20  Severe unilateral cleft lip and palate (primary palate component)

The three forms of bilateral cleft lip and palate deformity based on primary palate component are (Figs. 2.21, 2.22, and 2.23) as follows. • Mild  Cleft width less than 5 mm (more severely affected side). • Moderate  Cleft width between 5 and 10 mm (more severely affected side). • Severe  Cleft width greater than 10 mm (more severely affected side).

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2 Classification

Fig. 2.21  Mild bilateral cleft lip and palate (primary palate component)

Fig. 2.22 Moderate bilateral cleft lip and palate (primary palate component)

The classification for the incomplete secondary palate component is as follows (Figs. 2.24, 2.25, and 2.26). • Mild  Cleft palate index is less than 0.20. Includes submucous cleft palates. • Moderate  Cleft palate index is between 0.20 and 0.40. • Severe  Cleft palate index is greater than 0.40.

2.1  Classification of Severity

39

Fig. 2.23  Severe bilateral cleft lip and palate (primary palate component)

Fig. 2.24  Mild incomplete cleft palate

The classification for the unilateral secondary palate component is as follows (Figs. 2.27, 2.28, and 2.29). • Mild  Cleft palate index is less than 0.20. • Moderate  Cleft palate index is between 0.20 and 0.40. • Severe  Cleft palate index is greater than 0.40.

40 Fig. 2.25 Moderate incomplete cleft palate

Fig. 2.26 Severe incomplete cleft palate

Fig. 2.27  Mild unilateral cleft palate

2 Classification

2.1  Classification of Severity

41

Fig. 2.28 Moderate unilateral cleft palate

Fig. 2.29 Severe Unilateral Cleft Palate

The classification for the bilateral secondary palate component is as follows (Figs. 2.30, 2.31, and 2.32). • Mild  Cleft palate index is less than 0.20. • Moderate  Cleft palate index is between 0.20 and 0.40. • Severe  Cleft palate index is greater than 0.40.

42 Fig. 2.30  Mild bilateral cleft palate

Fig. 2.31 Moderate bilateral cleft palate

Fig. 2.32  Severe bilateral cleft palate

2 Classification

2.2  The Clock Diagram

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2.2  The Clock Diagram Different cleft lip and palate descriptions have been used traditionally. The Kernahan and Stark’s diagram is one of the most used diagrams around the world [1]. This diagram (the striped Y method) illustrate us which anatomic segment is involved but not how severely it is affected [5]. The clock diagram represents an illustration of the cleft lip and palate deformity based on the cleft lip and palate severity’s distortion [2] (Fig. 2.33). This is a circle divided into four areas, one for each cleft component described before. Each one is subdivided into three segments (like clock’s hours) which represent the three degrees of severity: mild, moderate, and severe. The clock numbers (1–12) are assigned to each degree of severity of the four components as follows: A. Right superior quadrant (lip component). Degrees: Mild (1), Moderate (2), Severe (3) B. Right inferior quadrant (nose component). Degrees: Mild (4), Moderate (5), Severe (6) C. Left inferior quadrant (primary palate component). Degrees: Mild (7), Moderate (8), Severe (9) D. Left superior quadrant (secondary palate component). Degrees: Mild (10), Moderate (11), Severe (12)

Fig. 2.33  The clock diagram for cleft lip and palate description

12

1

11

2

10

3

9

4

8

5 7

6

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2.3  The Cleft Code The cleft code consists of four numbers, one from each cleft component described in the clock diagram. This is a simple method to provide an accurate description of the severity of the cleft deformity. This is a very valuable instrument developed to characterize clefts according to their severity and facilitate the communication between the members of the cleft team using a simple cleft code based on four digits. This updated severity-based classification is directly related to the present cleft protocol used in our hospital. Examples (Figs. 2.34 and 2.35)

Fig. 2.34  Case 1. Complete left unilateral cleft lip and palate

Fig. 2.35  Case 1. Complete left unilateral cleft lip and palate

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References 1. Kernahan DA, Stark RB.  A new classification for cleft lip and palate. Plast Reconstr Surg. 1958;22(5):435–42. 2. Rossell-Perry P.  New diagram for cleft lip and palate description: the clock diagram. Cleft Palate Craniofac J. 2009;46(3):305–13. 3. Fisher D, Tse R, Marcus J. Objective measurements for grading the primary unilateral cleft lip nasal deformity. Plast Reconstr Surg J. 2008;122(3):874–80. 4. Rossell-Perry P, Caceres-Nano E, Gavino-Gutierrez A. Association between palatal index and cleft palate repair outcomes in patients with complete unilateral cleft lip and palate. JAMA Facial Plast Surg. 2014;16(3):206–10. 5. Kernahan DA. The striped Y: a symbolic classification for cleft lips and palate. Plast Reconstr Surg. 1971;47(5):469–70.

Chapter 3

Protocol

In Perú, approximately 1  in 700 live births is affected by cleft lip and palate. Actually, the prenatal diagnosis before birth is more frequent and lets us provide information to the parents about the protocol of management to help them understand their role in the treatment of their infant (Fig. 3.1). The first evaluation should be done by the pediatrician to establish patient’s condition and associated anomalies if present. The initial visit with the surgeon is recommended during the first week of life. Presurgical management is used by our team only in patients with severe bilateral cleft lip and palate. Lack of scientific evidence and associated complications are the reasons why we are not using this treatment frequently in our practice [1–3]. A meta-analysis published by Hamid Reza et  al. in 2017 concluded that further research is necessary to provide relevant recommendations of this treatment [1]. Another meta-analysis published by Papadopoulos et al. in 2012 [2] concluded that there is no benefit of presurgical orthopedics for cleft lip and palate patients. The lip is repaired at approximately 3–6 months of age and the palate around 9–12 months. Non-syndromic patients are discharged from the hospital the same day (cheiloplasty) or the next day after surgery (palatoplasty). The patient is then followed at regular intervals till adolescence. The present protocol is used for patients with non-­ syndromic cleft lip and/or palate. Syndromic patients should receive a special management developed by the medical board with special considerations in psychosocial aspect and family interaction. Management of the cleft lip and palate must be provided by interdisciplinary team.

© Springer Nature Switzerland AG 2020 P. Rossell-Perry, Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair, https://doi.org/10.1007/978-3-030-44681-9_3

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3.1  Cleft Lip and Palate: General Protocol of Management Newborn to three months old A. A pediatrician evaluates and establishes diagnosis and associated anomalies. Baby care and feeding instructions are also provided. B. Genetic counseling is provided if there is a positive family history. C. Then, the orthodontist and the surgeon examine cleft morphology to establish tissue deficiencies and classification of the cleft. The treatment plan is developed and explained to the parents. D. Severe bilateral cleft lip and palate (alveolar gap wider than 1 cm) should receive presurgical orthopedic management (Naso Alveolar Molding (NAM), elastic bandages, tapes, or lip adhesion). Premaxillary setback osteotomy should be used for refractory cases to non-surgical methods and a later age [4]. We don’t use presurgical treatment for unilateral cleft lip and palate cases in our hospital. E. Pediatrician evaluates prematurity and nutritional status and provides recommendation for feeding. Three to six months old A. Primary cheilorhinoplasty (Figs. 3.1, 3.2, 3.3, 3.4, 3.5, and 3.6). Lip and nose surgery is indicated for healthy patients with proper height and hemoglobin level. The rule of tens is used as parameter of presurgical patient condition. Ten pounds of height (around 5–6 kilograms), 10 gram of hemoglobin per deciliter, and 10 weeks of life (around 3 months old) are the criteria for cleft lip surgery [5, 6]. Presurgical evaluation is completed with the following tests:

Fig. 3.1  Surgical technique for mild unilateral cleft lip repair + rotational composite flap rhinoplasty

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Fig. 3.2  Surgical technique for moderate unilateral cleft lip repair + V-Y-Z rhinoplasty

Fig. 3.3  Surgical technique for severe unilateral cleft lip repair + V-Y-Z rhinoplasty

• Full blood count, hemostasis, urine test, ECG, and cardiologic evaluation for ASA grade estimation. Pediatric evaluation is recommended to determine nutritional status and acute or chronic infections. There is no consensus about which surgical technique is the best to address cleft lip and nose deformity because of absence of scientific evidence supporting differences between the techniques used. Surgeon skills and expertise may improve surgical technique limitations. For a long time and even now, the concept proposed by Millard (rotation advancement) and its modifications (like Mohler’s) is being used in our country.

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Fig. 3.4  Surgical technique for mild bilateral cleft lip repair + rotational composite flap rhinoplasty

Fig. 3.5  Surgical technique for moderate bilateral cleft lip repair + V-Y combined with mucosal flaps rhinoplasty

Use of Millard technique has been influenced by teams from United States through the surgical campaigns developed in Peru since late 1960s. The current trend is the use of triangular techniques based on Fisher’s technique. This is not a new concept; in fact, this is a reminiscence of Bardach’s technique.

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Fig. 3.6  Surgical technique for severe bilateral cleft lip repair + V-Y-Z or combined rhinoplasty + small skin resection

I moved my personal preference from Millard and its modifications to triangular techniques like Pool’s and triple unilimb Z plasty techniques for unilateral Primary cheiloplasty Unilateral cleft lip Mild unilateral cleft lip: Triangular technique based on Pool’s concepts. Moderate unilateral cleft lip: Triangular technique based on Tennison-­ Randall’s and Pool’s concepts. Severe unilateral cleft lip: Triangular technique (the triple unilimb Z plasty). Bilateral cleft lip∗ Mild bilateral cleft lip: Straight line closure based on Millard and Noordhoff’s techniques. Moderate bilateral cleft lip: Straight line closure plus unilimb Z plasty technique. Severe bilateral cleft lip: Straight line closure combined with skin excision plus unilimb Z plasty technique after presurgical orthopedic or lip adhesion. ∗Presurgical orthopedics or lip adhesion is indicated when severe primary palate component is diagnosed.

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Primary rhinoplasty Unilateral cleft lip Mild unilateral cleft lip nose: Rotational composite flap rhinoplasty. Moderate unilateral cleft lip nose: V-Y-Z technique based on Potter’s and Berkeley’s concepts. Severe unilateral cleft lip nose: V-Y-Z technique based on Potter’s and Berkeley’s concepts. Bilateral cleft lip Mild bilateral cleft lip nose: Bilateral rotational composite flap rhinoplasty. Moderate bilateral cleft lip nose: Bilateral Potter’s technique combined with lateral mucosal flaps. Severe bilateral cleft lip nose: Bilateral V-Y-Z technique or bilateral Potter’s technique combined with lateral mucosal flaps + small skin resection.

cleft lip [7, 8]. Modified Noordhoff’s technique and triangular techniques are used for bilateral cleft lip repair [9]. The surgical technique is selected according to the cleft lip and nose severity of the upper lip and nose components: Gingivoperiosteoplasty (GPP) and associated hard palate closure (Oslo’s protocol) are not used in our hospital due to lack of evidence supporting their utility and associated complications (such as increased rate of fistulas). A recent systematic review and meta-analysis published by El-Ashmawi et al. [10] indicated that GPP might not be an efficient method for alveolar reconstruction for patients with unilateral and bilateral cleft lip and palate. Also it could lead to maxillary growth inhibition in these patients. Closure of the lateral incisor space always results in flattening of the anterior alveolus and anterior crossbite [11]. B. Use of postoperative nasal conformers is mandatory after primary rhinoplasty in our protocol during the first 6 months. C. Postoperative follow-up is performed the day before the surgery, 1 week, 1 month, and 6 months by the surgeon. D. ENT evaluation is performed to determine if acute or chronic otitis media is present. Management of acute otitis media (AOM) may require myringotomy with tympanostomy tube insertion if this is symptomatic. One year old A. Evaluations by pediatrician and ENT specialist were carried out to establish the nutritional status and diagnosis of acute or chronic diseases at this time. B. Primary palatoplasty (Figs. 3.7, 3.8, 3.9, 3.10, 3.11, 3.12, 3.13, 3.14, 3.15, 3.16, and 3.17)

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Fig. 3.7  Randall’s modification of Furlow’s technique

Fig. 3.8  Randall’s modification of Furlow’s technique

Cleft palate surgery is indicated for healthy patients with proper height and hemoglobin level. The rule of tens is used as parameter of presurgical patient condition. Ten kilograms of height, more than 10 grams of hemoglobin per deciliter, and 10–12 months of life are the criteria for cleft palate surgery. Presurgical evaluation is completed with the following tests:

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Fig. 3.9  Hybrid surgical technique (Furlow + relaxing incision)

Fig. 3.10  Von Langenbeck technique

3 Protocol

3.1 Cleft Lip and Palate: General Protocol of Management

Fig. 3.11  Hybrid technique (unilateral relaxing incision)

Fig. 3.12  One-flap technique.

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Fig. 3.13  Hybrid surgical technique (one flap + unilateral relaxing incision)

Fig. 3.14  Hybrid surgical technique (unilateral relaxing incision)

3 Protocol

3.1 Cleft Lip and Palate: General Protocol of Management

Fig. 3.15  Von Langenbeck technique

Fig. 3.16  Hybrid surgical technique (one flap + unilateral relaxing incision)

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58 Fig. 3.17 Delayed hard palate closure technique

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• Full blood count, hemostasis, urine test, ECG, and cardiologic evaluation for ASA grade estimation. Pediatric evaluation is recommended to determine nutritional status and acute or chronic infections. Different surgical protocols for cleft palate repair are used around the world without consensus and absence of scientific evidence supporting better outcomes using any specific protocol. We use a surgical protocol based on our cleft palate classification: the Lima protocol [12]. For a long time and even now, the concept proposed by Bardach (two flap technique) is being popular in our country. According to my personal experience on cleft palate repair during the past 25 years, I would not recommend the use of this technique.

Primary Palatoplasty Incomplete cleft palate Veau I type: Randall’s modification Furlow’s technique. Veau II type: Mild incomplete cleft palate: Modified Furlow’s or minimal incision technique. Moderate incomplete cleft palate: Hybrid technique (Furlow + relaxing incision). Severe incomplete cleft palate: Von Langenbeck’s technique. Unilateral cleft palate Mild unilateral cleft palate: Hybrid technique (unilateral relaxing incision). Moderate unilateral cleft palate: One-flap technique. Severe unilateral cleft palate: Hybrid palatoplasty (One flap at the non-­ cleft side plus relaxing incision at the cleft side). Based on Davis-Colley concept. Bilateral cleft palate Mild bilateral cleft palate: Hybrid technique (unilateral relaxing incision). Moderate bilateral cleft palate: Von Langenbeck’s technique. Severe bilateral cleft palate∗: (a) Before 6 months: Delayed hard palate closure. (b) After 6 months: Hybrid palatoplasty (combination of one flap and lateral relaxing incision). ∗The strategy in this type is to transform the severe form into a moderate or mild form. The soft palate closure may change the width of the cleft if this is repaired before 6  months. Then the hard palate can be closed using Von Langenbeck technique at 1 year of age. If the soft palate closure is done after

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6 months, the width of the cleft is not changed and a hybrid palatoplasty is required to close the cleft without risk of palatal fistula development. All these types are operated using non-radical intravelar veloplasty for muscular repair, and uvular reconstruction is done using the unilateral uvuloplasty method. Elevation of mucoperiosteal tissues as monopedicled flaps at the cleft side leaves these tissues in higher risk of flap necrosis. I moved my personal preference to more conservative techniques avoiding unipedicled flaps at the cleft side. Different studies developed during the past years have supported this hypothesis [12–14]. The surgical technique is selected according to cleft palate severity (the Lima cleft palate protocol) as follows: C. Speech therapy evaluation and treatment 6 months after surgery. Two to Four years old A. Orthopedic maxillary arch expansion. Collapse of the upper maxillary arch could be severe in bilateral cleft lip and palate cases. Orthopedic devices like Hyrax or Haas may be required. B. Severe palatal fistulas closure. Due to the distortion of the nasal resonance observed in relation with severe palatal fistulas, we recommended fistula closure at this age. Use of obturators may be an alternative if the surgical correction is not possible. C. Tympanometry. Five years old A. Interdisciplinary evaluation (surgery and speech therapy) in order to determine speech disorders (velopharyngeal insufficiency) and its treatment. Nasoendoscopy and fluoroscopy are recommended to confirm the velopharyngeal insufficiency diagnostic. B. Velopharyngeal insufficiency surgical correction. Mild hypernasality is corrected using the Furlow’s technique or secondary intravelar veloplasty. Severe cases with increased hypernasality require obstructive techniques. We use the modified Hynes pharyngoplasty. C. Mild and moderate palatal fistula closure. Six to eight years old (dental mixed period) A. Orthodontic treatment before alveolar bone graft. Radiological evaluation to determine canine or lateral incisive position. Additionally, the following are recommended before alveolar bone graft: (a) Maxillary expansion. To correct transverse discrepancy.

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(b) Maxillary protraction. To correct sagittal discrepancy. Petit’s mask is one of the widely used devices. Requires a period of 6 months of treatment [15–17]. (c) Incisive alignment. (d) Supernumerary teeth should be removed at least 40  days before alveolar bone graft. Bilateral cleft lip and palate cases with prominent premaxilla may require surgical reposition of this segment at this time [12]. B. Alveolar cleft closure is performed at least 6  months before the alveolar bone graft. C. Alveolar bone graft. Alveolar bone deficiency is repaired using cancellous autologous bone graft raised from iliac crest or tibia. D. Orthodontic treatment after alveolar bone graft is recommended starting around 90 days. E. Audiometry. Sixteen to eighteen years old A. Interdisciplinary evaluation (dentist and surgeon) in order to determine occlusal disorders and its treatment. Cephalometric study is recommended to design surgical correction of the skeletal disorder. Orthodontic treatment before orthognathic surgery is necessary. B. Orthognathic surgery. Based on cephalometric study, Le Fort I maxillary advancement or bimaxillary surgery may be indicated. Distraction osteogenesis may be considered as alternative in cases with large occlusal discrepancy. Evaluation by speech therapist and nasoendoscopy are necessary after orthognathic surgery. C. Secondary rhinoplasty. Recommended 6 months after orthognathic surgery. Major septoplasty may be required at this time.

References 1. Hamid Reza H, Eleftherios K, Athanasios A. Treatment outcomes of presurgical infant orthopedics in patients with non-syndromic cleft lip and/or palate: a systematic review and meta-­ analysis of randomized controlled trials. PLoS One. 2017;12(7):e0181768. 2. Papadopoulos M, Koumpridou E, Vakalis M. Effectiveness of presurgical infant orthopedics treatment for cleft lip and palate patients: a systematic review and meta-analysis. Orthod Craniofac Res. 2012;15(4):207–36. 3. Levy-Bercowsky D, Abreu A, De Leon D, Looney S, et al. Complications and solutions in presurgical nasoalveolar molding therapy. Cleft Palate Craniofac J. 2009;46(5):521–8.

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4. Vyas R, Kim D, Padwa B, Mulliken J.  Primary premaxillary setback and repair of bilateral complete cleft lip: indications, technique and outcomes. Cleft Palate Craniofac J. 2016;53(3):302–8. 5. Wilhelmsen H, Musgrave R. Complications of cleft lip surgery. Cleft Palate J. 1966;3:223–31. 6. Chow I, Purnell C, Hanwright P, Gosain A. Evaluating the rule of 10s in cleft lip repair: to data support dogma? Plast Reconstr Surg J. 2016;138(3):670–9. 7. Rossell-Perry P. A 20-year experience in unilateral cleft lip repair: from Millard to the triple unilimb Z-plasty technique. Ind J Plast Surg. 2016;49(3):340–9. 8. Rossell-Perry P, Gavino-Gutierrez A. Upper double rotation advancement method for unilateral cleft lip repair of severe forms: classification and surgical technique. J Craniofac Surg. 2011;22(6):2036–42. 9. Lee SH, Koh KS, Lee TJ. Correction of complete bilateral cleft lip with Noordhoff method. Arch Craniofac Surg. 2000;1(1):23–8. 10. El-Ashmawi N, Elkordy S, Salah Fayed M, El-Beialy A, et al. Effectiveness of gingivoperiosteoplasty on alveolar bone reconstruction and facial growth in patients with cleft lip and palate: a systematic review and meta-analysis. Cleft Palate Craniofac J. 2018;56(1):7–14. 11. Berkowitz S. Why hasn’t Cutting and Grayson done a longitudinal study to show why nasoalveolar molding should not be used? Cleft Palate Craniofac J. 2019;56(1):141. 12. Rossell-Perry P, Cotrina-Rabanal O, Caceres-Nano E. New approach to the surgical treatment of congenital cleft palate. Circ Plast Ibero Latin. 2015;41(4):409–17. 13. Rossell-Perry P, Figallo-Hudtwalcker O, Vargas-Chanduvi R, Calderon-Ayvar Y, et  al. Risk factors leading to mucoperiosteal flap necrosis after primary palatoplasty in patients with cleft palate. J Plast Surg Hand Surg. 2017;51(5):348–51. 14. Rossell-Perry P, Cotrina-Rabanal O, Barrenechea-Tarazona L, Vargas-Chanduvi R. Mucoperiosteal flap necrosis after primary palatoplasty in patients with cleft palate. Arch Plast Surg. 2017;44(3):217–22. 15. Manosudprasit M, Wangsrimongkol T, Pisek P, Chowchuen B, Somsuk T. Growth modification in unilateral cleft lip and palate patients with face mask. J Med Assoc Thail. 2012;Suppl 11:S42–8. 16. Buschang P, Porter C, Genecov E, Genecov D, Salyer K. Face mask therapy of preadolescents with unilateral cleft lip and palate. Angle Orthod. 1994;64(2):145–50. 17. Dogan S.  The effects of face mask therapy in cleft lip and palate patients. Ann Maxillofac Surg. 2012;2(2):116–20.

Chapter 4

Preoperative Considerations

4.1  Cleft Lip and Palate Preoperative Considerations Even if parents are anxious to receive lip repair as soon as possible, there is a consensus to schedule cheiloplasty at 3 months of age and palatoplasty at 9–12 months of age. This decision is supported by surgical and anesthesiologist considerations [1, 2]. The preoperative analysis for primary cleft lip repair can be outlined in a “rule of ten” (10 pounds of weight, 10 grams of hemoglobin per deciliter, and 10 weeks of life) [3]. For primary palatoplasty, preoperative analysis can be outlined in a “cleft palate’s rule of ten” (10 kilos of weight, 10 grams of hemoglobin per deciliter, and 10–12 months of life). This concept is supported by our experience and not by scientific evidence. Presurgical evaluation is completed with the following tests: full blood count, hemostasis, urine test, ECG, and cardiologic evaluation for ASA grade estimation. Chest X-ray is required only if the patient’s history or physical exam suggests pulmonary abnormalities. Pediatric evaluation (through preoperative history, physical examination, and health clearance) is necessary to determine nutritional status and acute or chronic infections. Patients qualified for primary surgery must have physical status class 1 or 2 (based on American Society of Anesthesiology (ASA)) [4]. Non-syndromic cleft lip healthy child with no other medical problems would typically fall into an ASA 1 or 2 classification. Syndromic patients (ASA 3 or 4) should receive individual management developed by the medical board with special considerations in psychosocial aspect and family interaction. Preoperative anesthesia evaluation should be performed the day before surgery (or the same day) by pediatric anesthesiologist to identify if any active respiratory or urinary tract infection (UTI) is present [5]. These cases may need to be delayed 2–4 weeks until the health status is improved. The anesthetic plan should be discussed with the parents and signed informed consent obtained. Signed informed consent should be always obtained after detailed © Springer Nature Switzerland AG 2020 P. Rossell-Perry, Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair, https://doi.org/10.1007/978-3-030-44681-9_4

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information is delivered to the parents. Nothing per oral (NPO) guidelines is an important guidelines and has to be fulfilled by the parents. These recommendations include the following fasting time: breast milk (4  hours) and solids (6  hours). Surgical center must have a well-implemented postoperative PACU care and access to an intensive care unit (ICU) for patients with severe and life-threatening illnesses and injuries who require close monitoring. Cleft lip and palate surgery should be performed by an experienced team. Presurgical orthopedics is commonly used in different centers around the world. In our center, we do not use presurgical orthopedics to achieve proper surgical outcomes for any type of unilateral cleft lip and palate. Even severe unilateral cleft lip and nose can be repaired successfully without presurgical management. In our protocol, any form of presurgical orthopedics or surgical lip adhesion is necessary only for severe bilateral cleft lip and palate cases (alveolar gap wider than 1 cm). Adequate surgical instruments are recommended to perform this kind of microsurgery. Surgical loupes (3.5×) should be used to magnify the upper lip and palate structures and perform the surgical marking properly. Loupes should be used in combination with a surgical light (operating light or surgical light head) to assist the surgeon during the surgical procedure by illuminating the upper lip nasal (vestibule) and oral cavity. The use of microscope for cleft palate repair (radical intravelar veloplasty) promoted by Brian Sommerlad from UK is an alternative, but it is not used in our hospital. A 6.5× surgical loupes may be a good alternative for intravelar veloplasty during primary palatoplasty. The cleft lip surgical instrumental set includes (Fig. 4.1) the following: • Surgical marker pen • Castroviejo caliper measuring range • Scalpel round handle no. 3 Blades: I personally use 11 blade or 15C blade to score the skin to dermis along the marked incisions. Fifteen blade is used for the rest of surgical incisions including the skin of the nose. • • • • • •

Joseph double skin hook Stitch scissor Iris supercut scissors curved Iris supercut scissors straight Needle holder Adson tissue forceps

The cleft palate surgical instrumental set includes (Figs.  4.2 and 4.3) the following: • • • • •

Monopolar electrocautery Dingman mouth gag complete Palatometer Frazier suction tip Scalpel handle no. 7

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Fig. 4.1  Cleft lip instrumental set. Castroviejo caliper. B. Scalpel round handle no. 3. C. Joseph double skin hook. D. Stitch scissor. E. Iris supercut scissor curved. F. Iris supercut scissors straight. G. Needle holder. H. Adson tissue forceps

Fig. 4.2  Dingman mouth gag and tongue blade

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Fig. 4.3  Cleft palate instrumental set. A. Tissue forceps. B. Palatometer. C. Frazier suction tip. D. Scalpel handle no. 7. E. Gillies skin hook. F. Crile-Wood needle holder. G. Fomon curve scissor. H, I.  Metzenbaum scissors. J.  Nasal lining periosteal elevator. K.  Joseph periosteal elevator. L. Freer periosteal elevator

• • • • • • • • • •

Blades: 15 or 12 blade Joseph periosteal elevator Freer periosteal elevator Fomon lower lateral scissor strong curve Metzenbaum scissor Stitch scissor Crile-Wood needle holder Gillies skin hook Semken tissue forceps Cushing dressing forceps

The surgery is performed under general anesthesia provided by pediatric anesthesiologist. The patient is intubated in supine position and the endotracheal tube is centrally placed and fixed using adhesive tapes. Use of temperature monitors and perioperative warming devices are recommended during pediatric anesthesia [6, 7] (Fig. 4.4).

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Fig. 4.4  Forced air warming system for pediatric anesthesia

Fig. 4.5 (a) Pediatric head positiong device. (b) Patient in supine position using the head device

A pediatric head positioning cushion (horseshoe head pad) is used to limit the movement of the head during the surgery and avoid neck injuries (Fig. 4.5). Surgical asepsis is performed using diluted iodine or chlorhexidine solutions. Fenestrated surgical drapes are commonly used for this kind of surgery. Likewise, throat packs are used to prevent ingestion or aspiration of blood during cleft surgery. Unlike cleft lip repair, cleft palate surgery requires special instruments and patient position. This is due to the characteristics of this operation in which it is required to work inside the mouth, being a limited space, small, and less illuminated. The instrumental requirements for cleft palate surgery are as follows: (a) Illumination The use of adequate lighting becomes an element fundamental in cleft palate surgery. Three types of light sources are used for cleft palate surgery: fixed, mobile, and microscope light sources.

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Fixed light source: these are the operating room lamps (cialitic lamps). They have some limitations since they don’t adapt to the changes required by the different areas of the palate that are operated during surgery. Mobile light source: these are the headlights. They are used more often than fixed light sources. They have the advantage to illuminate, light sources. Cephalic movements of the surgeon have proper illumination for the different areas of the palate depending on how they are intervening during the surgery. Microscope light source: Use of microscope has been introduced by Sommerlad in cleft palate surgery [8]. This technology is not widely accepted; however, it provides two advantages simultaneously: illumination and magnification. (b) Magnification Cleft palate surgery is usually performed by surgeons using magnification. Magnification adjustments are necessary for precise procedure such as muscle dissection of the soft palate. The most common instruments are surgical loupes and microscope. Surgical loupes  This is a more accessible option for surgical field magnification during cleft palate surgery. The main advantage is its cost and its use in limited conditions such as surgical campaigns. A 3× magnification is usually enough for cleft palate surgery. Authors like Pan from MD Anderson Hospital, Houston, demonstrated similar efficacy using surgical loupes and microscope. Microscope  This technology is not widely accepted; however has some advantages as it reduces the strain of the patient’s neck during the surgical procedure for the anterior part of the palate. Another advantages are: simultaneous magnification and illumination, surgeon may be in a more comfortable position, the assistance has the same vision of the surgical field improving his work and the surgery can be recorded in videos for educational purposes (Fig. 4.6). (c) Mouth gag (Fig. 4.7). Because of the anatomical nature of the intraoral cavity, a proper surgical exposition is necessary. In 1962, Dingman and Grabb designed a rectangular, closed-frame mouth gag [9]. For decades, the Dingman mouth gag has been widely used in cleft palate repair. The tongue blade is supported by the gag inferiorly and held the endotracheal tube over the tongue. Additional bilateral side retractors hooked the lips near the commissures pulling the cheeks laterally. Some disadvantages using this device are as follows: difficult suturing environment, mouth burns, tongue and lip edema, and chest skin lesions.

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Fig. 4.6  Use of surgical microscope for cleft palate repair

Fig. 4.7  Use of Dingman mouth gag. (a) Upper hooks and tongue blade are located between the upper dental arch and tongue. (b) Tongue blade is retracted inferiorly opening the mouth vertically. (c) Lateral side retractors are located at the oral commissure level opening the mouth horizontally

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References 1. Woo A. Evidence based medicine: cleft palate. Plast Reconstr Surg J. 2017;139:191e–203e. 2. Chepla K, Gosain A.  Evidence based medicine: cleft palate. Plast Reconstr Surg J. 2013;132:1644–8. 3. Chow I, Purnell C, Hanwright P, Gosain A. Evaluating the rule of 10s in cleft lip repair: to data support dogma? Plast Reconstr Surg J. 2016;138(3):670–9. 4. Law R, De Klerk C. Anesthesia for cleft lip and palate surgery. Updat Anesth. 2002;14:27–30. 5. Kwari DY, Chinda JY, Olasoji HO, Adeosun OO.  Cleft lip and palate surgery in children: anaesthetic considerations. Afr J Paediatr Surg. 2010;7(3):174. 6. Ford J, Harper M.  Perioperative warming devices: performance and clinical applications. Anesthesia. 2014;69:623–8. 7. Radauceanu D, Dragnea D, Graig J. NICE guidelines for inadvertent peri-operative hypothermia. Anaesthesia. 2009;64(12):1381–2. 8. Sommerlad B.  The use of operating microscope for cleft palate repair and pharyngoplasty. Plast Reconstr Surg. 2003;112(6):1540–1. 9. Dingman RO, Grabb WC. A new mouth gag. Plast Reconstr Surg Transpl Bull. 1962;29:208–9.

Chapter 5

Unilateral Cleft Lip Repair

5.1  Unilateral Cleft Lip Surgical Techniques There is no consensus about which surgical technique provides the best surgical outcome for unilateral cleft lip repair. Actually, there are many techniques for unilateral cleft lip repair, and most of them evolved as hybrid forms of traditional methods. We may consider three basic methods for unilateral cleft lip repair (Figs. 5.1, 5.2, and 5.3): (a) Straight closure techniques (b) Curved closure techniques (c) Triangular closure techniques (a) Straight closure techniques: These techniques are based on Rose-Thompson principle. Advantages: minimal scar and preservation of the upper lip anatomical

Fig. 5.1  Straight closure technique. (Rose-Thompson principle) © Springer Nature Switzerland AG 2020 P. Rossell-Perry, Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair, https://doi.org/10.1007/978-3-030-44681-9_5

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Fig. 5.2  Curved closure technique. (Rotation-advancement principle)

Fig. 5.3  Triangular closure technique. (Tennison-Randall principle)

subunits. Disadvantages: creation of an asymmetric lip and hypertrophic scar formation tendency [1, 2]. (b) Curved closure techniques: Most popular techniques based on this concept are Millard, Mohler, and Pfeiffer. Advantages: minimal scar and preservation of the upper lip anatomical subunit. Disadvantages: creation of an asymmetric lip, hypertrophic scar formation tendency, and short lip [3, 4]. (c) Triangular closure techniques: Most popular techniques in this group are Tennison-­Randall, Pool, and Fisher techniques [5–8]. Advantages: preservation of the lip symmetry. Disadvantages: non-preservation of the upper lip anatomical subunit and tendency of long lip formation.

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An innovative triangular technique is the triple unilimb Z plasty, a surgical technique developed by the author for severe forms of unilateral cleft lip [9, 10]. This surgical strategy proposed by the author is a more individualized method. Based on the classification of severity, the lip component is the parameter used to establish the degree of severity of the unilateral cleft lip [9]: • Mild unilateral cleft lip: Includes microforms and incomplete forms. Difference between the non-cleft and cleft segment lip height is less than 3 mm. • Moderate unilateral cleft lip: Difference between the non-cleft and cleft segment lip height is between 3 and 6 mm. These are mostly complete unilateral cleft lip and palates. • Severe unilateral cleft lip: Difference between the non-cleft and cleft segment lip height is more than 6 mm. These are complete unilateral cleft lip and palates.

5.2  Author’s Surgical Technique After 25  years of performing unilateral cleft lip repair, the author’s technique evolved from Millard concept (curved closure) and its modifications to a triangular closure combining Tennison-Randall and Pool techniques [5–7, 10]. Therefore, the author’s actual method should considered as a modification. During the first 10  years, I didn’t obtain good outcomes using curved closures (Millard) and observed increased rate of lip asymmetry, hypertrophic scars, and short lip. The surgical technique used for microform unilateral cleft lip is based on double unilimb Z plasty described for Mulliken [11]. The surgical technique used by the author for moderate deformity is a combination of Tennison-Randall and Pool’s technique [5, 6]. The Tennison-Randall technique (Randall’s modification of Tennison’s repair) is probably one of the most used triangular techniques [5, 6]. The author’s main modifications of this technique are the size of the triangle (which is smaller and no more than 3  mm of triangular base) and the position of the triangle, which is above the white roll. The Pool technique is another triangular technique for unilateral cleft lip repair based on the anatomical characteristics of the philtrum. Robert Pool emphasized the importance of the philtral anatomical subunits: the supra and infralabium [7]. In this technique, the triangle is located between these subunits and reproduces a pleasing lip and recreates the central depression. The severity deformity requires a special design since the tissue’s deficiency is important and there may be limitations using traditional techniques to address this type of unilateral cleft lip. The technique used by the author was described formerly as upper double rotation advancement method and later changed as triple unilimb Z plasty [9]. The triple unilimb Z plasty uses smaller triangles located between the anatomical subunits. The main contributions of the author’s proposed techniques are as follows: (a) More individualized management of the unilateral cleft lip deformity (b) Prevention of an asymmetrical upper lip creation

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Symmetry of the upper lip is prioritized instead of lip scar. Straight and curved techniques privilege the lip scar sacrificing the symmetry of the upper lip. (c) Prevention of the shortness of the upper lip height Straight and curved lines increase the rate of hypertrophic scar with the consequent shortness of the repaired upper lip. (d) Better lip scar Quality of the lip scar would be difficult to be predicted due to multifactorial nature of the associated factors. Based on personal experience, I may consider that triangular scar is less obvious than straight or curved lines and less hypertrophic.

5.3  Presurgical Considerations Under loupe magnification and proper illumination, Antomical landmarks of the upper lip are identified to proceed with the markings. There are different brands of surgical markers, but most of them do not resist the effect of bleeding. Therefore, tattoos (with methylene blue) are still used. I personally prefer to make the markings before asepsis and infiltration with local anesthetic. I consider more advantageous to perform the marking (and surgical procedure) at the level of the top of the patient’s head. After the markings are completed, local anesthesia is injected. One cc per Kg of 1% xylocaine or 0.5 cc per Kg of 2% xylocaine is recommended. A 0.1  ml of 1:200,000 epinephrine is safe to be used in combination with xylocaine. Infraorbital nerve block on cleft side is done during anesthetic infiltration for unilateral cleft lip repair. Local anesthesia is completed with field infiltration (Fig.  5.4). Around 5–7  minutes must be allowed after the injection to obtain a proper effect. Due to the flexibility and mobility of the upper lip, a gentle fingertip traction is applied over the vermilion border to facilitate lip incisions and reduce the bleeding (Fig. 5.5).

5.4  Unilateral Cleft Lip Surgical Protocol 5.4.1  Mild Unilateral Cleft Lip Mild unilateral cleft lip forms include different forms of incomplete cleft lips since minimal tissue deficiencies (microforms) to more extended upper lip defects (incomplete or minor forms). A mild unilateral cleft lip has less than 3 mm difference between the lip height of the non-cleft and cleft segments.

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Fig. 5.4  Infraorbital nerve block for primary unilateral cleft lip repair

 icroform Unilateral Cleft Lip M This type of unilateral cleft lip is characterized by minimal tissue deficiency (Fig. 5.6). The design of surgical incisions is based on the identification of anatomical landmarks of the upper lip previously described (Figs. 5.7 and 5.8). Two triangles are designed at the cleft side: xyz and ab8′. xyz Triangle The base of the triangle is determined by the difference between the non-cleft lip height (1–6) and the lip height at the non-cleft side (7–8). The height of the triangle is determined by the distance from point 4 to point w. Point 4 is located at the level of the midline of the upper lip (line between points 5 and 2) and between the supra and infralabium areas of the philtrum. It is characteristic the central depression of the philtrum in its lower portion. This is the infralabium, described by Pool [7]. This

76 Fig. 5.5  Maneuver using surgeon’s finger to facilitate the surgical incision of the marking in the unilateral cleft lip

5  Unilateral Cleft Lip Repair

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77

Fig. 5.6 Microform unilateral cleft lip deformity

anatomical area is variable according to the races and sometimes very difficult to be determined. In this situation, point 4 is designed at the level of the intersection of the upper three quarters with the lower quarter over the midline. Point w is determined by the junction of the perpendicular line to the upper lip midline across point 4 and the line perpendicular to point 3 (peak of the Cupid’s bow on the cleft side). These two points determine the distance w–4 which is equal to the xyz triangle’s height. In practice, the triangular sides xy and zy are equal to w–4 since the difference with the triangle’s height is very small. The base of the triangle xyz is designed from the white roll in a distance equal to 3–w (8–z = 3–w). ab8′ Triangle The base of the triangle is determined by the difference between the cleft sides’ vermilion height (8–8′)  – (3–3′). The height of the triangle is determined by the distance from point 3′ (point located at the level of point 3 over the red line) to point 2′ (point located at the level of point 2 over the red line). The base of the triangle ab8′ is designed from the white roll in a distance equal to 3–3′. Finally, the surgical marking incision is finalized based on the connection between points x and w with point 7. These triangles represent the soft tissue deficiency of the upper lip and upper vermilion. Sometimes the base of the nose is different between the cleft and non-cleft side A–7 and B–6. In these cases, a triangular shape form is designed at the base of the nose at the cleft side.

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Fig. 5.7  Unilateral microform cleft lip markings and measurements. 1 and 3. Peak of the Cupid’s bow. 2. Cupid’s bow (middle point). 1′, 2′, and 3′. Similar as points 1, 2, and 3 but located over red line. 4. Central point between supralabium and infralabium. 5. Midpoint of the lip columellar crease. 6 and 7. Lateral junction of the columella border and lip columellar crease. 8. White roll (end’s point). 8′. Same as point 8 but located over red line. A and B. Alar bases. C and D. Oral commissures

Formula



x−7 = w −7 x − z = (1 − 6 ) − ( 7 − 8 ) , x − y = z − y = w − 4 7 − x + z − 8 = 7 − w + w − 3 = 6 −1 z − 8 = w − 3, 8 − a = 3 − 3′, a − b = b − 8′ = 3′ − 2′ 8 − a + a − 8′ = 2 − 2′ = 1 − 1′



Surgical Procedure  This is the surgical sequence of the proposed technique for microform unilateral cleft lip.

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Fig. 5.8  Surgical incisions for microform unilateral cleft lip repair

(a) Surgical incision A full thickness skin incision is performed following the described markings perpendicular to the cutaneous plane using a scalpel no. 3 with a 11 blade or 15C for better precision. (b) Skin, vermilion, and mucosal resection After surgical incisions, a small area of skin, vermilion, and mucosa (limited by points 7–x–y–z–8–a–b–8′ to the gingival sulcus and continue with points 3′–3–w finalizing at point 7) is excised (Fig. 5.9). The skin and vermilion resection creates two triangular flaps: one cutaneous (xyz) and one in the vermilion (ab8′). If there is a significant difference between the nose bases, a triangular shape form should be removed from the base of the nose at the cleft side. (c) Skin flap elevation The skin is elevated from the underlying muscular plane in both sides of the cleft lip. The dissection at the philtral area on the non-cleft side is limited to the

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7

X Z

Y

3

8 b 8’

3’

Gingival sulcus

Fig. 5.9  Skin, vermilion and mucosal resection for microform unilateral cleft lip

midline and 1 cm lateral to the skin incision on the cleft side. This dissection separates the dermal skin from the upper lip muscles. (d) Muscular dissection (Fig. 5.10) After making the skin incisions along the cleft margins, upper lip muscles are dissected from the free edge of the cleft. Surgical dissection is then performed to separate the muscular plane (composed of levator labii superioris alaeque nasi muscle and two fascicles of orbicularis oris muscle: marginal and peripheral) from the abnormal insertion of the enveloped skin and mucosal flaps. The alar fascicle of the levator labii superioris alaeque nasi muscle is dissected from the alar base at the cleft side. The muscle is dissected as a unit freeing it from the alveolus, extending from the base of the columella and nostril floor to the base of the ala. (e) Dissection of the mucosa The mucosa is dissected free from the edge of the muscles for around 5 mm.

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Fig. 5.10  Incomplete unilateral cleft lip muscular dissection. 1. Nasal fascicle of levator labii superioris alaeque nasi muscle. 2. Marginal orbicularis oris muscle. 3. Peripheral orbicularis oris muscle

(f) Closure of the mucosa The cleft lip closure starts with the inner lip mucosa using interrupted vicryl 5/0. The oral mucosal lining is closed before using vicryl 5/0 stitches using the medial and lateral mucosa as advancement flaps. Then, the triangular vermilion flap (ab8′) is sutured medially into the vermilion rotational incision (3′–2′). The lateral and medial edges of the cleft must fit without excess of mucosa.

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Fig. 5.11  Microform unilateral cleft lip muscular reconstruction. 1. Nasal fascicle of levator labii superioris alaeque nasi muscle. 2. Marginal orbicularis oris muscle. 3. Peripheral orbicularis oris muscle. a. Nasal septum

(g) Reconstruction of the upper lip muscles (Figs. 5.11 and 5.12) The freed muscles are then reconstructed. The peripheral orbicularis oris muscle is repaired first using 5/0 polydioxanone (PDS) suture. At the vermilion level, the peripheral fascicle of the orbicularis oris is sutured in a border to border form. The medial and lateral marginal orbicularis oris muscles are transposed in an overlapping form to create the depressed groove on the philtrum and philtral column.

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Fig. 5.12  Microform unilateral cleft lip muscular reconstruction. Level A: Medial and lateral orbicularis oris muscles are transposed in an overlapping form. Level B: Marginal fascicle of the orbicularis oris is sutured in a border to border form

The lateral marginal orbicularis oris muscle is placed slightly higher than the medial marginal orbicularis oris muscle in order to simulate a philtral column. The lateral muscle flap is sutured to the dermis of the philtrum at the level of the midline, and the medial muscle flap is then advanced reaching a point beneath the expected philtral column. Both flaps are sutured together using 5/0 PDS. The levator alaeque nasi is transposed and sutured to the caudal septum to correct the depressed nostril sill using 5/0 PDS. (h) Skin closure (Figs. 5.13 and 5.14) Created skin flaps are inset using absorbable (5/0 vicryl) deep dermal sutures and absorbable (7/0 vicryl or 6/0 catgut fast absorbing) skin sutures in a simple interrupted manner. Corner stitches are necessary at the tip of the triangles (xyz and ab8′). The types of sutures and stitches used are described in Fig. 5.15.

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Fig. 5.13  Microform unilateral cleft lip repair line of skin closure

Fig. 5.14  Skin closure of the primary cheiloplasty repair using the proposed technique in a patient with microform unilateral cleft lip

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Fig. 5.15  Microform unilateral cleft lip skin closure. 1 and 2. Simple interrupted deep dermal sutures using vicryl 5/0. 3 and 4. Corner stitch using vicryl 7/0 or catgut fast-absorbing gut 6/0. The rest of the stitches is performed using simple interrupted skin with vicryl 7/0

I ncomplete Unilateral Cleft Lip This type of unilateral cleft lip is characterized by partial clefting of the skin, muscle, and mucosa of the upper lip (Figs. 5.16 and 5.17). The presented technique is based on Tennison-Randall and Pool’s concepts [5, 6]. The design of surgical incisions is based on the identification of anatomical landmarks of the upper lip previously described (Figs.  5.18 and 5.19). Two ­triangles ( xyz and ab8′) and one advancement flap and a columellar base flap are designed at the cleft side.

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Fig. 5.16 Incomplete unilateral cleft lip nose deformity

xyz Triangle The base of the triangle is determined by the difference between the cleft and non-­ cleft lip height (1–6) – (8–9). The height of this triangle is determined by the distance from point 4 to point w. Point 4 is located at the level of the midline of the upper lip (line between points 5 and 2) and between the supra and infralabium areas of the philtrum (Pool) [7]. Point w is determined by the junction of the perpendicular line to point 4 and the line perpendicular to point 3 (peak of the Cupid’s bow on the cleft side). These two points determine the distance w–4 which is equal to the xyz triangle’s height. Finally, the base of the triangle xyz is designed from the white roll in a distance equal to 3–w (8–z = 3–w). ab8′ Triangle The base of the triangle is determined by the difference between the cleft sides’ vermilion height (8–8′)  – (3–3′). The height of the triangle is determined by the distance from point 3′ (point located at the level of point 3 over the red line) to point 2′ (Point located at the level of point 2 over the red line). Finally, the base of the triangle ab8′ is designed from the white roll in a distance equal to 3–3′ (8–a = 3–3′).

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Fig. 5.17  Incomplete unilateral cleft lip nose. 1 and 3. Peak of the Cupid’s bow. 2. Cupid’s bow (middle point). 1′, 2′, and 3′. Similar as points 1, 2, and 3 but located over red line. 4. Central point between supralabium and infralabium. 5. Midpoint of the lip columellar crease. 6 and 7. Lateral junction of the columella border and lip columellar crease. 8. White roll (end’s point) 8′. Same as point 8 but located over red line. 9. Intersection between cleft margin and subalar crease. A and B. Alar bases. C and D. Oral commissures

Advancement Flap This flap is composed by the upper portion of the lateral lip segment and the base of the ala. This triangular flap is designed starting at point x, continuing to point 9 (tip of the flap), and then finishing with an incision inside the nose at the level of the pyriform aperture. Point 9 must be located at junction of the cutaneous border of the cleft lip with the subalare crease.

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Fig. 5.18  Surgical incisions for incomplete unilateral cleft lip nose repair

Columellar Base Flap A small flap is designed laterally to the base of the columella (beside point 7). This flap is used for nasal floor repair in combination with the alar portion of the advancement flap. Special attention must be paid in relation with the nasal floor repair. The alar portion of the advancement flap must be preserved avoiding a narrowing of the nasal base, common complication of observing. Formula



x −9 = w −7 x − z = (1 − 6 ) − ( 8 − 9 ) , x − y = z − y = w − 4 9 − x + x − z + z − 8 = 7 − w + w − 3 + x − z = 6 −1 z − 8 = w − 3, 8 − a = 3 − 3′, a − b = b − 8′ = 3′ − 2′ 8 − a + a − 8′ = 2 − 2′ = 1 − 1′



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Fig. 5.19  Surgical incisions for incomplete unilateral cleft lip nose repair. A. xyz triangle. B. ab8′ triangle. C. Advancement flap. D. Columellar base flap. a. w–4 upper rotational incision. b. 3′–2′ lower rotational incision. Yellow dot line: White roll. Red dot line: Red line

Surgical Procedure  This is the surgical sequence of the proposed technique for incomplete unilateral cleft lip. (a) Surgical incision A full thickness skin incision is performed following the described markings perpendicular to the cutaneous plane using a scalpel no. 3 with a 11 blade or 15C for better precision. The incision continues toward the oral mucosa and releases the upper labial frenulum at the medial side of the cleft. After the surgical incisions are made, primary rhinoplasty is performed. (b) Skin, vermilion, and mucosal resection After primary rhinoplasty, a small area of skin, vermilion, and mucosa (starting at the cleft side of the nostril sill, following the points 9–x–y–z–8–a–b–8′ to the gingival sulcus and continuing with medial side of the cleft following the points 3′–3–w finalizing with point 7) is excised (Figs.  5.20 and 5.21). The

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Fig. 5.20  Area of skin, vermilion, and mucosal resection for incomplete unilateral cleft lip

mucosal borders of the cleft lip are both resected and the upper labial frenulum located at the medial segment gingival sulcus is sectioned freeing the medial segment. The incisions and skin and vermilion resection create two triangular flaps: one cutaneous (xyz) and one in the vermilion (ab8′), an advancement flap and a columellar base flap. (c) Skin flap elevation The skin is elevated from the underlying muscular plane on both sides of the cleft lip. • Medial segment The dissection at the philtral area on the non-cleft side is limited to the midline and 1 cm lateral to the skin incision on the cleft side. This dissection separates the dermal skin from the upper lip muscles. A quadrangular, medially based flap is elevated at the subcutaneous level from the base of the columella creating the columellar base flap.

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Fig. 5.21  Medial rotations and lateral flaps after skin resection performed using the proposed surgical technique. 1. Columellar base flap. 2. Alar base. 3. Advancement flap. 4. Upper rotational incision. 5. xyz triangle. 6. Lower rotational incision. 7. ab8′ triangle. 8. White roll

• Lateral segment A small incision (1 cm) at the pyriform aperture and supraperiosteal dissection over the maxilla are necessary in order to facilitate the proper position of the repaired ala and nostril sill. After this, the lateral advancement flap (composed of the upper portion of the lateral lip segment and the base of the ala) is elevated. The triangular flaps xyz and ab8′ are finally elevated at the dermal level. (d) Muscular dissection (Figs. 5.22 and 5.23) Surgical dissection using sharp scissors is performed to separate the muscular plane from the abnormal insertion of the enveloped skin and mucosal flaps. In the dermal plane, the upper lip muscles are dissected over the philtral and perialar areas. In the deep plane, the muscles are released from the cleft margin to the anterior nasal spine at the non-cleft side and the piriform aperture base at the cleft side.

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Fig. 5.22  Incomplete unilateral cleft lip muscular dissection. 1. Nasal columella. 2. Alae. 3. Nasal fascicle of levator labii superioris alaeque nasi muscle. 4. Orbicularis oris muscle at the cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 5. Orbicularis oris muscle at the non-cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 6. Alveolar ridge (gum). 7. xyz triangular flap. 8. ab8′ triangular flap. 9. Medial upper lip rotational incision. 10. Medial vermilion rotational incision

(e) Dissection of the mucosa The mucosa is dissected free from the edge of the muscles for around 5 mm. Medial incision is extended releasing the upper lip frenulum and a lateral advancement flap is elevated at the cleft segment as in Fig. 5.24. Distances from the red line to the buccogingival sulcus must be the same on both sides. Any difference must be corrected in order to prevent any excess of vermilion. (f) Closure of the mucosa The oral mucosal lining is repaired using the medial and lateral mucosal flaps. The lateral advancement flap is used to repair the defect created by the upper frenulum section at the non-cleft side (Figs.  5.24 and 5.25). Then, the

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a

b

c

d

e

f

Fig. 5.23  Incomplete unilateral cleft lip repair performed using the proposed surgical technique. (a) Preoperative view. (b) Markings. (c) Medial segment muscular dissection. (d) Lateral segment muscular dissection. (e) Muscular repair. (f) Final skin closure

triangular vermilion flap (ab8′) is sutured medially into the medial rotational incision (3′–2′). Any excess of mucosa must be corrected. (g) Reconstruction of the upper lip muscles (Figs. 5.26, 5.27, and 5.28) After the repair of the oral mucosa and vermilion, the dissected muscles are reconstructed. At the vermilion level, the marginal fascicle of the orbicularis

5  Unilateral Cleft Lip Repair

94 Fig. 5.24  Oral mucosal and vermilion incisions and upper frenulum release for incomplete unilateral cleft lip repair

Fig. 5.25  Oral mucosal, vermilion, and frenulum repair for incomplete unilateral cleft lip. 1. Oral mucosal flap at the non-cleft side. 2. Oral mucosal advancement flap from cleft side. 3. Non-cleft side alveolar ridge. 4. Nose

oris is sutured in a border to border form. Then, a transposition of the o­ rbicularis oris fascicles is performed in an overlapping form to create a central depression of the philtrum. The lateral muscle flap is sutured to the dermis of the philtrum at the level of the midline, and the medial muscle flap is then advanced reaching a point beneath the expected philtral column. Both flaps are sutured together using 5/0 PDS. The levator alaeque nasi is finally transposed and sutured to the caudal septum to correct the depressed nostril sill using 5/0 PDS. This muscle

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Fig. 5.26  Incomplete unilateral cleft lip muscular repair. 1. Nasal columella. 2. Alae. 3. Nasal fascicle of levator labii superioris alaeque nasi muscle. 4. Orbicularis oris muscle at the cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 5. Orbicularis oris muscle at the non-cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 6. Nasal septum. 7. xyz triangular flap. 8. ab8′ triangular flap. 9. Medial upper lip rotational incision. 10. Medial vermilion rotational incision. 11. Columellar base flap. 12. Gum

sutured in this position rotates the nasal ala to its proper position and gives it additional support. The levator alaeque nasi fills in the apex of the lateral flap, the area beneath the columella. ( h) Skin closure Created skin flaps are inset using absorbable (5/0 vicryl) deep dermal sutures and absorbable (7/0 vicryl or 6/0 catgut fast absorbing) skin sutures in a simple interrupted manner. Corner stitches are necessary at the tip of the triangles (xyz and ab8′). The types of sutures and stitches used are described in Figs. 5.29, 5.30, and 5.31.

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5  Unilateral Cleft Lip Repair

Fig. 5.27  Incomplete unilateral cleft lip muscular reconstruction. 1. Nasal fascicle of levator labii superioris alaeque nasi muscle. 2. Marginal orbicularis oris muscle. 3. Peripheral orbicularis oris muscle. a. Nasal septum

5.4.2  Moderate Unilateral Cleft Lip As we mentioned in Chap. 2, the criterion to determine the severity of the unilateral cleft lip deformity is the difference between the lip height of the normal and cleft segments. A moderate unilateral cleft lip has a 3–6 mm difference between the lip height of the non-cleft and cleft segments (Fig.  5.32). This degree of severity is mostly observed in complete unilateral cleft lip cases. The presented technique is based on Tennison-Randall and Pool’s concepts and includes two unilimb Z plasties (5–7).

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Fig. 5.28  Incomplete unilateral cleft lip muscular reconstruction. Level A: Medial and lateral orbicularis oris muscles are transposed in an overlapping form. Level B: Marginal fascicle of the orbicularis oris is sutured in a border to border form

Fig. 5.29 Incomplete unilateral cleft lip repair line of skin closure

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5  Unilateral Cleft Lip Repair

Fig. 5.30  Skin closure of the primary cheiloplasty repair performed using the proposed technique in a patient with incomplete unilateral cleft lip

Fig. 5.31  Incomplete unilateral cleft lip skin closure. 1, 2, and 3. Simple interrupted deep dermal sutures using vicryl 5/0. 4 and 5. Corner stitch using vicryl 7/0 or catgut fast absorbing 6/0. The rest of the stitches is performed using simple interrupted skin with vicryl 7/0

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Fig. 5.32 Moderate unilateral cleft lip nose deformity

The design of surgical incisions is based on the identification of anatomical landmarks of the upper lip previously described (Figs. 5.33, 5.34, and 5.35). • Skin flaps: Two triangles ( xyz and ab8′), one advancement and one columellar base flaps, are designed at the cleft side. • Mucosal flaps: One advancement flap from the cleft side and two mucosal flaps are raised from the cleft margins (lateral and medial). xyz Triangle The base of the triangle is determined by the difference between the non-cleft lip height (1–6) and the lip height at the non-cleft side (8–9). The height of the triangle is determined by the distance from point 4 to point w. Point 4 is located at the level of the midline of the upper lip (line between points 5 and 2) and between the supra and infralabium areas of the philtrum. Point w is determined in a similar way as it was determined for the mild cases. These two points determine the distance w–4 which is equal to the xyz triangle’s height. The base of the triangle xyz is designed from the white roll in a distance equal to 3–w (8–z = 3–w). ab8′ Triangle The base of the triangle is determined by the difference between the cleft sides’ vermilion height (8–8′)  – (3–3′). The height of the triangle is determined by the distance from point 3′ (point located at the level of point 3 over the red line) to point 2′ (point located at the level of point 2 over the red line). The base of the triangle ab8′ is designed from the white roll in a distance equal to 3–3′. Advancement Flap This flap is composed of the upper portion of the lateral lip segment and the base of the ala. This triangular flap is designed starting at point x, continuing to the point 9

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5  Unilateral Cleft Lip Repair

Fig. 5.33  Moderate unilateral cleft lip nose. 1 and 3. Peak of the Cupid’s bow. 2. Cupid’s bow (middle point). 1′, 2′, and 3′. Similar as points 1, 2, and 3 but located over red line. 4. Central point between supralabium and infralabium. 5. Midpoint of the lip columellar crease. 6 and 7. Lateral junction of the columella border and lip columellar crease. 8. White roll (end’s point). 8′. Same as point 8 but located over red line. 9. Intersection between the cleft margin and subalar crease. A and B. Alar bases. C and D. Oral commissures

(tip of the flap), and then finishing with an incision inside the nose at the level of the pyriform aperture. Point 9 must be located at the junction of the cutaneous border of the cleft lip with the subalare crease. The dissection of the lateral segment is in direct relation with the cleft’s width. A supraperiosteal dissection over the maxilla is necessary in wide clefts in order to decrease the tension of the lip closure. Columellar Base Flap A small flap is designed laterally to the base of the columella (beside point 7). This flap is used for nasal floor repair in combination with the alar portion of the advancement flap.

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Fig. 5.34  Surgical incisions for moderate unilateral cleft lip nose repair

Special attention must be paid to the position of the base of the ala. The alar facial groove is not always evident and the ala could be repaired in wrong position if this landmark is not well identified previously. Formula



x −9 = w −7 x − z = (1 − 6 ) − ( 8 − 9 ) , x − y = z − y = w − 4 9 − x + x − z + z − 8 = 7 − w + w − 3 + x − z = 6 −1 z − 8 = w − 3, 8 − a = 3 − 3′, a − b = b − 8′ = 3′ − 2′ 8 − a + a − 8′ = 2 − 2′ = 1 − 1′



Surgical Procedure  This is the surgical sequence of the proposed technique for moderate unilateral cleft lip.

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5  Unilateral Cleft Lip Repair

Fig. 5.35  Surgical incisions for moderate unilateral cleft lip nose repair. A. xyz triangle. B. ab8′ triangle. C. Advancement flap. D. Columellar base flap. a. w–4 upper rotational incision. b. 3′–2′ lower rotational incision. Yellow dot line: White roll. Red dot line: Red line

(a) Surgical incision A full thickness skin incision is performed following the described markings perpendicular to the cutaneous plane using a scalpel no. 3 with a 11 blade or 15C for better precision. The incision continues toward the oral mucosa releasing the upper labial frenulum and creating two mucosal flaps from the cleft borders (medial and lateral mucosal flaps as described by Millard) [3]. The extension of the incision over the pyriform aperture is in direct relation with the width of the cleft. After the surgical incisions are made, primary rhinoplasty is performed. (b) Skin, vermilion, and mucosal resection After surgical incisions, a small area of skin, vermilion, and mucosa is excised only from the cleft side (Figs. 5.36 and 5.37). The skin incisions and tissue resection create two triangular flaps: one cutaneous (xyz) and one in the vermilion (ab8′), a lateral advancement flap and a columellar base flap.

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Fig. 5.36  Area of skin, vermilion, and mucosa resection from cleft side for moderate unilateral cleft lip

(c) Skin flap elevation The skin is elevated from the underlying muscular plane on both sides of the cleft lip. • Medial segment The cutaneous dissection of the non-cleft side is performed at the dermal plane of the philtral area and 1 cm lateral to the skin incision on the cleft side. This dissection separates the dermal skin from the upper lip muscles. A quadrangular, medially based flap is elevated at the subcutaneous level from the base of the columella (columellar base flap). • Lateral segment Through the cutaneous incision performed at the base of the pyriform aperture, a supraperiosteal dissection over the maxilla is required to elevate the advancement flap from the cleft side. The extension of this incision is in direct relation with the width of the cleft. The triangular flaps xyz and ab8′ are finally elevated at the dermal level.

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Fig. 5.37  Medial rotations and lateral flaps after skin resection performed using the proposed surgical technique. 1. Columellar base flap. 2. Alar base. 3. Advancement flap. 4. Upper rotational incision. 5. xyz triangle. 6. Lower rotational incision. 7. ab8′ triangle. 8. White roll

(d) Mucosal flaps elevation (Fig. 5.38) Two rectangular mucosal flaps are elevated from the cleft margins in a similar way as Millard described for its technique [3]. The medial mucosal flap is raised form the medial cleft lip margin and it is used for oral mucosa repair as a new oral sulcus. The lateral mucosal flap is taken from the lateral cleft lip margin and it is used to cover the raw posterior surface of the advancement flap and upper lip muscles. Both flaps should be elevated at the muscular level and have at least a width of 1 cm to guarantee flap survival. (e) Dissection of the mucosa (Figs. 5.38 and 5.39) The mucosa is dissected free from the edge of the muscles for around 5 mm. Medial incision is extended releasing the upper lip frenulum and a lateral advancement flap is elevated at the cleft segment as in Fig. 5.38. Distances from the red line to the buccogingival sulcus must be the same on both sides. Any difference must be corrected in order to prevent any excess of vermilion.

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Fig. 5.38  Oral mucosal incisions, vermilion incisions, mucosal flaps elevation, and upper frenulum release for moderate unilateral cleft lip repair

5

1 m

3

7

6

1

2

8 4

Fig. 5.39  Oral mucosal incisions and mucosal flaps. 1. Oral mucosa, non-cleft side. 2. Oral mucosa, cleft side. 3. Alveolar ridge non-cleft side. 4. Alveolar ridge cleft side. 5. Nose. 6. Piriform aperture. 7. Nasal septum. 8. Lower turbinate. m: Medial mucosal flap. l: Lateral mucosal flap

(f) Muscular dissection (Figs. 5.40 and 5.41) Surgical dissection using sharp scissors is performed to separate the muscular plane from the abnormal insertion of the enveloped skin and mucosal flaps. In the dermal plane, the upper lip muscles are dissected over the philtral and perialar areas. The two segments of the orbicularis oris are separated from their abnormally inserted bony structure and the enveloped skin and mucosa (Fig. 5.40). In the deep plane, these muscles are released from the cleft margin to the anterior nasal spine at the non-cleft side and the piriform aperture base at the cleft side. The extent of dissection is set as wide as necessary depending on cleft width.

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a

b

c

d

Fig. 5.40  Moderate unilateral cleft lip muscular dissection. (a) Dermal plane dissection of muscles at the cleft segment. (b) Mucosal plane dissection of muscles at the cleft segment. (c) Upper lip muscles elevated at the cleft side. (d) Muscular dissection at the non-cleft side. 1. Nasal columella. 2. Nasal tip. 3. Alae. 4. Advancement flap. 5. xyz triangular flap. 6. ab8′ triangle. 7. Oral mucosa advancement flap. 8. Nasal fascicle of levator labii superioris alaeque nasi muscle. 9. Orbicularis oris muscle at the cleft side. 10. Gum. 11. Nasal septum. 12. Columellar base flap. 13. Medial upper rotation. 14. Orbicularis oris muscle. 15. Oral mucosa. 16. Labial artery

The levator labii superioris alaeque nasi muscle is dissected from the dermal plane of the alae of the nose. Its distal segment is conformed as a nasal fibrous tendon (Fig. 5.41). (g) Closure of the mucosa The oral mucosa lining is repaired using the medial and lateral mucosal flaps. The lateral advancement flap is used to repair the defect created by the upper frenulum section at the non-cleft side (Figs. 5.42 and 5.43). Then, the triangular vermilion flap (ab8′) is sutured medially into the medial rotational incision (3′–2′). This flap is used to repair the defect created by the upper

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Fig. 5.41  Moderate unilateral cleft lip flap elevation and muscular dissection. 1. Nasal columella. 2. Alae. 3. Nasal fascicle of levator labii superioris alaeque nasi muscle. 4. Orbicularis oris muscle at the cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 5. Orbicularis oris muscle at the non-cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 6. Alveolar ridge (gum) at the non-cleft side. 7. Alveolar ridge (gum) at the cleft side. 8. xyz triangular flap. 9. ab8′ triangular flap. 10. Medial upper lip rotational incision. 11. Medial vermilion rotational incision. 12. Columellar base flap. m: Medial mucosal flap. l: Lateral mucosal flap

frenulum section. For complete unilateral cleft lip repair, the lateral (l) and medial (m) mucosal flaps, elevated from the cleft margins (Figs.  5.39 and 5.42), are used to repair the upper segment of the oral side of the upper lip. These flaps are sutured one above the other for covering the oronasal lining (Fig. 5.42).

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Fig. 5.42  Moderate unilateral cleft lip oral mucosa closure. 1. Nasal columella. 2. Alae. 3. Nasal fascicle of levator labii superioris alaeque nasi muscle. 4. Orbicularis oris muscle at the cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 5. Orbicularis oris muscle at the non-cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 6. Alveolar ridge (gum) at the non-cleft side. 7. Alveolar ridge (gum) at the cleft side. 8. xyz triangular flap. 9. ab8′ triangular flap. 10. Medial upper lip rotational incision. 11. Medial vermilion rotational incision. 12. Columellar base flap. m: Medial mucosal flap. l: Lateral mucosal flap

(h) Reconstruction of the upper lip muscles (Figs. 5.44, 5.45, and 5.46) After the repair of the oral mucosa and vermilion, the dissected muscles are reconstructed. At the vermilion level, the marginal fascicle of the orbicularis oris is sutured in a border to border form. Then, a transposition of the orbicularis oris fascicles is performed in an overlapping form to create the philtral column.

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4

1

2

3

Fig. 5.43  Oral mucosa, vermilion, and frenulum repair for moderate unilateral cleft lip. 1. Oral mucosal flap at the non-cleft side. 2. Oral mucosal advancement flap from cleft side. 3. Alveolar ridge at the non-cleft side. 4. Nose

The lateral muscle flap is sutured to the dermis of the philtrum at the level of the midline, and the medial muscle flap is then advanced reaching a point beneath the expected philtral column. Both flaps are sutured together using 5/0 PDS. The levator alaeque nasi is finally transposed and sutured to the caudal septum to correct the depressed nostril sill using 5/0 PDS. This muscle sutured in this position rotates the nasal ala to its proper position and gives it additional support. The levator alaeque nasi fills in the apex of the lateral flap, the area beneath the columella. The upper lip muscular reconstruction acts over the cleft segments as a surgical alveolar molding doing a natural orthopedy. This is the surgical alveolar molding concept. (i) Skin closure Created skin flaps are inset using absorbable (5/0 vicryl) deep dermal sutures and absorbable (7/0 vicryl or 6/0 catgut fast absorbing) skin sutures in a simple interrupted manner. Corner stitches are necessary at the tip of the triangles (xyz and ab8′). The types of sutures and stitches used are described in Figs. 5.47, 5.48, and 5.49.

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Fig. 5.44  Moderate unilateral cleft lip muscular repair. 1. Nasal columella. 2. Alae. 3. Nasal fascicle of levator labii superioris alaeque nasi muscle. 4. Orbicularis oris muscle at the cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 5. Orbicularis oris muscle at the non-cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 6. Nasal septum. 7. xyz triangular flap. 8. ab8′ triangular flap. 9. Medial upper lip rotational incision. 10. Medial vermilion rotational incision. 11. Columellar base flap. 12. Gum

5.4.3  Severe Unilateral Cleft Lip A severe unilateral cleft lip has more than 6 mm difference between the lip height of the non-cleft and cleft segments (Fig. 5.50). This degree of severity is observed in complete unilateral cleft lip cases. The presented technique is the Dr. Rossell-Perry method named as triple unilimb Z plasty (formerly upper double rotation advancement). This technique includes three unilimb Z plasties [9, 10]. The design of surgical incisions is based on the identification of anatomical landmarks of the upper lip previously described (Figs. 5.51, 5.52, and 5.53).

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Fig. 5.45  Moderate unilateral cleft lip muscular reconstruction. 1. Nasal fascicle of levator labii superioris alaeque nasi muscle. 2. Marginal orbicularis oris muscle. 3. Peripheral orbicularis oris muscle. a. Nasal septum

• Skin flaps: Three triangles ( 7dc, xyz, and ab8′) are designed on both sides of the cleft. • Mucosal flaps: One advancement flap from the cleft side and two mucosal flaps are raised from the cleft margins (lateral and medial). 7dc Triangle The base of this triangle is determined by the difference between the non-cleft lip height (1–6) and the distance 9–x–z–8 at the cleft side. The height of this triangle is equal to the distance between points 9 and B. This triangle conforms with the incision 9–B, the upper unilimb Z plasty.

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Fig. 5.46  Moderate unilateral cleft lip muscular reconstruction. Level A: Medial and lateral orbicularis oris muscles are transposed in an overlapping form. Level B: marginal fascicle of the orbicularis oris is sutured in a border to border form

Fig. 5.47 Moderate unilateral cleft lip repair line of skin closure

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Fig. 5.48  Skin closure of the primary cheiloplasty repair performed using the proposed technique in a patient with moderate unilateral cleft lip

Fig. 5.49  Moderate unilateral cleft lip skin closure. 1 and 2. Simple interrupted deep dermal sutures using vicryl 5/0. 3 and 4. Corner stitch using vicryl 7/0 or catgut fast absorbing 6/0. The rest of the stitches is performed using simple interrupted skin with vicryl 7/0 or catgut fast absorbing 6/0

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Fig. 5.50  Severe unilateral cleft lip nose deformity

xyz Triangle The base of the triangle is determined by the difference between the non-cleft lip height (1–6) and the lip height at the non-cleft side (8–9). It is usually measured as 3 mm. The height of the triangle is determined by the distance from point 4 to point w. Point 4 is located at the level of the midline of the upper lip (line between points 5 and 2) and between the supra and infralabium areas of the philtrum. Point w is determined in a similar way as it was determined for the mild and moderate cases. The base of the triangle xyz is designed from the white roll in a distance equal to 3–w (8–z = 3–w). This triangle conforms with the incision 4–w, the middle unilimb Z plasty. ab8′ Triangle The base of the triangle is determined by the difference between the cleft sides’ vermilion height (8–8′) – (3–3′). The height of the triangle is determined by the distance from point 3′ (point located at the level of point 3 over the red line) to point 2′ (point located at the level of point 2 over the red line). The base of the triangle ab8′ is designed from the white roll in a distance equal to 3–3′. This triangle conforms with the incision 3′–2′, the lower unilimb Z plasty. Columellar Base Flap A small flap is designed laterally to the base of the columella (beside point 7). This flap is used for nasal floor repair in combination with the alar flap.

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Fig. 5.51  Severe unilateral cleft lip nose. 1 and 3. Peak of the Cupid’s bow. 2. Cupid’s bow (middle point). 1′, 2′, and 3′. Similar as points 1, 2, and 3 but located over red line. 4. Central point between supralabium and infralabium. 5. Midpoint of the lip columellar crease. 6 and 7. Lateral junction of the columella border and lip columellar crease. 8. White roll (end’s point). 8′. Same as point 8 but located over red line. 9. Intersection between cleft margin and subalar crease. A and B. Alar bases. C and D. Oral commissures

Formula



x −9 = w −c x − y = z − y = w − 4, 7 − d = d − c = 9 − B 9 − x + x − z + z − 8 + 7 − c = 1− 6 z − 8 = w − 3, 8 − a = 3 − 3′, a − b = b − 8′ = 3′ − 2′ 8 − a + a − 8′ = 2 − 2′ = 1 − 1′



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Fig. 5.52  Surgical incisions for severe unilateral cleft lip repair

Surgical Procedure  (a) Surgical incision A full thickness skin incision is performed following the described markings perpendicular to the cutaneous plane using a scalpel no. 3 with a 11 blade or 15C for better precision. The extension of the incision over the pyriform aperture is in direct relation with the width of the cleft. The incision continues toward the oral mucosa releasing the upper labial frenulum and creating two mucosal flaps from the cleft borders (medial and lateral mucosal flaps). (b) Skin, vermilion, and mucosa resection After surgical incisions, a small area of skin, vermilion, and mucosa is excised only from the cleft side according to the Figs. 5.54 and 5.55. The incisions and skin and vermilion resection create three triangular flaps: two cutaneous (xyz) and one in the vermilion (ab8′).

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Fig. 5.53  Surgical incisions for severe unilateral cleft lip nose repair. A. xyz triangle. B. ab8′ triangle. C. 7dc triangle. D. Columellar base flap. E. Alar advancement flap. a. w–4 upper medial rotational incision. b. 3′–2′ lower medial rotational incision. c. 9–B lateral rotational incision. Yellow dot line: White roll. Red dot line: Red line

(c) Skin flap elevation (Fig. 5.56) The skin is elevated from the underlying muscular plane on both sides of the cleft lip. • Medial segment The dissection at the philtral area on the non-cleft side is limited to the midline and 1 cm lateral to the skin incision on the cleft side. This dissection separates the dermal skin from the upper lip muscles. • Lateral segment A supraperiosteal dissection over the maxilla is necessary in wide clefts in order to decrease the tension of the lip closure. A fingertip dissection is used as a blunt dissection to perform this lateral segment release. A medially based skin flap is elevated from the base of the columella, and this is used for nasal floor reconstruction.

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Fig. 5.54  Area of skin, vermilion, and mucosal resection from the cleft side for severe unilateral cleft lip

(d) Mucosal flaps elevation and closure (Figs. 5.56, 5.57, 5.58, and 5.59) Two rectangular mucosal flaps are elevated from the cleft margins. Both flaps are used to cover the raw posterior surface of the advancement flap and upper lip muscles. These flaps should be elevated at the muscular level and have at least a width of 1 cm to guarantee flap survival (Fig. 5.56). The oral mucosa lining is repaired using the medial and lateral mucosal flaps (Fig. 5.57). The lateral advancement flap is used to repair the defect created by the upper frenulum section at the non-cleft side. This is elevated in the supraperiosteal plane. The lateral (l) and medial (m) mucosal flaps, elevated from the cleft margins

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Fig. 5.55  Medial and lateral flaps and rotations after skin resection using the triple unilimb Z plasty technique. 1. Columellar base flap. 2. 7dc triangle. 3. Upper medial rotational incision (w–4). 4. Lower medial rotational incision (vermilion) (3′–2′). 5. ab8′ triangle. 6. xyz triangle. 7. Lateral rotational incision (9–B). 8. Alar advancement flap

(Fig. 5.58), are used to repair the upper segment of the oral side of the upper lip. These flaps are sutured one above the other for covering the oronasal lining (Fig. 5.59). (e) Muscular dissection and repair (Figs. 5.58, 5.59, and 5.60) Muscles of the upper lip are separated from the overlying skin, vermilion, and oral mucosa in a similar way as described for the moderate unilateral cleft lip (Fig. 5.61). Orbicularis oris muscle is released from its upturned insertion and turned it down.

120 Fig. 5.56  Oral mucosal incisions and upper frenulum release for severe unilateral cleft lip repair

Fig. 5.57  Oral mucosal and frenulum repair for severe unilateral cleft lip

5  Unilateral Cleft Lip Repair

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Fig. 5.58  Severe unilateral cleft lip flaps elevation and muscular dissection. 1. Nasal columella. 2. Alae. 3. Nasal fascicle of levator labii superioris alaeque nasi muscle. 4. Orbicularis oris muscle at the cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 5. Orbicularis oris muscle at the non-cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 6. Alveolar ridge (gum) at the non-cleft side. 7. Alveolar ridge (gum) at the cleft side. 8. xyz triangular flap. 9. ab8′ triangular flap. 10. Medial upper lip rotational incision. 11. Medial vermilion rotational incision. 12. 7dc triangular flap. 13. Columellar base flap. m: Medial mucosal flap. l: Lateral mucosal flap

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Fig. 5.59  Severe unilateral cleft lip oral mucosa closure. 1. Nasal columella. 2. Alae. 3. Nasal fascicle of levator labii superioris alaeque nasi muscle. 4. Orbicularis oris muscle at the cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 5. Orbicularis oris muscle at the non-cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 6. Alveolar ridge (gum) at the non-cleft side. 7. Alveolar ridge (gum) at the cleft side. 8. xyz triangular flap. 9. ab8′ triangular flap. 10. Medial upper lip rotational incision. 11. Medial vermilion rotational incision. 12. 7dc triangular flap. 13. Columellar base flap. m: Medial mucosal flap. l: Lateral mucosal flap

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Fig. 5.60  Severe unilateral cleft lip muscular repair. 1. Nasal columella. 2. Alae. 3. Nasal fascicle of levator labii superioris alaeque nasi muscle. 4. Orbicularis oris muscle at the cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 5. Orbicularis oris muscle at the non-cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 6. Alveolar ridge (gum) at the non-cleft side. 7. Alveolar ridge (gum) at the cleft side. 8. xyz triangular flap. 9. ab8′ triangular flap. 10. Medial upper lip rotational incision. 11. Medial vermilion rotational incision. 12. 7dc triangular flap. 13. Columellar base flap. 14. Subnasal incision. m: Medial mucosal flap. l: Lateral mucosal flap

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5  Unilateral Cleft Lip Repair

Fig. 5.61  Upper lip muscles dissection during primary cleft lip surgery of severe unilateral cleft lip surgery. 1. Nasal tip. 2. Alae. 3. Lateral segment of the cleft lip. 4. xyz triangular flap. 5. ab8′ triangular flap. 6. Oral mucosa. 7. Gum. 8. Nasal fascicle of levator labii superioris alaeque nasi muscle. 9. Levator labii superioris alaeque nasi muscle (nasal fibrous tendon) 10. Orbicularis oris muscle. 11. Medial segment of the cleft lip

Transposition of the orbicularis oris in an overlapping form to create the philtral column and depressed groove on the philtrum is necessary. At the vermilion level, the marginal fascicle of the orbicularis oris is sutured in a border to border form (Figs. 5.62 and 5.63). Both flaps are sutured together using 5/0 PDS. The levator alaeque nasi is transposed and sutured to the caudal septum to correct the depressed nostril sill using 5/0 PDS.  The muscular repair of the upper lip works over the cleft segments as a surgical orthopedic in a similar form as the presurgical orthopedics (the surgical nasoalveolar molding (NAM) concept). (f) Skin closure (Figs. 5.64 and 5.65) Created skin flaps are inset using absorbable (5/0 vicryl) deep dermal sutures and absorbable (7/0 vicryl or 6/0 catgut fast absorbing) skin sutures in a simple interrupted manner. Corner stitches are necessary at the tip of the triangles (7dc, xyz, and ab8′). The type of sutures and stitches used are described in Fig. 5.66.

5.5  U  nilateral Cleft Lip Primary Rhinoplasty: The Surgical Nasal Molding Concept The unilateral cleft lip nose deformity is characterized by the following components: alar cartilage malposition, shortened vestibule of the nose, septal deviation, skeletal deformity abnormal muscular insertion, and nasal floor deficiency (Fig. 5.67).

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Fig. 5.62  Severe unilateral cleft lip muscular reconstruction. 1. Nasal fascicle of levator labii superioris alaeque nasi muscle. 2. Marginal orbicularis oris muscle. 3. Peripheral orbicularis oris muscle. a. Nasal septum

The main objective of unilateral cleft lip nose repair is the reorientation of the abnormal anatomy and the creation of the balanced platform. Actually, the use of presurgical orthopedics for cleft lip nose management has become very popular; however, this is not used in our hospital due to the lack of scientific evidence supporting its use in unilateral cleft lip nose, presence of associated complications, and the efficacy of our protocol. Our protocol for unilateral cleft lip nose repair is based on early primary surgery of the components of the nasal deformity at 3 months old during lip surgery. In addition, the surgical technique used is selected depending

126

5  Unilateral Cleft Lip Repair

Fig. 5.63  Severe unilateral cleft lip muscular reconstruction. Level A: Medial and lateral orbicularis oris muscles are transposed in an overlapping form. Level B: Marginal fascicle of the orbicularis oris is sutured in a border to border form

on the degree of severity. Main objectives of the primary treatment of the unilateral cleft lip nose deformity are as follows: 1. Alar cartilage reposition for nasal tip repair The reposition of the affected alar cartilage is based on vestibular lengthening. Rotational and advance flaps are used for this purpose. Lower rate of ­cartilage malposition recurrence has been observed with these techniques. Both techniques have been described by the author as rotational method and V–Y–Z technique for unilateral cleft lip nose repair [12, 13]. They are modifications of the technique described by Potter in 1954 [14]. 2. Nasal floor reconstruction 3. Nasal septum correction Actually, caudal portion of the nasal septum correction is done primarily by suturing the nasolabial muscles to the base of the septum during primary cheiloplasty. Definitive correction of the septum is performed at later age depending on the degree of functional impairment of respiratory function. The surgical nasoalveolar molding (NAM) is a concept developed by the author. This is a concept based on the presurgical orthopedic NAM, and this method molds (through the use of plates and nasal devices) the form of the nasal vestibule and aligns the cleft segments. The proposed techniques for cleft lip nasal repair produce a vestibular lengthening in a similar way as the presurgical NAM method without

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Fig. 5.64  Severe unilateral cleft lip repair line of skin closure

Fig. 5.65  Skin closure of the primary cheiloplasty repair using the triple unilimb Z technique in a patient with severe unilateral cleft lip

increasing the rate of relapse and related complications observed with the presurgical treatment [15]. Severity’s degree of unilateral cleft lip nose is based on the angle of the nasal septum deviation (columellar angle). The three forms of unilateral cleft lip deformity based on nose component are as follows: (a) Mild. Columellar angle is greater than 60°. (b) Moderate. Columellar angle is between 30 and 60°. (c) Severe. Columellar angle is less than 30°.

128

5  Unilateral Cleft Lip Repair

Fig. 5.66  Severe unilateral cleft lip skin closure. 1, 2, and 3. Simple interrupted deep dermal sutures using vicryl 5/0. 4, 5, and 6. Corner stitch using vicryl 7/0 or catgut fast absorbing 6/0. The rest of the stitches is performed using simple interrupted skin with vicryl 7/0 or catgut fast absorbing 6/0

5.5.1  Mild Unilateral Cleft Lip Nose Mild forms of unilateral cleft lip nose are mostly associated with incomplete cleft lips since there is a minimal tissue deficiency (Fig. 5.68). The recommended surgical technique for alar cartilage reposition for nasal tip repair of mild unilateral cleft lip nose is the rotational composite flap method, a surgical technique described by the author [12]. This is performed at 3 months old during primary cheiloplasty.

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Fig. 5.67  Unilateral cleft lip nose deformity. 1. Alar cartilage malposition. 2. Shortened nasal vestibule. 3. Septal deviation. 4. Skeletal deformity. 5. Abnormal muscular insertion. 6. Nasal floor deficiency

Surgery (Figs. 5.69, 5.70, 5.71, 5.72, 5.73, 5.74, 5.75, 5.76, and 5.77) The surgeon must first identify the caudal margin of the alar cartilage and the intercartilaginous margin prior to executing any incision. Using a double skin hook and a gentle fingertip traction (with the middle finger of the non-dominant hand), the surgeon retracts the caudal vestibular skin and presents the caudal margin of the alar cartilage itself (Figs.  5.69 and 5.70). Additional recommendations to locate this anatomical landmark are the non-hair-bearing area and the palpation of the

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Fig. 5.68  The mild unilateral cleft lip nose deformity. 1. Alar cartilage malposition. 2. Shortened nasal vestibule. 3. Septal deviation. 4. Skeletal deformity. 5. Abnormal muscular insertion. 6. Nasal floor deficiency

cartilage edge with the handle of the scalpel. Using a skin hook, the cephalic margin of the alar cartilage is identified, which represents the intercartilaginous border known as limen nassi. This rotational flap is created as a combination of marginal and small intercartilaginous incisions. The rotational composite flap is designed following the marginal border of the alar cartilage at the cleft side. It starts at the limen nassi level (intercartilaginous border) and follows the marginal edge until you reach the nasal columella as illustrated in Fig. 5.69. The second incision follows the intercartilaginous borders until you reach the internal nasal valve level (Figs. 5.69 and 5.70). Once the incisions are made using a fine-pointed dissecting scissors, the

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Fig. 5.69  Rotational composite flap incisions for mild unilateral cleft lip nose repair. 1. Vestibular rotational composite flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Columella. 5. Alae

Fig. 5.70  Alar cartilage position and rotational composite flap technique. 1. Vestibular rotational composite flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Columella. 5. Alae. 6. Lateral crus. 7. Domus. 8. Medial crus

132

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Fig. 5.71  Rotational composite flap elevation. 1. Vestibular rotational composite flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Columella. 5. Alae. 6. Alar cartilage

soft tissues are dissected from the surface of the alar cartilage (supra perichondrial plane) and the rotational composite flap is elevated (Figs.  5.71, 5.72, and 5.73). This is a medially based composite (skin cartilaginous) vestibular flap. The nose dissection should be extended to the non-cleft side using the described incision, so both alar cartilages must be degloved at the nasal tip level. After flap elevation, transcutaneous sutures are used for alar cartilage reposition and repair of the performed incisions. A transcutaneous interdomal suture (transfixion) is placed first in two points: anterior, between the lowest border of the domus; posterior, between the nasal septum and highest point of the domus at the level of the internal nasal valve using a 5/0 PDS suture. Then the lateral genu of the alar cartilage is elevated using a vertical transcutaneous suture. Using 5/0 absorbable sutures, stitches are performed through the skin starting inside the nose, coming out at the level of the supra alar crease, returning through the same hole, and coming out inside the nose tying finally the suture (Fig. 5.74). Special care must be paid with the position of

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Fig. 5.72  Rotational composite flap incisions for mild unilateral cleft lip nose repair. 1. Vestibular rotational composite flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Columella. 5. Alae

this vertical suture since it may produce a notch at the level of the soft triangle of the nose. This maneuver moves the composite flap upward and medially creates a lateral triangular defect as illustrated in Figs. 5.71 and 5.72. This defect is closed using the same transcutaneous stitches. The technique lets us the reposition of the alar cartilage and the lengthening of the nasal vestibule. This is the surgical nasal molding method (Fig. 5.73). Nasal packing is recommended in all cases to prevent postoperative bleeding inside the operate nostril. The packing is removed the next day. Postoperative nostril stenting is not mandatory in this technique.

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Fig. 5.73  Rotational composite flap elevation for mild unilateral cleft lip nose repair. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral incisions. 5. Alae. a. Vestibular skin. b. Alar cartilage

5.5.2  Moderate and Severe Unilateral Cleft Lip Nose Moderate and severe forms of unilateral cleft lip nose are mostly associated with complete clefts (Figs. 5.78 and 5.79). The recommended surgical technique is the same for these types of cleft lip nose: the V–Y–Z method, a surgical technique described by the author [13]. This is performed at 3 months of age during primary cheiloplasty.

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Fig. 5.74  Rotational composite flap technique closure and transdomal sutures. 1. Vestibular rotational composite flap. 2. Marginal incision. 3. Closure of the lateral defect. 4. Columella. 5. Alae. 6. Lateral crus. 7. Domus. 8. Medial crus. a. Upper interdomal suture. b. Lower interdomal suture

Surgery (Figs. 5.80, 5.81, 5.82, 5.83, 5.84, 5.85, 5.86, 5.87, 5.88, 5.89, 5.90, and 5.91) Same recommendations are provided to identify the caudal margin of the alar cartilage and the intercartilaginous margin. The V–Y–Z technique is a combination of the Potter’s concept (V–Y composite advanced flap) and Berkeley’s concept (lateral Z plasty) [14, 16]. The V–Y advanced composite flap is designed following the marginal border of the alar cartilage at the cleft side. It starts at the limen nassi level (intercartilaginous border) and follows the marginal edge until you reach the nasal columella as illustrated in Fig. 5.80. The second incision follows the intercartilaginous borders until you reach the internal nasal valve level. The two limbs of the lateral Z-plasty are incised and elevated (Figs. 5.80, 5.81, 5.82, and 5.83). Once the incisions are made using a fine-pointed dissecting scissors, the soft tissues are dissected from the surface of the alar cartilage (supra perichondrial plane) on both

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Fig. 5.75  The surgical nasal molding concept. Rotational composite flap technique closure for mild unilateral cleft lip nose repair. 1. Vestibular composite V flap. 2. Marginal incision closure. 3. Lateral incision closure. 4. Columella. 5. Alae

Fig. 5.76  Rotational composite flap technique closure for mild unilateral cleft lip nose repair: pre- and postoperative views

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Fig. 5.77  Rotational composite flap rhinoplasty for incomplete cleft lip nose repair

Fig. 5.78  Moderate unilateral cleft lip nose deformity. 1. Alar cartilage malposition. 2. Septal deviation. 3. Skeletal deformity. 4. Abnormal muscular insertion. 5. Nasal floor deficiency

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Fig. 5.79  Severe unilateral cleft lip nose deformity. 1. Alar cartilage malposition. 2. Shortened nasal vestibule. 3. Septal deviation. 4. Skeletal deformity. 5. Abnormal muscular insertion. 6. Nasal floor deficiency

sides and the V composite flap is elevated (Fig. 5.84). This V-form composite flap is displaced medially and the lateral flaps are transposed in a Z plasty form (Fig. 5.85). All the performed incisions are closed using transcutaneous stitches. Two transcutaneous (transfixion) interdomal sutures are placed first as described before and then the lateral crus of the alar cartilage is suspended using the same stitches (Fig. 5.86). These transcutaneous stitches are performed using a 5/0 polyglycolic acid sutures through the skin starting inside the nose, coming out at the level of the supra alar crease, returning through the same hole, and coming out inside the nose tying finally the suture. The use of these sutures in combination with the V–Y–Z method allowed us to obtain the following objectives: (i) reposition the alar cartilage improving tip projection and columellar lengthening; (ii) lengthen the nasal vestibule and prevent

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Fig. 5.80  Composite V flap and lateral Z plasty incisions for moderate and severe unilateral cleft lip nose repair. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral incisions. 5. Alae. 6. Columella

Fig. 5.81  Alar cartilage position and composite V–Y–Z technique. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral incisions. 5. Alae. 6. Columella. 7. Lateral crus. 8. Domus. 9. Medial crus

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Fig. 5.82  Composite V flap incisions for moderate and severe unilateral cleft lip nose repair. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Intercartilaginous border (limen nassi). 5. Alae. 6. Columella. 7. Nasal septum

the scar contracture using a lateral Z-plasty (the surgical nasal molding concept), and (iii) reduce the space created by surgical dissection with better reposition of the soft tissues of the nose, which reduce the risk of postoperative bleeding and hematoma formation. This is the nasal molding concept (Fig. 5.89). Special care must be paid with the position of this vertical suture since it may produce a notch at the level of the soft triangle of the nose. Nasal packing is recommended in all cases to prevent postoperative bleeding inside the operated nostril. The packing is removed the next day. Postoperative nostril stenting during 6 months is strongly recommended in this technique in order to prevent vestibular synechia and scar contractures.

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Fig. 5.83  Composite V flap and lateral Z plasty incisions for moderate and severe unilateral cleft lip nose repair. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral incisions. 5. Alae. 6. Columella. 7. Nasal septum. 8. Posterior triangle of the lateral Z plasty. 9. Anterior triangle of the lateral Z plasty

 equence of Nasal Stitches V–Y–Z Technique (Fig. 5.90) S The stitches should be placed as follows: 1. Posterior transfixion interdomal suture. This is placed between the inferior border of upper lateral cartilages, nasal septum, and inferior border of lower lateral cartilages (domes). 2. Anterior transfixion interdomal suture. This is placed between the lowest borders of both lower lateral cartilages (domes). These transfixion sutures are done using PDS 5/0.

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Fig. 5.84  Composite V flap elevation. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral Z plasty. 5. Alae. 6. Columella

Fig. 5.85  V–Y–Z technique closure and transdomal sutures. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral Z plasty. 5. Alae. 6. Lateral crus. 7. Columella. 8. Domus. 9. Medial crus. a. Upper interdomal suture. b. Lower interdomal suture

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4

2

1

a 7

6 b 3

5 8

Fig. 5.86  V–Y–Z technique closure and transdomal sutures. 1. Vestibular rotational composite flap. 2. Marginal incision. 3. Closure of the lateral defect. 4. Alar cartilage. 5. Nasal septum. 6. Alae. 7. Internal nasal valve. 8. Medial crus. a. Lower interdomal suture. b. Upper interdomal suture

3. Intercartilaginous transcutaneous suture. This is placed between the superior border of the lower lateral cartilage and inferior border of the upper lateral cartilage. The suture goes through the skin starting inside the nose, coming out at the level of the supra alar crease, returning through the same hole, and coming out inside the nose tying finally the suture. This suture lifts the alar cartilage.

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Fig. 5.87  V–Y–Z rhinoplasty for complete unilateral cleft lip nose repair

Fig. 5.88  V–Y–Z rhinoplasty for complete unilateral cleft lip nose repair

Fig. 5.89  The surgical nasal molding concept. Left: Preoperative view. Right: Effect of the vestibular lengthening using the V–Y–Z for severe complete unilateral cleft lip nose repair. Columellar length and nasal tip projection are improved with this technique

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Fig. 5.90  V–Y–Z rhinoplasty sequence of nasal stitches. Red circle: Soft triangle area

4. Anterior skin suture. This suture must be applied between the skin borders of the middle third of the marginal incision. This type and location of stitch prevent the retraction of the soft triangle (red circle). 5. V–Y transcutaneous stitch. This is placed at the posterior border of the V composite advanced flap in a similar form as suture 3. 6 and 7. Transcutaneous stitches. These sutures are located between the skin borders of the Z plasty after flaps transposition in a similar form as suture 3. 8. Alar base transcutaneous stitch. This is used for reposition of the alar advancement flap preventing the lateral web commonly observed after primary cleft rhinoplasty. The suture starts at the skin border of the lateral incision and then goes through the alae at the level of the lateral alar crease returning through the same hole and coming out inside the nose tying finally the suture. 9. Columellar base transfixion suture. Sutures 3–8 are done using vicryl 5/0. The author does not recommend to use too many sutures because these stitches may affect the blood supply of the alae of the nose and necrosis would occur.

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5.5.3  Nasal Floor Reconstruction (Fig. 5.91) In our protocol, the nasal floor is composed of three segments that are repaired at different surgical times. I. Anterior (nostril sill) is repaired at 3 months old during cleft lip repair. II. Middle (primary palate) is repaired during mixed dentition period using local gingival mucoperiosteal flaps and autologous bone graft. III. Posterior (secondary palate) is repaired at 1 year old using the one-flap technique. The anterior segment is the floor of the nasal vestibule and this is repaired at 3 months old during primary cheiloplasty. This anterior segment of the nasal floor is repaired using two flaps: (a) Medial flap This is the columellar base flap. A small flap is designed laterally to the base of the columella at the cleft border. This is a 1 × 1 cm cutaneous flap based medially.

Fig. 5.91  Surgical technique for vestibular segment of the nasal floor repair. Flap A (lateral): Alar segment of the lateral advancement cutaneous flap. Flap B (medial): Columellar base flap. The nasal fascicle of levator labii superioris alaeque nasi muscle is used to provide structural support for the vestibular nasal floor

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(b) Lateral flap This is the alar segment of the lateral advancement cutaneous flap. This flap is composed of the upper portion of the lateral lip segment and the base of the ala. A structural support of the anterior segment of the nasal floor is necessary since there is no skeletal framework due to the cleft. This is provided by the muscular repair of the upper lip. The nasal fascicle of levator labii superioris alaeque nasi muscle is used to provide support for the vestibular nasal floor. This muscle is sutured to the caudal septum. Nasal packing is used in all cases inside the operated nostril to prevent postoperative bleeding. The packing should be removed 1 day after surgery. Postoperative nostril stenting is used to prevent scar contracture of the vestibular incisions. This is mandatory after using any primary rhinoplasty with vestibular nose incisions. Scar contracture may close (partially or totally) the nostril affecting the normal breathing of the baby (Fig. 5.92).

Fig. 5.92  Use of postoperative nasal conformer after V–Y–Z primary rhinoplasty in a patient with severe unilateral cleft lip nose deformity (preoperative and short-term postoperative views). This is an acrylic-made device used during 6 months after surgery

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5.6  Skeletal Reconstruction The skeletal deficiency in patients with unilateral cleft lip and palate includes significant boney defects of the maxilla, primary palate (alveolus), and secondary palate with discontinuity of the cleft segments. Main consequences of the unrepaired bone deficiency in patients with unilateral cleft lip are lack of tooth eruption, collapse of the cleft segments and maxillary crossbite, and persistence of nasolabial fistula. The skeletal reconstruction of the cleft includes two parts: (a) Maxillary arch alignment: the surgical alveolar molding The medial and lateral segments of the cleft are separated by the cleft. This space is sometimes very wide and the segments could be collapsed. In order to proceed with the bone reconstruction, the cleft segments must be well aligned. The maxillary arch alignment can be done using presurgical orthopedics or by action of the upper lip muscular repair (the surgical alveolar molding concept) (Figs. 5.93 and 5.94). The surgical method is the technique used by the author because of many advantages compared to the presurgical method. (b) Bone reconstruction: the alveolar bone graft The time and surgical technique of alveolar cleft repair remain controversial. Early repair using bone grafts or gingivoperiosteoplasty (GPP) and use of

Fig. 5.93  The surgical alveolar molding. Maxillary arch alignment obtained by surgical alveolar molding (muscular action) in a 3-year-old patient

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Fig. 5.94  The surgical alveolar molding. Maxillary arch alignment performed using the surgical alveolar molding in a 5-year-old patient

Fig. 5.95  Frontal and lateral CAT views of left unilateral alveolar cleft in a 7-year-old patient with unilateral cleft lip and palate

vomer flaps have been studied with controversial results. A recent systematic review and meta-analysis published by El-Ashmawi et al. [17] indicated that GPP might not be an efficient method for alveolar reconstruction for patients with unilateral and bilateral cleft lip and palate. Also it could lead to maxillary growth inhibition in these patients. Primary autologous bone graft during mixed dentition period (7–9 years of age) is used in our hospital for alveolar cleft reconstruction. Computed tomography and/or panoramic radiograph is used to visualize preoperatively the alveolar cleft and evaluate the eruption of the canine crown (Figs. 5.95 and 5.96). We personally consider a staging protocol for alveolar bone graft, observing less associated infection and graft resorption. The alveolar cleft is closed using gingivoperiosteal flaps at 5 years of age, and then the alveolar bone graft is performed during mixed dentition period. Autologous bone graft is used

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Fig. 5.96  Panoramic X-ray of a 7-year-old patient with unilateral cleft lip and palate and left alveolar cleft

because of its increased success rate compared to other materials (80–90%) [18]. The iliac crest is preferred as donor site. Using a trephine the skin incision and surgical dissection is minimize with improvement of postoperative condition of the patient. Alternatively, the tibia is used as donor site. Surgical Technique The surgery is performed in two surgical times as follows: First Time: Alveolar Cleft Closure The alveolar cleft is closed at 5 years of age. The defect may include nasolabial or oronasal fistula. The incision is done using a 15 blade scalpel around the alveolar cleft margins and following the dental margins of the gingiva at the cleft side as in Fig.  5.97. The medial and lateral mucoperiosteal flaps are raised in a subperiosteal plane. The periosteum is scored vertically and horizontally to facilitate the flap mobilization. The nasal floor is closed using a vomer muco perichondrial flap medially and lateral nasal wall flap raised in the subperiosteal plane laterally (Fig. 5.98). Oral gingival mucosa closure is then performed using 5-0 vicryl suture (Fig. 5.99). If the alveolar cleft is extended to the palate, this should be closed using palatal mucoperiosteal flaps. The alveolar cleft should be closed previously to prevent any salivary contamination of the bone graft and resorption.

5.6 Skeletal Reconstruction Fig. 5.97 Upper: Unilateral alveolar cleft line of surgical incision. Middle: Gingivo mucoperiosteal flaps elevation and nasal mucosa closure. Lower: Unilateral alveolar cleft closure

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Fig. 5.98  Cancellous bone graft raised from the iliac crest

Second Time: Alveolar Bone Graft This procedure is performed during mixed dentition period (7–9 years of age). (a) Bone graft harvest The widely used donor site is the iliac crest and less often tibia. The length of the skin incision is 2 cm and located 2 cm lateral to the anterior superior iliac crest. The surgical dissection through muscles and fascia exposes the iliac crest at this level. Then using a trephine device and a curette, the cancellous bone is harvested (Fig. 5.100). The amount of bone graft required is 5 cc approximately. Overlaying tissue is closed in three layers. (b) Grafting The closed gingival mucosa over the alveolar cleft is open through a 1 cm incision. The cleft borders are dissected at the subperiosteal plane preserving the scar tissue created by the alveolar cleft closure. The integrity of the nasal and oral mucosa must be preserved in order to guarantee the isolation of the graft reducing the probability of contamination and graft resorption. Cancellous

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a

b

c

d

Fig. 5.99  Alveolar cleft repair using cancellous bone graft in a unilateral cleft lip and palate patient. Oronasal fistula (a): CAT of a 7-year-old (mixed dentition period) at the bone graft time illustrating the lateral incisor teeth (red arrow). (b) Nasal mucosa closure, gingivoperiosteal flap elevation, and bone graft. (c) One-year postoperative view of the repaired alveolar cleft (d)

bone graft is then placed filling the gap created by dissection of the alveolar cleft. The gingival borders of the incision are finally closed using vicryl 5/0. Dental splint may be used to provide mechanical protection to the healing mucosa during 6 weeks.

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a

b

c

d

e

f

g

h

Fig. 5.100  Alveolar cleft repair using tibial bone graft in a unilateral cleft lip and palate patient. Oronasal fistula (a): alveolar cleft closure at 5 years and later the bone graft. (b) X-ray at 7 years of age (mixed dentition period) at the bone graft time. (c, d) Surgical incision for tibial graft. (e) Fasciocutaneous flap and periosteal flap elevation. (f) Small cortical hole for cancellous bone graft harvesting. (g) One-year postoperative view of the repaired alveolar cleft (h) Postoperative view after one year showing the alveolar cleft closure after bone grafting

5.7 Postoperative Care

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5.7  Postoperative Care Postoperative care is provided according to the short- and long-term moments. (a) Immediate postoperative care (first 24 hours) • Monitoring Post-anesthetic observations are important requirements for patient assessment after primary cleft lip repair. Continuous cardio-respiratory and pulse oximetry monitoring at PACU (Post Anesthesia Care Unit) is mandatory. If the baby’s vital signs are stable, then he will be moved to regular patient room if hospitalization is indicated. Outpatient primary cleft lip surgery has been shown to be safe; however, hospitalization of patients is indicated in the following conditions: non-stable vital signs, intolerance toward oral foods, and uncontrollable pain. Hyperthermia during the first day of surgery is frequently observed and it is associated with physiological mechanisms and not surgical infection. Its presence is not an indication for hospital admission. Patient’s breathing is predominantly oral in cleft lip and palate patients. After cleft lip and nose surgery, the patient may need to breathe through their mouths and noses for the first week. Medical discharge criteria: stable vital signs, oral feeding restored, and surgical wound without active bleeding. • Feeding Feeding is initiated with IV administration of saline solution and oral feeding is initiated 2 or 3 hours after the surgery using a small spoon. Lip suction of the repaired cleft is not recommended initially due to the risk of bleeding. Breastfeeding may be initiated 2 or 3 days after the surgery. • Pain management Multimodal pain management is actually recommended for pain management. Nerve block in combination with acetaminophen is usually sufficient for pain control. Opioids are not used in our practice due to the risk of non-desired side effects. • Agitation control Sedation may be necessary in selected patients. Use of benzodiazepines is indicated when the pain is not successfully controlled and the baby is still crying. Intranasal or intravenous midazolam may be used with this purpose. Special attention must be considered if there is some bleeding because of the risk of aspiration of a sedated patient. • Wound care Nasal packing is removed slowly the day before the surgery. If the wound is not clean, it would be cleaned using a cotton swab and saline solution. Parents should not try to remove scabs (if present) because of the risk of bleeding. Finally an antibiotic ointment (bacitracin) is recommended to be applied on the incision. Absorbable sutures need not be removed. Tapes, coverage with gauze, and arm splints are not necessary.

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Medical indications: • Oral feeding including diet according to patient’s age • Prophylactic antibiotics and analgesics conditional to pain • Soft diet and chlorhexidine or saline mouthwash three times daily for patients after alveolar bone graft (b) Short-term postoperative care (first week to first month). • Feeding Oral feeding should be supervised by a pediatrician to guarantee its restoration. • Wound care Antibiotic ointment (bacitracin) is used over the surgical wound until the stitches disappear (1 or 2 weeks). Any remaining stitch after this time should be manually removed by the surgeon in order to prevent development of granulomas. Best suture material for short-term resorption in our experience is the catgut fast absorbing 6/0; if this suture is not available, vicryl 7/0 may be used. • Antibiotics and analgesics Prophylactic antibiotic is used orally during this period. Analgesics are conditioned to pain. Persistent manifestation of crying or discomfort should be evaluated by a pediatrician as a probability of associated disease. • Nasal conformer Nasal stents must be used after primary rhinoplasty to prevent scar contracture and synechia of the vestibular nose. This device requires an individualized design and could be used since the second or third week and during 6 months at least. It is applied with some moisturizing cream to prevent injury of the soft tissues and fixed using tapes. (c) Long-term postoperative care (first year) • Child development Weight and size of the child should be monitored by the pediatrician in order to guarantee normal feeding. Associated chronic infections may be related with abnormal development of the patients. • Scar care The healing of the surgical wound is usually completed after 2 or 3 weeks. A gentle massage of the scar may be used once the wound has healed. The silicone gel is recommended to be used during 6 months once or twice a day as necessary. Corticoid infiltration is rarely used in our practice. In addition, protection from the sun is required for at least 3 or 4 months.

5.8 Case Studies

5.8  Case Studies (Figs. 5.101, 5.102, 5.103, and 5.104) Case 1 Diagnostic: right microform unilateral cleft lip (Fig. 5.101). Fig. 5.101 Upper: Preoperative view of right microform cleft lip. Lower: Postoperative view after one year

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Case 2 Diagnostic: right incomplete unilateral cleft lip nose (Fig. 5.102).

Fig. 5.102  Upper: Preoperative view of right incomplete cleft lip. Lower right: Postoperative frontal view after one year. Lower left: Worm eye postoperative view after one year

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Case 3 Diagnostic: right moderate complete unilateral cleft lip (Fig. 5.103).

Fig. 5.103 Upper: Preoperative view of right moderate complete cleft lip. Lower right: Postoperative frontal view after one year. Lower left: Worm eye postoperative view after one year

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Case 4 Diagnostic: right severe complete unilateral cleft lip (Fig. 5.104).

Fig. 5.104  Upper: Preoperative view of right severe complete cleft lip. Lower: Postoperative frontal view after 3 years. Lower left: Worm eye postoperative view after three years

References 1. Rose W. On harelip and cleft palate. London: H.K. Lewis; 1891. p. 203. 2. Thompson JE. An artistic and mathematically accurate method of repairing the defect in cases of harelip. Surg Gynecol Obstet. 1912;14:498–505. 3. Millard DR Jr. A radical rotation in single harelip. Am J Surg. 1958;95(2):318–22. 4. Mohler LR. Unilateral cleft lip repair. Plast Reconstr Surg. 1987;80(4):511–7. 5. Tennison CW. The repair of the unilateral cleft lip by the stencil method. Plast Reconstr Surg (1946). 1952;9(2):115–20. 6. Randall P. A triangular flap operation for the primary repair of unilateral clefts of the lip. Plast Reconstr Surg Transplant Bull. 1959;23(4):331–47. 7. Pool R. The configurations of the unilateral cleft lip with reference to the rotation advancement repair. Plast Reconstr Surg. 1966;37(6):558–65.

References

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8. Fisher DM, Tse R, Marcus JR. Objective measurements for grading the primary unilateral cleft lip nasal deformity. Plast Reconstr Surg. 2008;122(3):874–80. 9. Rossell-Perry P, Gavino-Gutierrez A. Upper double-rotation advancement method for unilateral cleft lip repair of severe forms: classification and surgical technique. J Craniofac Surg. 2011;22(6):2036–42. 10. Rossell-Perry P. A 20 year experience in unilateral cleft lip repair: from Millard to the triple unilimb Z plasty technique. Indian J Plast Surg. 2016;49(3):48–57. 11. Mulliken J.  Double unilimb Z plasty repair of microform cleft lip. Plast Reconstr Surg. 2005;116(6):1623–32. 12. Rossell-Perry P. Rotational composite flap technique for primary incomplete cleft nose deformity. Plast Recon Surg Global Open. 2020;e2870. 13. Rossell-Perry P. Primary unilateral cleft lip nasal deformity repair using VYZ plasty. Indian J Plast Surg. 2017;50(2):180–6. 14. Potter J. Some nasal tip deformities due to alar cartilage abnormalities. Plast Reconstr Surg (1946). 1954;13(5):358–66. 15. Levy-Bercowski D, Abreu A, De Leon E, Looney S, Stockstill J, Weiler M, Santiago P.  Complications and solutions in presurgical nasoalveolar molding therapy. Cleft Palate Craniofac J. 2009;46(5):521–8. 16. Berkeley W. The cleft lip nose. Plast Reconstr Surg. 1959;23:567. 17. El-Ashmawi N, Elkordy S, Salah Fayed M, El-Beialy A, Attia K. Effectiveness of gingivoperiosteoplasty on alveolar bone reconstruction and facial growth in patients with cleft lip and palate: a systematic review and meta-analysis. Cleft Palate Craniofac J. 2019;56(4):438–53. 18. Stein M, Zhang Z, Fell M, Mercer N, Malic C.  Determining postoperative outcomes after cleft palate repair: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2019;72(1):85–91.

Chapter 6

Bilateral Cleft Lip Repair

6.1  Presurgical Orthopedics Management of skeleton and soft tissues in patients with bilateral cleft lip and palate has been a challenge in cleft care. Position of the premaxilla in severe cases (alveolar gap wider than 1  cm) creates a difficult scenario for primary repair of the bilateral cleft lip. A presurgical management of the position of the premaxilla is mandatory in order to prevent potential complications as lip dehiscence or hypertrophic scars (Fig. 6.1). Different surgical and non-surgical orthopedics have been described with this purpose. Both methods are effective alternatives to align alveolar segments with the premaxilla. The objective is to transform a severe form of bilateral cleft lip to moderate or mild form of this type of cleft facilitating the primary repair. These methods mold the underlying bony structures, reduce tension for lip closure, and let us reposition the alar base. There are two types of presurgical orthopedics: non-surgical and surgical methods. (a) Non-surgical methods (nasoalveolar molding, elastic bandages, tapes, etc.) represent the first option for prominent premaxilla management in our proposed protocol. (b) Surgical methods for premaxilla management in bilateral cleft lip are: surgical lip adhesion and premaxillary setback. The surgical lip adhesion (unilateral or bilateral) is still a value instrument to improve the position of the premaxilla. This surgery is expanding soft tissues and molds the cleft segments. It is indicated when the non-surgical orthopedic fails or wasn’t used at early age. The surgical technique used for lip adhesion was based on the technique described by Randall and applied bilaterally or unilaterally [1]. Unilateral lip adhesion is used in our protocol for severe asymmetrical bilateral cleft lip and palate when there is a significant asymmetry between the two alveolar

© Springer Nature Switzerland AG 2020 P. Rossell-Perry, Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair, https://doi.org/10.1007/978-3-030-44681-9_6

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Bilateral cleft lip and palate

Primary

Secondary

Non severe form

Severe form (Cleft width more than 10 mm)

Ok

Non surgical methods

Cheiloplasty

Fail Surgical methods

Alveolar bone graft

Ok

Orthognathic surgery

Surgical setback

Lip adhesion Fail Ok

Fig. 6.1  Bilateral cleft lip management diagram flow

gaps. We consider the cases as severe asymmetric bilateral cleft lip and palate when the size of the wider alveolar gap is double or more than the narrower side. Definitive bilateral cleft lip repair was performed 3–6 months after lip adhesion. The lip adhesion effect as presurgical orthopedic method finishes when the alveolar gap is less than 10  mm. After 6  months of age, the surgical lip adhesion is limited to change the cleft segments’ position, and the premaxilla may remain in protruded position. The premaxillary setback technique is based on concepts described by Von Bardeleben in 1865 and Burston and Kernahan in 1961 [2]. It is indicated when the non-surgical orthopedics or lip adhesion failed. The patient may have a lip dehiscence after many attempts of closure with the premaxilla severely protruded. The patient in both conditions has a severity deformity of the face. In this situation, the benefit of the setback osteotomy improving the facial appearance over the potential distortion of the facial growth is justified.

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6.2  Bilateral Cleft Lip Surgical Techniques There is no scientific evidence about which surgical technique provides the best surgical outcome for bilateral cleft lip repair. We may consider two basic methods for primary bilateral cleft lip repair: (a) Central lip repaired using the prolabium and lateral segments (Millard type) (Fig. 6.2). (b) Central lip repaired using only the prolabium (Manchester type) (Fig. 6.3). (a) These techniques are based on Millard principle [3]. Advantages: Better appearance of the central portion of the lip (central white roll and philtral tubercle). Disadvantages: Visible scar at the lower portion of the philtrum and shorter width of the upper lip.

Fig. 6.2  Millard type of primary bilateral cleft lip repair

Fig. 6.3  Manchester type of primary bilateral cleft lip repair

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(b) Most popular techniques based on this concept are: Manchester and Spina [4, 5]. Advantages: Wider upper lips. Disadvantages: Tendency to produce central whistler deformity.

6.3  Author’s Surgical Technique During my professional practice performing bilateral cleft lip repair, I have been used initially techniques based on Millard concept and then Noordhoff’s modifications [3, 6]. Ralph Millard proposed the use of the prolabium and lateral segments for upper central lip repair, and Samuel Noordhoff proposed the elimination of the bilateral subnasal incisions. The main problem in bilateral cleft lip repair is the reconstruction of the central segment of the upper lip. Manchester’s concept is using only the prolabium (always hypoplasic in different degrees) for central lip repair [4]. This is the reason why the frequency of whistler deformity associate with this technique is increased. I didn’t obtain good outcomes using this technique. My actual personal technique for primary cleft lip repair is a modification of Millard and Noordhoff’s concept plus primary rhinoplasty. Main author’s modifications are the correction of the upper lip’s asymmetry and the primary rhinoplasty technique. There are three types of asymmetry in bilateral cleft lip: (a) Alveolar cleft asymmetry: Corrected by presurgical treatment when this is severe and using primary cheiloplasty when the cleft is mild or moderate. (b) Upper lip lateral segments asymmetry: Corrected by primary cheiloplasty. (c) Nose asymmetry: Corrected by primary rhinoplasty. Authors like Mulliken correct the upper lip asymmetry reducing the lip’s height of the longer side producing a shorter lip [7]. The author’s proposition is to lengthen the shorter side creating a longer lip or combine lengthening and reduction preserving more the upper lip tissues. The used technique is based on the degree of severity according to the proposed classification. The degree of the deformity requires an individualized design since the tissue’s deficiency should be well addressed. There may be limitations using traditional techniques to address asymmetries in bilateral cleft lip. The main contributions of the proposed author’s techniques are: (a) More individualized management of the bilateral cleft lip deformity (b) Prevention of upper lip’s asymmetry (c) Nose correction during primary cheiloplasty without presurgical molding (d) Correction of the skeletal deformity without presurgical orthopedics (with exception of severe bilateral cleft lip cases)

6.4  Presurgical Considerations Under loupe magnification and proper illumination, anatomical landmarks of the upper lip are identified to proceed with the markings.

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Fig. 6.4  Infraorbital nerve block for primary bilateral cleft lip repair

Lip markings must be done before local anesthetic injection. I personally prefer the use of a surgical pen marker instead of use of methylene blue. The surgery is initiated with the lip markings. Markings should be done before asepsis and infiltration with local anesthetic at the level of the top of the patient’s head. After the markings are completed, the injection of local anesthetic is performed. Maximal dose of 1% xylocaine is 1 or 0.5 cc/kg with 2% xylocaine. A 0.1 ml of 1:200,000 epinephrine is safe to be used in combination with the xylocaine. Infraorbital nerve block on both sides is done during anesthetic infiltration for bilateral cleft lip repair (Fig. 6.4). Local anesthesia is completed with field infiltration around the nose and prolabium. Five to seven minutes must be allowed after the injection to obtain a proper effect. Due to the flexibility and mobility of the upper lip, a gentle fingertip traction is applied over the vermillion border to facilitate lip incisions and reduce the bleeding (Fig. 6.5).

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Fig. 6.5  Maneuver to facilitate the surgical incision of the marking in the bilateral cleft lip. A gentle fingertip traction is applied over the vermillion border of the cleft segments to facilitate lip incisions and reduce the bleeding. Traction of the prolabium using a double skin hook or forceps is used to facilitate prolabium incisions

6.5  Bilateral Cleft Lip Surgical Protocol 6.5.1  Surgical Orthopedics These techniques are indicated for severe alveolar component of the bilateral cleft lip and palate cases (alveolar gap wider than 1 cm) when the non-surgical orthopedics failed or wasn’t used (Fig. 6.6).

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Fig. 6.6  Severe alveolar component of bilateral cleft lip and palate. 1. Nasal tip. 2. Ale. 3. Prolabium. 4. Premaxilla. 5. Vomer. 6. Lateral segments of the upper lip. 7. Alveolar gap (wider than 1 cm). 8. Alveolar ridge

Surgical Lip Adhesion The used method is based on Randall’s technique [1]. Markings Based on proper identification of the anatomical landmarks, the following points must be located and marked (Fig. 6.7):

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Fig. 6.7  Severe alveolar component of bilateral cleft lip. 1. Cupid’s bow (middle point). 2 and 3. Cupid’s bow (lateral point). 1′, 2′, and 3′. Similar as points 1, 2, and 3 but located over red line. 4 and 5. Columellar base (lateral point). 6 and 7. Intersection of the lateral columellar base point and cleft margin. 8 and 9. Intersection of the alar base line and cleft margin. 10 and 11. White roll (end’s point). 10′ and 11′. Same as points 10 and 11 but located over red line. A and B. Alar bases. C and D. Oral commissures

The design of surgical incisions is based on the identification of anatomical landmarks of the upper lip previously described (Figs. 6.7 and 6.8). Two flaps are designed at the central segment (prolabium and columellar base flaps) and three flaps are designed at the lateral segments (lateral mucosa, oral mucosa, and alar flaps). Prolabium Flaps A rectangular flap is designed at the prolabium on each side. These are posteriorly based flaps. The length represents the distance between the lateral point of the designed cupid’s bow (points 2 and 3) and the points located at the intersection of the lateral columellar base point and cleft margin (points 6 and 7). The width

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Fig. 6.8  Bilateral lip adhesion incisions for severe alveolar component bilateral cleft lip repair. 2 and 3. Lateral points of the cupid’s bow. 6 and 7. Intersection of the lateral columellar base and cleft margin. 8 and 9. Intersection of the alar base and cleft margin. 10 and 11. White roll end’s point

is extended to the full thickness of the prolabium (at the level of the prolabium-­ premaxilla sulcus). Columellar Base Flaps A small skin flap is designed on each side laterally to the base of the columella (beside points 6 and 7). This flap is used for nasal floor adhesion in combination with the alar portion of the advancement flap. Lateral Mucosal Flaps A rectangular flap is designed at the lateral segment on each side. These are anteriorly based flaps. The length represents the distance between the intersection of the alar base line and cleft margin (points 8 and 9) and the points located at the white roll end’s point (points 10 and 11). The width is designed using the same distance as the width of the prolabium flaps.

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Oral Mucosa Flaps This flap is the oral mucosa of the lateral segment released from its insertion at the maxilla and displaced as advancement flap medially. A lateral back cut is frequently used in order to decrease the tension of the flap closure. Alar Flaps This flap is composed by the base of the alae. This flap is designed on each side starting at point 8 and 9 and then continues with an incision inside the nose at the level of the pyriform aperture. The extension of this incision is in direct relation with the cleft’s width. Surgical Procedure This is the surgical sequence of the bilateral surgical lip adhesion for severe bilateral cleft lip management. Lip landmarks must be preserved and care was taken

Fig. 6.9  Bilateral surgical lip adhesion: prolabium and lateral flaps elevation. 1. Nasal tip. 2.  Columella. 3. Prolabium. 4. Premaxilla. 5. Alae. 6. Upper lip lateral segments. 7. Upper lip muscles. P. Prolabium posteriorly based flaps. L. Lateral anteriorly based flaps. O. Oral mucosa flap

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avoiding violation of lip tissue that could be used later in the definitive bilateral cleft lip repair. Surgical incisions should be done over the mucosa close to the skinmucosa junction. (a) Surgical incision (Fig. 6.8). A full thickness skin incision is performed following the described markings perpendicular to the cutaneous plane using a scalpel No 3 with a 11 blade or 15 C for better precision. (b) Flap elevation (Fig. 6.9). Two flaps are elevated from the central segment: prolabium flap and columellar base flap. • Prolabium flap. The prolabium flaps are elevated from the subcutaneous plane in both sides of the prolabium as in Fig. 6.9. These mucosal flaps are posteriorly based. This dissection separates the mucosa from the subcutaneous tissue due to the muscles are absent in the prolabium. • Columellar base flap. A small flap is designed laterally to the base of the columella (beside points 6 and 7). This flap is used for nasal floor adhesion in combination with the alar advancement flap. Three flaps are elevated from the lateral segment: • Lateral mucosal flap. The lateral flaps are elevated from the muscular plane in both sides of the upper lip lateral segments as in Fig. 6.9. These mucosal flaps are anteriorly based of the cleft edge. • Oral mucosa flap. An incision over the buccal sulcus releasing the oral mucosa and a relaxing incision (back cut) is performed laterally in order to decrease any tension at the wound closure (Fig. 6.9). Wide supraperiosteal undermining of the lateral segment is required at this level. • Alar base flap. The lateral incision is extended inside the nose over the pyriform aperture releasing the alar base from the maxillary element. In order to release the tension of the adhesion, a significant amount of undermining of the lateral segment (mucosal and alar flaps) is carried out at the supraperiosteal level. (c) Muscular dissection and adhesion (Fig. 6.10). The upper lip muscles are freed from their abnormal insertion in the alveolar cleft margin. This muscular complex is sutured to the subcutaneous level of the prolabium in both sides using nylon 4/0. This suture is later removed during primary cheiloplasty. (d) Lip adhesion closure (Figs. 6.11, 6.12, and 6.13). The lip adhesion closure starts with the oral mucosal repair using the medial mucosal flap from prolabium (P) which is turned up laterally and sutured to the oral mucosa flap (O) of the lateral segments in both sides. Then the muscles are attached to the subcutaneous tissue of the prolabium in both sides using a 4/0 nylon. Finally, the lateral mucosal flap is turned up medially and sutured to the skin of the prolabium. The skin closure is performed using

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Fig. 6.10  Bilateral surgical lip adhesion: oral mucosa, muscular and nostril sill adhesion. 1. Nasal tip. 2. Columella. 3. Prolabium. 4. Premaxilla. 5. Alae. 6. Upper lip lateral segments. 7. Upper lip muscles. P. Prolabium posteriorly based flaps. L. Lateral anteriorly based flaps. O. Oral mucosa flap. c. Columellar base flaps. a. Alar flap

absorbable sutures (polyglycolic acid) 5–0  in a border-to-border approximation.  urgical Premaxillary Setback S The used technique is based on septal ostectomy and premaxillary reposition. The presented procedure is based on concepts described by Von Bardeleben in 1865 and Burston and Kernahan in 1961 [2]. It is indicated when the non-surgical orthopedics or lip adhesion failed. The patient may have many attempts of closure or the lip with the premaxilla severely protruded. In these cases, the reposition of the premaxilla is indicated.

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Fig. 6.11  Bilateral surgical lip adhesion: upper lip skin adhesion. 1. Nasal tip. 2. Columella. 3.  Prolabium. 4. Premaxilla. 5. Alae. 6. Upper lip lateral segments. L.  Lateral anteriorly based flaps. c. Columellar base flaps. a. Alar flap

Surgical Procedure The blood supply to premaxilla and prolabium must be preserved in order to prevent necrosis of these segments. The blood supply is provided by nasal and ethmoidal arteries. Mucosal incision must be done at the midline and subperichondrial dissection should be limited (Figs. 6.14 and 6.15). Septal growth zones must be preserved in order to limit the impact of the surgery over the facial growth. The premaxillary-­vomerine junction must be preserved. The zone of bone resection is located behind the premaxilla. A 2  cm mucoperiosteal incision is done along the free border of the vomer behind the premaxilla and then the mucoperiosteum is elevated in both sides (Fig. 6.15). After exposition of the vomer, a triangular wedge resection is performed removing 10–15 mm of bone.

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a

b

c

d

e

f

Fig. 6.12  Lip adhesion surgical technique. (a) Premaxilla position of severe bilateral cleft lip and palate. (b) Prolabial mucosal flaps elevation. (c) Bilateral lateral segment dissection. (d) Oral mucosa closure. (e) Preoperative view. (f) Postoperative view. P.  Prolabium. Pr. Premaxilla. M. Upper lip muscles. L. Lateral segments. m. Medial mucosal flap. l. Lateral mucosal flap. c. Columella. o. Oral mucosa. v. Vermillion

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a

b

c

d

e

f

Fig. 6.13  Bilateral cleft lip adhesion for severe alveolar component bilateral cleft lip and palate. (a) Worm eye presurgical view (alveolar gap 15 mm). (b) Frontal presurgical view. (c) Postoperative view after surgery. (d) Postoperative view after 4  months. (e) New position of the premaxilla (alveolar gap 5 mm). (f) Postoperative view 1 year after primary cheiloplasty

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Fig. 6.14  Prolabium and premaxilla blood supply. 1. Nasal tip branches. 2. Anterior ethmoidal artery. 3. Posterior ethmoidal artery. 4. Angular artery. 5. Lateral nasal artery. 6. Infraorbital artery. 7. Superior labial artery. 8. Facial artery. 9. Prolabium blood supply

A 3 mm osteotome is used with this purpose. Then the premaxilla is manually set back in a position necessary to allow successful closure of the lip (Fig. 6.16). The mobilization of the premaxilla is limited because the vomer resection is small and use of wires or plates is not necessary. Pressure generated by the lip closure corrects the premaxilla position and healing of the vomer can be obtained. Simultaneous surgical premaxillary setback and primary cheilorhinoplasty is possible but not recommended by the author. A combination with surgical lip adhesion is preferable. If the premaxillary setback is done at later age (older than 5 years of age), the alveolar cleft closure is associated. Mucoperiosteal incision is closed using vicryl 5/0.

6.5.2  Primary Bilateral Cleft Lip Repair Primary bilateral cleft lip nose repair is indicated for all the clefts with an alveolar gap narrower than 1 cm. Bilateral cleft lip deformity includes different forms, since minimal tissue deficiencies (microforms) to more extended upper lip defects. Asymmetrical bilateral cleft lip (complete or incomplete) are frequent and not well addressed by current surgical techniques. Surgical management of these deformities

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Fig. 6.15  Site of ostectomy for surgical premaxillary setback. 1. Greater palatine artery. 2. Descending palatine artery. 3. Ascending palatine artery. 4. Area of mucosa incision and ostectomy. 5. Branches from infraorbital artery. 6. Superior alveolar artery. 7. Superior labial artery. 8. Dorsal nasal artery. A: Vascular anatomoses between descending palatine artery and ascending palatine artery through lesser palatine vessels. B: Columella. C: Prolabium. D: Premaxilla. E: Premaxillary-vomerine suture. F: Vomer

is based on author’s classification. The primary palate component is not used for election of the surgical technique since this is corrected previously (presurgical orthopedics). Author’s proposed classification is characterized by the degree of soft

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a

b

c

d

Fig. 6.16  Premaxillary setback surgical technique. (a) Three-year-old patient with severe alveolar component bilateral cleft lip and palate after two failed attempts of cleft lip closure. (b) Vomer midline incision and ostectomy. (c) Premaxilla position 6 months after successful bilateral cleft lip closure. (d) Premaxilla and maxillary arch position 1 year after primary palatoplasty. 1. Premaxilla. 2. Premaxillary-vomerine suture. 3. Vomer. 4. Cleft palate segments. 5. Maxillary arch. 6. Alveolar cleft. 7. Repaired palate. X. Ostectomy

tissue’s asymmetry since the nasolabial symmetry is the primary guiding principle during repair of any cleft lip deformity. The cleft types are: (a) Mild bilateral cleft lip. This type of bilateral cleft lip is characterized by minimal cleft lip asymmetry. Difference between the right and left segment lip height is less than 3 mm. (b) Moderate bilateral cleft lip. The difference between the right and left segment lip height is between 3 and 6 mm. (c) Severe bilateral cleft lip. This type of bilateral cleft lip is characterized by severe discrepancy between both cleft lip sides. Difference between the right and left segment lip height is more than 6 mm.

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Fig. 6.17  Mild incomplete bilateral cleft lip deformity

Fig. 6.18  Mild complete bilateral cleft lip deformity

The reconstruction of the upper lip muscles and oral mucosa is the same for these three types. The difference between the used surgical techniques is related to the skin and nose deformities management.

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Fig. 6.19  Mild incomplete bilateral cleft lip deformity. 1. Cupid’s bow (middle point). 2 and 3. Cupid’s bow (lateral point). 1′, 2′, and 3′. Similar as points 1, 2, and 3 but located over red line. 4 and 5. Columellar base (lateral point). 6 and 7. Intersection of the lateral columellar base point and cleft margin. 8 and 9. Intersection of the alar base line and cleft margin. 10 and 11. White roll (end’s point). 10′ and 11′. Same as points 10 and 11 but located over red line. A and B. Alar bases. C and D. Oral commissures

 ild Bilateral Cleft Lip (Figs. 6.17 and 6.18) M This type of bilateral cleft lip is characterized by minimal cleft lip asymmetry. Difference between the right and left segment lip height is less than 3 mm. Markings Based on proper identification of the anatomical landmarks of the affected upper lip, the following points must be located and marked (Figs. 6.19 and 6.20): The design of surgical incisions is based on the identification of anatomical landmarks of the upper lip previously described (Figs.  6.19, 6.20, 6.21, 6.22, 6.23, and 6.24). Two flaps from the lateral segment (labial nasal advancement and

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Fig. 6.20  Mild complete bilateral cleft lip deformity. 1. Cupid’s bow (middle point) and 3. Cupid’s bow (lateral point). 1′, 2′, and 3′. Similar as points 1, 2, and 3 but located over red line. 4 and 5. Columellar base (lateral point). 6 and 7. Intersection of the lateral columellar base point and cleft margin. 8 and 9. Intersection of the alar base line and cleft margin. 10 and 11. White roll (end’s point). 10′ and 11′. Same as points 10 and 11 but located over red line. A and B. Alar bases. C and D. Oral commissures

vermillion-­white roll), two from the prolabium, and two columellar base flaps are designed. Prolabium Flaps The first one, is a random rhomboidal shape cutaneous flap and limited by the points 4–2–1–3–5. It represents the philtrum of the reconstructed upper lip. Distances 4–2 and 3–5 corresponds to the philtral columns and the points 2–1–3 are the cupid’s bow. Distance between points 4 and 5 must be 4  mm at least. The design of the new philtral columns is limited by the size of the prolabium. The distances between points 2–1 and 1–3 are established by the author as 3 mm each one. This design creates a 6-mm-wide cupid’s bow. This is wider than the 4–mm-wide philtrum proposed by Mulliken. The author estimates that a wider philtrum let us reduce the

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Fig. 6.21  Surgical incisions for mild incomplete bilateral cleft lip deformity

tension of the closure and the probability of necrosis, lip dehiscence, or hypertrophic scars. If the philtrum is looking too wide, this issue may be corrected later easily. The hypoplasic oral mucosa and vermillion of the prolabium is used for oral mucosa sulcus repair. This is the second prolabial flap. Labionasal Advancement Flaps These flaps are composed by the labial portion of the lateral lip segment and the base of the ala at each side. This flap is designed starting at points x and y, continuing to the points 8 and 9 (tip of the flaps), and then finishing with a incision inside the nose at the level of the pyriform aperture. The points 8 and 9 must be located at junction of the cutaneous border of the cleft lip with the subalare crease to avoid a wrong position of the repaired alar base. Vermillion-White Roll Musculocutaneous Flaps These flaps (one per each side) are composed by lateral vermillion and white roll and include the marginal segment of the orbicularis oris muscle. The prolabium is

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Fig. 6.22  Surgical incisions for mild complete bilateral cleft lip deformity

deficient of white roll, vermillion, and labial muscles; therefore, these tissues must be provided by the lateral segment. The vermillion flap is designed at points x and y following the points 10 and 11 on each side and then finishing at the points 10′ and 11′. This is a composite flap since it is including the peripheral segment of the orbicularis oris muscle. Lines 10–10′ and 11–11′ should not be straight in order to avoid the development of whistler deformity. Columellar Base Flaps A small flap is designed laterally to the base of the columella (between points 4–6 and 5–7). This flap is used for nasal floor repair in combination with the alar portion of the advancement flap on each side.

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Fig. 6.23  Flaps for mild incomplete bilateral cleft lip deformity. A. Prolabial flap. B. Lateral columellar flap. C.  Labionasal advancement flap. D.  Vermillion-white roll musculocutaneous flap. E. Prolabial vermillion

Formula



8 − 10 − x = 9 − 11 − y = 2 − 4∗ = 3 − 5 ∗ 10 − x = 1 − 2 = 11 − y = 1 − 3 A −8 = B−9 C−x = D−y



∗ If the prolabium is too small, the distances 2–6 and 3–7 may be too short and a small shortening of the distances 8–10–x and 9–11–y would be required using subnasal skin excision.

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Fig. 6.24  Flaps for mild complete bilateral cleft lip deformity. A. Prolabial flap. B. Lateral columellar flap. C.  Labionasal advancement flap. D.  Vermillion-white roll musculocutaneous flap. E. Prolabial vermillion

Surgical Procedure (a) Surgical incision (Figs. 6.21, 6.22, 6.23, and 6.24). A full thickness skin incision is performed following the described markings perpendicular to the cutaneous plane using a scalpel No 3 with a 11 blade or 15 C for better precision. • Prolabium. A full thickness skin incision following the markings is performed creating a cutaneous rhomboid flap and a mucosal vermillion flap. The distance between points 4 and 5 must be at least 4 mm in order to guarantee the blood supply of the flap. The prolabium incision continues upward from points 6 and 7 creating to rectangular cutaneous flaps medially based (columellar base flaps) used for nasal floor repair.

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Fig. 6.25  Area of skin, vermillion, and mucosa resection for mild incomplete bilateral cleft lip

Fig. 6.26  Area of skin, vermillion, and mucosa resection for mild complete bilateral cleft lip

• Lateral segments. A full thickness skin incision following the cleft margins between points x–10–8 and y–11–9 on each side. Lateral segment incision continues upward over the pyriform aperture in direct relation with the width of the cleft. Downward, lateral incisions are following the points 10–10′ and 11–11′ creating the vermillion-white roll flaps. Oral mucosa incision is located over the labial sulcus, and its extension is in relation with the width of the cleft

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Fig. 6.27  Mild incomplete bilateral cleft lip muscular dissection. 1. Nasal tip. 2. Prolabium flap. 3. Alae. 4. Premaxilla. 5. Prolabium vermillion mucosal flap. 6. Premaxilla. 7. Fascicle of levator labii superioris alaeque nasi muscle. 8 and 9. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 10. Fascicle of levator labii superioris alaeque nasi muscle. 11. Vermillion-white roll flap. 12. Gum. 13. Columellar base flap

too. Lateral back cut would be necessary if some tension of the mucosal closure is observed. (b) Prolabium and lateral segment skin resection (Figs. 6.25 and 6.26). Based on the proposed technique, an area of prolabial skin is resected in order to create a philtrum in proper size. The area of skin resection is located between the points 6–4–2–1–3–5–7 and the cutaneous vermillion limit according to Figs. 6.25 and 6.26. (c) Skin flap elevation (Figs. 6.27 and 6.28). The incisions and prolabium skin resection create two flaps from the lateral segment (labial nasal advancement and vermillion), two from the prolabium, and two columellar base flaps.

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Fig. 6.28  Mild complete bilateral cleft lip muscular dissection. 1. Nasal tip. 2. Prolabium flap. 3. Alae. 4. Prolabium. 5. Premaxilla. 6. Fascicle of levator labii superioris alaeque nasi muscle. 7 and 8. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 9. Fascicle of levator labii superioris alaeque nasi muscle. 10. Vermillion-white roll flap. 11. Gum. 12. Lateral columellar base flap

• Prolabium. A rhomboidal cutaneous flap and a mucosal vermillion flap are elevated from the premaxilla. The dissection at the prolabial area after skin incisions separates the subcutaneous tissue from the supraperiosteal plane of the premaxilla and hypoplasic prolabial vermillion. A medially based skin flap is elevated from the base of the columella on each side in a supraperichondrial plane. • Lateral segments. The skin is elevated from the underlying muscular plane in both sides of the clefts. The alar segment is elevated doing s supraperiosteal dissection over the maxilla as much as necessary in order to decrease the tension of the lip closure. A fingertip dissection is used as a blunt dissection to perform this

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Fig. 6.29  Mild complete bilateral cleft lip vermillion tissue resection. 1. Nasal tip. 2. Prolabium flap. 3. Alae. 4. Prolabium. 5. Premaxilla. 6. Fascicle of levator labii superioris alaeque nasi muscle. 7 and 8. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 9. Fascicle of levator labii superioris alaeque nasi muscle. 10. Vermillion-white roll flap. 11. Gum. 12. Lateral columellar base flap. x and y. Vermillion-skin resection of the prolabium

lateral segment release. Vermillion-white roll flaps are created including marginal segment of the orbicularis oris muscle. (d) Mucosal flaps elevation and repair (Figs. 6.27 and 6.28). Two oral mucosal flaps are elevated from each lateral segment. Both flaps are used for oral mucosa repair and they are sutured at midline. The oral mucosa lining is closed using vicryl 5/0 stitches using the right and left mucosal flaps as advancement flaps. The oral sulcus is created in combination with the prolabial mucosal-vermillion flap (Figs. 6.29, 6.30, 6.31, 6.32, 6.33, and 6.34) (e) Muscular dissection and repair (Figs. 6.27, 6.28, and 6.35). There is absence of muscles at the prolabium; therefore, the upper lip muscular repair is done using the lateral segment muscular component. Upper lip muscles (composed by the levator labii superioris alaeque nasi muscle and two fascicles of orbicularis oris muscle: marginal and peripheral)

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Fig. 6.30  Mild complete bilateral cleft lip labial sulcus repair. 1. Nasal tip. 2. Prolabium flap. 3. Alae. 4. Mucosal Vermillion flap. 5. Premaxilla. 6. Fascicle of levator labii superioris alaeque nasi muscle. 7 and 8. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 9. Fascicle of levator labii superioris alaeque nasi muscle. 10. Vermillion-white roll flap. 11. Gum. 12. Lateral columellar base flap

are separated from the abnormal insertion of the overlying skin, vermilion, and oral mucosa from each lateral segment. These muscles are released from its upturned insertion and turned it down on each side. Then, the orbicularis oris muscle and the alar fascicle of the levator labii superioris alaeque nasi muscle from each side are sutured in a border-to-border form at midline. Both muscles are sutured together using 5/0 PDS. The muscular repair of the upper lip works over the cleft segments as a surgical orthopedic in a similar form as the presurgical orthopedics (the surgical NAM concept). The marginal segment of the orbicularis oris muscle included in the vermillionwhite roll flaps is not dissected, and this is repaired together with the vermillion component.

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Fig. 6.31  Mild complete bilateral cleft lip muscular dissection. 1. Nasal tip. 2. Prolabium flap. 3. Alae. 4. Vermillion mucosal flap sutured to premaxilla. 5. Premaxilla. 6. Fascicle of levator labii superioris alaeque nasi muscle. 7 and 8. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 9. Fascicle of levator labii superioris alaeque nasi muscle. 10. Oral mucosa flap. 11. Gum. 12. Lateral columellar base flap. 13. Vermillion-white roll flap

Fig. 6.32  Oral mucosa view of mild complete bilateral cleft lip and palate. Left: Preoperative view. Right: Postoperative view. 1. Prolabium. 2. Premaxilla. 3. Oral mucosa 4. Gum. 5. Nasal tip

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Fig. 6.33  Oral mucosa incisions and repair for mild complete bilateral cleft lip and palate deformity. 1. Prolabium. 2. Premaxilla. 3. Oral mucosa. 4. Lateral relaxing incisions. 5. Premaxillary-­ vomerine suture. 6. Nasal septum. 7. Upper lip muscles

Fig. 6.34  Oral mucosa incisions and repair for mild incomplete bilateral cleft lip and palate deformity. 1. Prolabium. 2. Premaxilla. 3. Oral mucosa. 4. Lateral rotational incision. 5. Upper lip muscles. 6. Vermillion. 7. Red line. 8. Gum

(f) Skin closure (Figs. 6.36, 6.37, 6.38, and 6.39). Created skin flaps are inset using absorbable (5/0 vicryl) deep dermal sutures and absorbable (7/0 vicryl or 6/0 catgut fast absorbing) skin sutures in a simple interrupted manner. Corner stitches are necessary at the junction of the prolabial and vermillion-white roll flaps.  oderate Bilateral Cleft Lip (Figs. 6.40 and 6.41) M The difference between the right and left segment lip height is between 3 and 6 mm.

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Fig. 6.35  Mild Complete Bilateral Cleft Lip muscular repair. 1. Prolabium 2 and 3. Alae. 4. Fascicle of levator labii superioris alaeque nasi muscle. 5. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 6. Labio nasal advancement flap. 7. Vermillion-white roll flap. 8. Lateral columellar base flap

Markings Based on proper identification of the anatomical landmarks of the affected upper lip, the following points must be marked (Figs. 6.42 and 6.43): The design of surgical incisions is based on the identification of anatomical landmarks of the upper lip previously described (Figs.  6.44, 6.45, 6.46, and 6.47). Three flaps from the lateral segment (labial advancement, alar, and vermillion-white roll), three from the prolabium, and two columellar base flaps are designed.

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Fig. 6.36  Mild bilateral cleft lip repair line of skin closure

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Fig. 6.37  Mild bilateral cleft lip skin closure. 1. Simple interrupted skin sutures using vicryl 5/0. 2. Corner stitch using vicryl 6/0. 3. Corner stitch using vicryl 6/0 or catgut fast absorbing 6/0. 4. Mattress sutures using vicryl 5/0 for vermillion closure. The rest of stitches is performed using simple interrupted skin with vicryl 7/0

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Fig. 6.38  Skin closure of the primary cheilorhinoplasty repair using the proposed technique in a patient with mild incomplete bilateral cleft lip

Fig. 6.39  Skin closure of the primary cheilorhinoplasty repair using the proposed technique in a patient with mild complete bilateral cleft lip

Prolabium Flaps (a) Rhomboid flap. This is a random rhomboidal shape cutaneous flap and limited by the points 4–2–1–3–5. It represents the philtrum of the reconstructed upper lip. Distances 4–2 and 3–5 corresponds to the philtral columns and the points 2–1–3 are the cupid’s bow. The distances between points 2–1 and 1–3 are established by the author as 3 mm each one. (b) Lateral triangular flap (4ab). This is a cutaneous flap limited by the points 4ab. The distance 4–b represents the difference between the distances 9–11 and 8–10. Distances a–4 and a–b must be equal. (c) Vermillion-mucosa flap. This flap is created after rhomboid flap elevation, and it is composed by the hypoplasic oral mucosa and vermillion of the prolabium that is around the prolabial flap. Excision of lateral extra tissue is necessary. It is used for oral mucosa sulcus repair.

6.5 Bilateral Cleft Lip Surgical Protocol Fig. 6.40 Moderate incomplete bilateral cleft lip deformity

Fig. 6.41 Moderate complete bilateral cleft lip deformity

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Fig. 6.42  Moderate incomplete bilateral cleft lip deformity. 1. Cupid’s bow (middle point). 2 and 3. Cupid’s bow (lateral point). 1′, 2′, and 3′. Similar as points 1, 2, and 3 but located over red line. 4 and 5. Columellar base (lateral point). 6 and 7. Intersection of the lateral columellar base point and cleft margin. 8 and 9. Intersection of the alar base line and cleft margin. 10 and 11. White roll (end’s point). 10′ and 11′. Same as points 10 and 11 but located over red line. A and B. Alar bases. C and D. Oral commissures

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Fig. 6.43  Moderate complete bilateral cleft lip deformity. 1. Cupid’s bow (middle point). 2 and 3. Cupid’s bow (lateral point). 1′, 2′, and 3′. Similar as points 1, 2, and 3 but located over red line. 4 and 5. Columellar base (lateral point). 6 and 7. Intersection of the lateral columellar base point and cleft margin. 8 and 9. Intersection of the alar base line and cleft margin. 10 and 11. White roll (end’s point). 10′ and 11′. Same as points 10 and 11 but located over red line. A and B. Alar bases. C and D. Oral commissures

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Fig. 6.44  Surgical incisions for moderate incomplete bilateral cleft lip deformity

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Fig. 6.45  Surgical incisions for moderate complete bilateral cleft lip deformity

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Fig. 6.46  Flaps for moderate incomplete bilateral cleft lip deformity. A. Prolabial flap. B. Lateral columellar flap. C. Labionasal advancement flap. C1. Alar component of the lateral advancement flap. D. Vermillion-white roll musculocutaneous flap. E. Prolabial vermillion. X. Triangular flap

Labionasal Advancement Flaps (a) Labial advancement flap. These flaps are composed by the labial portion of the lateral lip segment at each side. The base of the ala is included at the longer side. These flaps are designed starting at points x and y, continuing to the points 8 and 9 (tip of the flaps), and then finishing with a incision inside the nose at the level of the pyriform aperture. (b) Alar flap. The alar flap (A–8–6) is used only at the shorter side of the bilateral cleft, and it is created after the rotational incision (8–A) is done. A small rotational incision (8–A) is located at the shorter side to elongate the lateral segment using the prolabium triangular flap (4ab). This flap is used for nostril sill repair. Vermillion-White Roll Musculocutaneous Flaps These flaps (one per each side) are composed by lateral vermillion and white roll and include the marginal segment of the orbicularis oris muscle. The prolabium is deficient of white roll, vermillion, and labial muscles; therefore, these tissues must be provided by the lateral segment. The vermillion flap is designed at points x and y following the points 10 and 11 on each side and then finishing at the points 10′ and 11′, respectively. Lines 10–10′ and 11–11′ should not be straight in order to avoid the development of whistler deformity.

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Fig. 6.47  Flaps for moderate complete bilateral cleft lip deformity. A. Prolabial flap. B. Lateral columellar flap. C. Labionasal advancement flap. C1. Alar component of the lateral advancement flap. D. Vermillion-white roll musculocutaneous flap. E. Prolabial vermillion. X. Triangular flap

Columellar Base Flaps A small flap is designed laterally to the base of the columella (between points 4–6 and 5–7). This flap is used for nasal floor repair in combination with the alar portion of the advancement flap on each side. Formula



8 − 10 − x + 4 − b = 9 − 11 − y = 2 − 4∗ = 3 − 7 ∗ 10 − x = 1 − 2 = 11 − y = 1 − 3 A −8 = B−9 = 4 −a C − x = D − y ∗∗



• ∗ If the prolabium is too small, the distances 2–6 and 3–7 may be too short and a small shortening of the distances 8–10–x and 9–11–y would be required using subnasal skin excision. • ∗∗ The distances C–x and/or D–y may be congenital shorter. Then the asymmetry of this distance is not possible to be corrected.

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Surgical Procedure (a) Surgical incision. A full thickness skin incision is performed following the described markings perpendicular to the cutaneous plane using a scalpel No 3 with a 11 blade or 15 C for better precision. • Prolabium. A full thickness skin incision following the markings is performed creating a cutaneous rhomboid flap, lateral triangular flap, and a mucosal vermillion flap. The prolabium incision continues upward from points 6 and 7 creating to rectangular cutaneous flaps medially based (columellar base flaps) used for nasal floor repair. • Lateral segments. A full thickness skin incision following the cleft margins between points x–10–8 and y–11–9 on each side. Lateral segment incision continues upward over the pyriform aperture in direct relation with the width of the cleft. Downward, lateral incisions are following the points 10–10′ and 11–11′ creating the musculocutaneous vermillion-white roll flaps. A rotational incision (A–8) is performed at the level of the alarfacial groove of the shorter side. Oral mucosa incision is located over the labial sulcus, and its extension is in relation with the width of the cleft too. Lateral back cut would be necessary if some tension of the mucosal closure is observed. (b) Prolabium and lateral segment skin resection (Figs. 6.48 and 6.49). Based on the proposed technique, an area of prolabial skin is resected in order to create a philtrum in proper size and lateral triangular flap for shorter side elongation. The area of skin resection is located between the

Fig. 6.48  Area of skin, vermillion, and mucosa resection for moderate incomplete bilateral cleft lip

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Fig. 6.49  Area of skin, vermillion, and mucosa resection for moderate complete bilateral cleft lip

points 4–a–b–2–1–3–5–7 and the cutaneous vermillion limit according to the Figs. 6.48 and 6.49. (c) Skin flap elevation (Figs. 6.50 and 6.51). The incisions and prolabium skin resection create three flaps from the lateral segment (labial, nasal, and vermillion), three from the prolabium, and two columellar base flaps. • Prolabium. A rhomboidal cutaneous flap, lateral triangular prolabial flap (4ab), and a mucosal vermillion flap are elevated from the premaxilla using a single incision. The dissection at the prolabial area after skin incisions separates the subcutaneous tissue from the supraperiosteal plane of the premaxilla. • Lateral segments. One labionasal advancement flap is elevated from the longer side and two flaps (labial and nasal) are elevated from the shorter side. The skin is elevated from the underlying muscular plane in both sides of the clefts. The alar segment is elevated doing s supraperiosteal dissection over the maxilla as much as necessary in order to decrease the tension of the lip closure. Vermillion flaps are created including marginal segment of the orbicularis oris muscle. Finally, a medially based skin flap is elevated from the base of the columella on each side in a supraperichondrial plane to create the lateral columellar flaps. (d) Mucosal flaps elevation and repair (Figs. 6.50, 6.51, and 6.52). Two oral mucosal flaps are elevated from each lateral segment (Figs. 6.50, 6.51, and 6.52). Both flaps are used for oral mucosa repair and they are sutured

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Fig. 6.50  Moderate incomplete bilateral cleft lip muscular dissection. 1. Nasal tip. 2. Prolabium flap. 3. Alae. 4. Prolabium. 5. Premaxilla. 6. Fascicle of levator labii superioris alaeque nasi muscle. 7 and 8. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 9. Fascicle of levator labii superioris alaeque nasi muscle. 10. Vermillion-white roll flap. 11. Gum. 12. Columellar base flap. 13. Alar flap. 14. Lateral triangular flap

at midline without tension. The oral mucosa lining is closed using vicryl 5/0 stitches using the right and left mucosal flaps as advancement flaps. The oral sulcus is created in combination with the prolabial mucosal-vermillion flap (Figs. 6.53, 6.54, 6.55, and 6.56). (e) Muscular dissection and repair (Figs. 6.50, 6.51, 6.52, and 6.57). There is absence of muscles at the prolabium; therefore, the upper lip muscular repair is done using the lateral segment muscular component. Upper lip muscles (composed by the levator labii superioris alaeque nasi muscle and two fascicles of orbicularis oris muscle: marginal and peripheral) are separated from the abnormal insertion of the overlying skin, vermilion, and oral mucosa from each lateral segment. Then, the orbicularis oris muscle and the alar fascicle of the levator labii superioris alaeque nasi muscle from each side are sutured in a border-to-border form at midline. Both muscles are sutured together using 5/0 PDS.

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Fig. 6.51  Moderate complete bilateral cleft lip muscular dissection. 1. Nasal tip. 2. Prolabium flap. 3. Alae. 4. Prolabium. 5. Premaxilla. 6. Fascicle of levator labii superioris alaeque nasi muscle. 7 and 8. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 9. Fascicle of levator labii superioris alaeque nasi muscle. 10. Vermillion-white roll flap. 11. Gum. 12. Columellar base flap. 13. Alar flap. 14. Lateral triangular flap

The marginal segment of the orbicularis oris muscle included in the vermillion-­white roll flaps is not dissected, and this is repaired together with the vermillion component. (f) Skin closure (Fig. 6.58). Created skin flaps are inset using absorbable (5/0 vicryl) deep dermal sutures and absorbable (7/0 vicryl or 6/0 catgut fast absorbing) skin sutures in a simple interrupted manner. Corner stitches is necessary at the junction of the prolabial and vermillion-white roll flaps. Used type of sutures and stitches are described in Figs. 6.59, 6.60, and 6.61. Another type of moderate asymmetrical bilateral cleft lip with discrepancy between segments is the combination of incomplete cleft lip with microform cleft lip (Fig. 6.62).

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Fig. 6.52  Moderate complete bilateral cleft lip muscular and mucosa dissection. 1. Nasal tip. 2. Prolabium flap. 3. Lateral triangular flap. 4. Vermillion mucosa flap. 5. Premaxilla. 6. Gum. 7. Alae. 8. Oral mucosa advancement flap. 9. Orbicularis oris muscle. 10. Fascicle of levator labii superioris alaeque nasi muscle. 11. Labial advancement flaps. 12. Vermillion-white roll flap. 13. Columellar base flap. 14. Lateral rotational incision. 15. Alar flap

Fig. 6.53  Prolabial flaps and oral sulcus repair for moderate complete bilateral cleft lip and palate. 1. Prolabial skin flap. 2. Lateral triangular flap. 3. Columellar base flaps. 4. Prolabial vessel. 5. Vermillion mucosa flap. 6. Premaxilla. 7. Alae. 8. Labial advancement flaps

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Fig. 6.54  Prolabial flaps for labial sulcus repair. A. Prolabial skin flap. B. Vermillion mucosa flap. C. Premaxilla

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Fig. 6.55  Oral mucosa incisions and repair for moderate incomplete bilateral cleft lip and palate deformity. 1. Prolabium. 2. Premaxilla. 3. Oral mucosa. 4. Lateral rotational incision. 5. Upper lip muscles. 6. Vermillion. 7. Red line. 8. Gum

Fig. 6.56  Oral mucosa incisions and repair for moderate complete bilateral cleft lip and palate deformity. 1. Prolabium. 2. Premaxilla. 3. Oral mucosa. 4. Lateral relaxing incisions. 5. Premaxillary-vomerine suture. 6. Nasal septum. 7. Upper lip muscles

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Fig. 6.57  Moderate complete bilateral cleft lip muscular repair. 1. Prolabium 2 and 3. Alae. 4. Fascicle of levator labii superioris alaeque nasi muscle. 5. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 6. Labio nasal advancement flap. 7. Vermillion-white roll flap. 8. Lateral columellar base flap. 9. Lateral triangular flap

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Fig. 6.58  Moderate bilateral cleft lip repair line of skin closure

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Fig. 6.59  Moderate bilateral cleft lip skin closure. 1. Simple interrupted skin sutures using vicryl 5/0. 2. Corner stitch using vicryl 6/0. 3. Corner stitch using vicryl 6/0. 4. Corner stitch using vicryl 6/0 or catgut fast absorbing 6/0. 5. Mattress sutures using vicryl 5/0 for vermillion closure. The rest of stitches is performed using simple interrupted skin with vicryl 7/0

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Fig. 6.60  Skin closure of the primary cheilorhinoplasty repair using the proposed technique in a patient with moderate incomplete bilateral cleft lip

Fig. 6.61  Skin closure of the primary cheilorhinoplasty repair using the proposed technique in a patient with moderate complete bilateral cleft lip

Markings Based on proper identification of the anatomical landmarks of the affected upper lip, the following points must be identified (Fig. 6.63): The design of surgical incisions for this type of cleft combines the technique described for moderate unilateral cleft lip and skin excisions based on the identification of anatomical landmarks of the upper lip previously identified (Figs. 6.64 and 6.65). Incomplete Cleft Side Two triangles (xyz and cd11′) and one advancement flap are designed at the cleft side. • xyz triangle. The base of the triangle is determined by the difference between the microform cleft and complete cleft lip height (8–10) – (11–9). The height of this triangle is determined by the distance from the point a to the point b. The point b is located at the level of the midline of the upper lip. The point a is determined by the junction of the perpendicular line to the point b and the line perpendicular to the point 3 (Peak of the Cupid’s bow on the cleft side). These two points deter-

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Fig. 6.62  Moderate bilateral cleft lip deformity (microform + incomplete cleft lip)

mine the distance a–b which is equal to the xyz triangle’s height. Finally, the base of the triangle xyz is designed in a distance equal to 3–a (11–z = 3–a). • cd11′ triangle. The base of the triangle is determined by the difference between the cleft side vermillion height (11–11′) – (3–3′). The distance c–d is determined by the distance from the point 3′ (point located at the level of the point 3 over the red line) to the point 2′ (Point located at the level of the point 2 over the red line). Finally, the base of this triangle cd11′ is designed in a distance equal to 3–3′ (11′–c + c–11 = 10–10′) (11–c = 3–3′). • Labionasal advancement flap. This flap is composed by the upper portion of the lateral lip segment and the base of the ala. This triangular flap is designed starting at point x, continuing to the point 9 (tip of the flap), and then finishing with a incision inside the nose at the level of the pyriform aperture. The point 9 must be located at junction of the cutaneous border of the cleft lip with the subalare crease. • Columellar base flap. A small flap is designed laterally to the base of the columella (beside point 7). This flap is used for nasal floor repair in combination with the alar portion of the advancement flap.

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Fig. 6.63  Moderate microform + incomplete bilateral cleft lip deformity. 1. Cupid’s bow (middle point). 2 and 3. Cupid’s bow (lateral point). 1′, 2′, and 3′. Similar as points 1, 2, and 3 but located over red line. 4 and 5. Columellar base (lateral point). 6 and 7. Intersection of the lateral columellar base point and cleft margin. 8 and 9. Intersection of the alar base line and cleft margin. 10 and 11. White roll (end’s point). 10′ and 11′. Same as points 10 and 11 but located over red line. A and B. Alar bases. C and D. Oral commissures

Microform Cleft Side • Labial nasal advancement flap. This flap is composed by the upper portion of the lateral lip segment and the base of the ala. This triangular flap is designed starting at point 10, continuing to the point 8 (tip of the flap), and then finishing at the point 6. • Columellar base flap. A small flap is designed laterally to the base of the columella (between points 4–6). This flap is used for nasal floor repair in combination with the alar flap.

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Fig. 6.64  Surgical incisions for moderate bilateral cleft lip deformity (microform + incomplete bilateral cleft lip)

Formula 5−a = 9−x x − z = 2 − 4 – 9 − 11 x − y = z − y = a − b 9 − x + x − z + z − 11 = 5 − a + x − z + a − 3 = 2 − 4 = 8 − 10 z − 11 = a − 311 − c = 3 − 3′ c − d = 11′ − d = 3′ − 1′ 11 − c + c − 11′ = 10 − 10′

A − 8 = B − 9 C − 10 = D − 11



Surgical Procedure (a) Surgical incision. A full thickness skin incision is performed following the described markings perpendicular to the cutaneous plane using a scalpel No 3 with a 11 blade or 15 C for better precision. After the surgical incisions are done, the primary rhinoplasty is performed at the incomplete cleft side.

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Fig. 6.65  Surgical incisions for moderate bilateral cleft lip deformity (microform + incomplete bilateral cleft lip). A. xyz triangle. B. cd11′ triangle. C. Labionasal advancement flap. D. Lateral columellar base flap. a. a–b upper rotational incision. b. 3′–1′ lower rotational incision. x. Area of skin excision of the incomplete side. y. Area of skin excision of the microform side. Yellow dot line: White roll. Red dot line: Red line

(b) Skin, vermillion, and mucosa resection (Figs. 6.66 and 6.67). • Incomplete cleft side. After surgical incisions, an area of skin, vermillion, and mucosa (limited by the points 7–9–x–y–z–11–c–d–3′–3–a–5–7) is excised. The skin and vermillion resection creates two triangular flaps: 1 cutaneous (xyz) and 1 in the vermillion (cd11′). • Microform cleft side. After surgical incisions, an area of skin, vermillion, and mucosa (limited by the points 6–8–10–10′ to the gingival sulcus and continue with the points 2′–2–4 finalizing at the point 6) is excised. Muscular tissue is preserved to guarantee the blood supply to the prolabium. (c) Skin flap elevation (Fig. 6.68). The skin is elevated from the underlying muscular plane only in the lateral segment of the incomplete cleft lip. • Incomplete cleft side. • Philtral segment. The skin dissection at the philtral area should not be performed to preserve blood supply of this segment. A quadrangular medially

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Fig. 6.66  Area of skin and vermillion excision for moderate (microform + incomplete) bilateral cleft lip

based flap is elevated at the subcutaneous level from the base of the columella (columellar base flap). Two rotational incisions are placed at the philtral and central vermillion area: a–b and 3′–1′. • Lateral segment. A small incision (1 cm) at the pyriform aperture and supraperiosteal dissection over the maxilla is necessary in order to facilitate the proper position of the repaired ala and nostril sill. After this, the lateral advancement flap composed by the upper portion of the lateral lip segment and the base of the ala is elevated. The triangular flaps xyz and cd11′ are finally elevated at the dermal level. (d) Muscular dissection (Fig. 6.68). Surgical dissection is then performed to separate the muscular plane (composed by the levator labii superioris alaeque nasi muscle and two fascicles of orbicularis oris muscle: marginal and peripheral) from the abnormal insertion. (e) Dissection of the mucosa (Fig. 6.69). The mucosa is dissected free from the edge of the muscles for around 5 mm in both sides.

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Fig. 6.67  Area of skin, vermillion, and mucosa resection for moderate (microform + incomplete) bilateral cleft lip

(f) Closure of the mucosa (Fig. 6.69). The cleft lip closure starts with the inner lip mucosa in both sides. • Incomplete cleft side. The oral mucosa lining is closed before using vicryl 5/0 stitches using advancement flaps and the mucosa of the prolabium. These flaps are sutured one above the other for covering the oronasal lining. The triangular vermillion flap (cd11′) is sutured medially into the medial rotational incision (3′–1′) at the complete cleft side. • Microform cleft side. Border-to-border closure (10–2 and 10′–2′ until the gingival sulcus) is done at the microform side using vycril 5/0. (g) Reconstruction of the upper lip muscles (Fig. 6.70). The freed muscles are then reconstructed at the incomplete cleft side. The peripheral and marginal orbicularis oris muscle is repaired first using 5/0 PDS suture. Both flaps are sutured together using 5/0 PDS. The levator alaeque nasi is transposed and sutured to the caudal septum to correct the depressed nostril sill using 5/0 PDS. (h) Skin closure (Figs. 6.71 and 6.72). Created skin flaps are inset using absorbable (5/0 vicryl) deep dermal sutures and absorbable (7/0 vicryl or 6/0 catgut fast absorbing) skin sutures in a simple interrupted manner. Corner stitches are necessary at the tip of the triangles (xyz and cd11′). Used type of sutures and stitches are described in Fig. 6.73.  evere Bilateral Cleft Lip (Fig. 6.74) S This type of unilateral cleft lip is characterized by severe discrepancy between both cleft lip sides. Difference between the right and left segment lip height is more than 6 mm. This is observed mostly in bilateral cleft lip and palate cases which combine complete and incomplete cleft lips.

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Fig. 6.68  Moderate incomplete + microform bilateral cleft lip muscular dissection. 1. Nasal tip. 2. Alae. 3. Fascicle of levator labii superioris alaeque nasi muscle. 4 and 5. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 6. Gum. 7. xyz triangle. 8. cd11′ triangle. 9. Philtral rotational incision. 10. Vermillion rotational incision. 11. Microform side skin excision

Markings Based on proper identification of the anatomical landmarks of the affected upper lip, the following points must be identified (Fig. 6.75): The design of surgical incisions is based on the identification of anatomical landmarks of the upper lip previously described (Figs. 6.76 and 6.77). Three flaps from each lateral segment (labial advancement, alar and vermillion-white roll), three from the prolabium, and two columellar base flaps are designed. Prolabium Flaps (a) Rhomboid flap. This is a random rhomboidal shape cutaneous flap and limited by the points 4–2–1–3–5. It represents the philtrum of the reconstructed upper lip. Distances 4–2 and 3–5 correspond to the philtral columns and the points 2–1–3 are the

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Fig. 6.69  Oral mucosa incisions and repair for moderate incomplete + microform bilateral cleft lip and palate deformity. 1. cd11′ triangle. 2. Vermillion rotational incision. 3. Excisional incision closure. 4. Upper lip muscles. 5. Oral mucosa advancement flap. 6. Frenulum. 7. Frenulum releasing incision. 8. Gum. 9. Vermillion. 10. Red line. 11. Oral mucosa

cupid’s bow. The distances between points 2–1 and 1–3 are established by the author as 3 mm each one. (b) Lateral triangular flap (4ab). This is a cutaneous flap limited by the points 4ab. The distance 4–b represents the difference between the distances d–11 and 8–10. Distances a–4 and a–b must be equal. This is used to elongate the shorter side. (c) Vermillion-mucosa flap. This flap is created after rhomboid flap elevation, and it is composed by the hypoplasic oral mucosa and vermillion of the prolabium that is around the

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Fig. 6.70  Moderate incomplete + microform bilateral cleft lip muscular repair. 1. Nasal columella. 2. Alae. 3. Nasal fascicle of levator labii superioris alaeque nasi muscle. 4. Orbicularis oris muscle at the cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 5. Orbicularis oris muscle at the non-cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 6. Nasal septum. 7. xyz triangular flap. 8. cd11′ triangular flap. 9. Medial upper lip rotational incision. 10. Medial vermillion rotational incision. 11. Columellar base flap. 12. Gum. 13. Microform side skin excision

prolabial rhomboidal flap. Excision of lateral extra tissue is necessary. It is used for oral mucosa sulcus repair. Labionasal Advancement Flaps (a) Labial advancement flap. These flaps are composed by the labial portion of the lateral lip segment at each side. These flaps are designed starting at points x and y, continuing to the points 8 and d (tip of the flaps), and then finishing with a incision inside the nose at the level of the pyriform aperture. (b) Alar flaps. The alar flaps are used in both sides of the bilateral cleft, and they are created after the rotational incisions (8–A) and excisional incision (9–B–d) are done.

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Fig. 6.71  Moderate bilateral cleft lip repair line of skin closure

Fig. 6.72  Skin closure of the primary cheilorhinoplasty repair using the proposed technique in a patient with moderate incomplete + microform bilateral cleft lip

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Fig. 6.73  Severe bilateral cleft lip repair line of skin closure. 1, 2, and 4. Simple interrupted deep dermal sutures using vicryl 5/0. 3 and 5. Corner stitch using vicryl 7/0 or catgut fast absorbing 6/0. The rest of stitches is performed using simple interrupted skin with vicryl 7/0

The 8–A rotational incision is located at the shorter side to elongate the lateral segment using the prolabium triangular flap (4ab). The 9–A–d excisional incision is located at the longer side to reduce the lateral segment and create a more symmetrical lip. These flaps are used for nostril sill repair. Vermillion-White Roll Musculocutaneous Flaps These flaps (one per each side) are composed by lateral vermillion and white roll and include the marginal segment of the orbicularis oris muscle. The prolabium is deficient of white roll, vermillion, and labial muscles; therefore, these tissues must be provided by the lateral segment. The vermillion flap is designed at points x and y following the points 10 and 11 on each side and then finishing at the points 10′ and 11′, respectively. Lines 10–10′ and 11–11′ should not be straight in order to avoid the development of whistler deformity.

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Fig. 6.74  Severe bilateral cleft lip deformity (incomplete + complete cleft lip)

Columellar Base Flaps A small flap is designed laterally to the base of the columella (between points 4–6 and 5–7). This flap is used for nasal floor repair in combination with the alar portion of the advancement flap on each side. Formula



8 − 10 − x + 4 − b = d − 11 − y = 2 − 4∗ = 3 − 5 ∗ 10 − x = 1 − 2 = 11 − y = 1 − 3 A −8 = B−9 = 4 −a C − x = D − y ∗∗



• ∗ If the prolabium is too small, the distances 2–6 and 3–7 may be too short and a small shortening of the distances 8–10–x and 9–11–y would be required using subnasal skin excision. • ∗∗ The distances C–x and/or D–y may be congenital shorter. Then the asymmetry of this distance is not possible to be corrected. Surgical Procedure (a) Surgical incision. A full thickness skin incision is performed following the described markings perpendicular to the cutaneous plane using a scalpel No 3 with a 11 blade or 15 C for better precision. • Prolabium. A full thickness skin incision following the markings is performed creating a cutaneous rhomboid flap, lateral triangular flap, and a mucosal vermillion flap. The prolabium incision continues upward from points 6 and 7

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Fig. 6.75  Severe incomplete + complete bilateral cleft lip deformity. 1. Cupid’s bow (middle point). 2 and 3. Cupid’s bow (lateral point). 1′, 2′, and 3′. Similar as points 1, 2, and 3 but located over red line. 4 and 5. Columellar base (lateral point). 6 and 7. Intersection of the lateral columellar base point and cleft margin. 8 and 9. Intersection of the alar base line and cleft margin. 10 and 11. White roll (end’s point). 10′ and 11′. Same as points 10 and 11 but located over red line. A and B. Alar bases. C and D. Oral commissures

creating to rectangular cutaneous flaps medially based (columellar base flaps) used for nasal floor repair. • Lateral segments. A full thickness skin incision following the cleft margins between points x–10–8 and y–11–9 on each side. Lateral segment incision continues upward over the pyriform aperture in direct relation with the width of the cleft. Downward, lateral incisions are following the points 10–10′ and 11–11′ creating the musculocutaneous vermillion-white roll flaps. Oral mucosa incision is located over the labial sulcus and its extension is in relation with the width of the cleft too. Lateral back cut would be necessary if some tension of the mucosal closure is observed. A rotational incision (A–8) is performed

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Fig. 6.76  Surgical incisions for severe bilateral cleft lip deformity (incomplete + complete bilateral cleft lip)

at the level of the alarfacial groove of the shorter side. This incision creates two flaps (alar and labial) and elongates the lateral segment using the prolabium triangular flap (4ab). (b) Prolabium and lateral segment skin resection (Fig. 6.78). Based on the proposed technique, an area of prolabial skin is resected in order to create a philtrum in proper size and lateral triangular flap for shorter side elongation. Additional skin excision (9–B–d) is necessary in this type of cleft in order to obtain a more symmetrical lip. The area of skin resection is located between the points a–b–2–1–3–5–7–9–B–d–11–11′ and the cutaneous vermillion limit according to the Fig. 6.78. (c) Skin flap elevation (Fig. 6.79). The incisions and skin resection create three flaps from the lateral segment (labial, nasal and vermillion), three from the prolabium, and two columellar base flaps.

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Fig. 6.77  Flaps for severe incomplete + complete bilateral cleft lip deformity. A. Prolabial flap. B. Lateral columellar flap. x. Prolabial triangular flap. C. Labial advancement flap. C1. Alar flap. D. Vermillion-white roll musculocutaneous flap. E. Prolabial vermillion. F. Alar flap. G. Labial advancement flap

• Prolabium. A rhomboidal cutaneous flap, lateral triangular prolabial flap (4ab), and a mucosal vermillion flap are elevated from the premaxilla using a single incision. The dissection at the prolabial area after skin incisions separates the subcutaneous tissue from the supraperiosteal plane of the premaxilla. • Lateral segments. Labial and nasal flaps are elevated from both sides after rotational incision (shorter side) and skin excision (longer side) were performed. The skin is elevated from the underlying muscular plane in both sides of the clefts. Vermillion flaps are created including marginal segment of the orbicularis oris muscle. Finally, a medially based skin flap is elevated from the base of the columella on each side in a supraperiochondrial plane to create the lateral columellar flaps. (d) Mucosal flaps elevation and repair (Fig. 6.80). Two oral mucosal flaps are elevated from each lateral segment. Both flaps are used for oral mucosa repair and they are sutured at midline without tension. The oral mucosa lining is closed using vicryl 5/0 stitches using the right and left

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Fig. 6.78  Area of skin, vermillion, and mucosa resection for severe (incomplete + complete) bilateral cleft lip

mucosal flaps as advancement flaps. The oral sulcus is created in combination with the prolabial mucosal-vermillion flap. (e) Muscular dissection and repair (Fig. 6.81). Upper lip muscles (composed by the levator labii superioris alaeque nasi muscle and two fascicles of orbicularis oris muscle: marginal and peripheral) are separated from the abnormal insertion of the overlying skin, vermilion, and oral mucosa from each lateral segment. Then, the orbicularis oris muscle and the alar fascicle of the levator labii superioris alaeque nasi muscle from each side are sutured in a border-to-border form at midline. Both muscles are sutured together using 5/0 PDS. The marginal segment of the orbicularis oris muscle included in the vermillion-white roll flaps is not dissected and this is repaired together with the vermillion component. (f) Skin closure (Figs. 6.82 and 6.83). Created skin flaps are inset using absorbable (5/0 vicryl) deep dermal sutures and absorbable (7/0 vicryl or 6/0 catgut fast absorbing) skin sutures in a simple interrupted manner. Corner stitches is necessary at the junction of the prolabial and vermillion-white roll flaps. Used type of sutures and stitches are described in Figs. 6.84 and 6.85. Another type of severe asymmetrical bilateral cleft lip with discrepancy between segments is the combination of complete cleft lip with microform cleft lip.

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Fig. 6.79  Severe incomplete + complete bilateral cleft lip muscular dissection. 1. Nasal tip. 2. Prolabium flap. 3. Alae. 4. Prolabium. 5. Premaxilla. 6. Fascicle of levator labii superioris alaeque nasi muscle. 7 and 8. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 9. Fascicle of levator labii superioris alaeque nasi muscle. 10. Vermillion-­ white roll flap. 11. Gum. 12. Columellar base flap. 13. Alar flap. 14. Lateral triangular flap

Markings Based on proper identification of the anatomical landmarks of the affected upper lip, the following points must be identified (Fig. 6.86): The design of surgical incisions for this type of cleft combines the technique described for moderate unilateral cleft lip and skin excisions based on the identification of anatomical landmarks of the upper lip previously identified (Figs. 6.87 and 6.88). Complete Cleft Side Two triangles (xyz and cd11′) and one advancement flap are designed at the cleft side.

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Fig. 6.80  Oral mucosa incisions and repair for severe bilateral cleft lip and palate deformity. 1. Prolabium. 2. Premaxilla. 3. Oral mucosa. 4. Lateral relaxing incisions. 5. Upper lip muscles. 6. Vermillion. 7. Red line. 8. Gum

• xyz triangle. The base of the triangle is determined by the difference between the microform cleft and complete cleft lip height (e–10) – (11–9). The height of this triangle is determined by the distance from the point a to the point b. The point b is located at the level of the midline of the upper lip. The point a is determined by the junction of the perpendicular line to the point b and the line perpendicular to the point 3 (Peak of the Cupid’s bow on the cleft side). These two points determine the distance a–b which is equal to the xyz triangle’s height. Finally, the base of the triangle xyz is designed in a distance equal to 3–a (11–z = 3–a).

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Fig. 6.81  Severe incomplete + complete bilateral cleft lip muscular repair. 1. Prolabium 2 and 3. Alae. 4. Fascicle of levator labii superioris alaeque nasi muscle. 5. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 6. Labio nasal advancement flap. 7. Vermillion-white roll flap. 8. Lateral columellar base flap. 9. Lateral triangular flap

• cd11′ triangle. The base of the triangle is determined by the difference between the cleft side vermillion height (11–11′) – (3–3′). The distance c–d is determined by the distance from the point 3′ (point located at the level of the point 3 over the red line) to the point 1′ (Point located at the level of the point 1 over the red line). The base of the triangle cd11′ is designed in a distance equal to 3–3′. • Labionasal advancement flap. This flap is composed by the upper portion of the lateral lip segment and the base of the ala. This triangular flap is designed starting at point x, continuing to the point 9 (tip of the flap), and then finishing with a incision inside the nose at the level of the pyriform aperture. The point 9 must be located at junction of the cutaneous border of the cleft lip with the subalare crease.

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Fig. 6.82  Severe bilateral cleft lip repair line of skin closure

Fig. 6.83  Skin closure of the primary cheilorhinoplasty repair using the proposed technique in a patient with severe incomplete + complete bilateral cleft lip

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Fig. 6.84  Skin closure of the primary cheilorhinoplasty repair using the proposed technique in a patient with severe incomplete + complete bilateral cleft lip

Fig. 6.85  Severe bilateral cleft lip skin closure. 1. Simple interrupted skin sutures using vicryl 5/0. 2. Corner stitch using vicryl 6/0. 3. Corner stitch using vicryl 6/0. 4. Corner stitch using vicryl 6/0 or catgut fast absorbing 6/0. 5. Mattress sutures using vicryl 5/0 for vermillion closure. The rest of stitches is performed using simple interrupted skin with vicryl 7/0

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Fig. 6.86  Severe bilateral cleft lip deformity (microform + complete cleft lip)

• Columellar base flap. A small flap is designed laterally to the base of the columella (beside point 7). This flap is used for nasal floor repair in combination with the alar portion of the advancement flap. Microform Cleft Side One advancement flap, one alar, and one columellar base flap are designed at the microform cleft side. • Labial advancement flap. This flap is composed by the upper portion of the lateral lip segment and the base of the ala. This triangular flap is designed starting at point 10, continuing to the point e (tip of the flap), and then finishing at the point A. • Alar flap. This flap is designed between the points A–8–6 and then finishing with a incision inside the nose at the level of the pyriform aperture. • Columellar base flap. A small flap is designed laterally to the base of the columella (between points 4–6). This flap is used for nasal floor repair in combination with the alar flap. Formula 5−a = 9−x x − z = 2 − 4 – 9 − 11 x − y = z − y = a − b 9 − x + x − z + z − 11 = 5 − a + x − z + a − 3 = 2 − 4 = e − 10 z − 11 = a − 311 − c = 3 − 3′ c − d = 11′ − d = 3′ − 1′ 11 − c + c − 11′ = 1 − 1′ = 2 − 2′

A − 8 = B − 9 C − 10 = D − 11



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Fig. 6.87  Severe microform + complete bilateral cleft lip deformity. 1. Cupid’s bow (middle point). 2 and 3. Cupid’s bow (lateral point). 1′, 2′, and 3′. Similar as points 1, 2, and 3 but located over red line. 4 and 5. Columellar base (lateral point). 6 and 7. Intersection of the lateral columellar base point and cleft margin. 8 and 9. Intersection of the alar base line and cleft margin. 10 and 11. White roll (end’s point). 10′ and 11′. Same as points 10 and 11 but located over red line. A and B. Alar bases. C and D. Oral commissures

Surgical Procedure (a) Surgical incision. A full thickness skin incision is performed following the described markings perpendicular to the cutaneous plane using a scalpel No 3 with a 11 blade or 15 C for better precision. After the surgical incisions are done the primary rhinoplasty is performed at the complete cleft side. (b) Skin, vermillion, and mucosa resection (Fig. 6.89). • Complete cleft side. After surgical incisions, an area of skin, vermillion, and mucosa (limited by the points 9–x–y–z–11–c–d–9) is excised. The skin and vermillion resection creates two triangular flaps: 1 cutaneous (xyz) and 1 in the vermillion (cd11′).

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Fig. 6.88  Surgical incisions for severe bilateral cleft lip deformity (microform + complete bilateral cleft lip)

• Microform cleft side. After surgical incisions, an area of skin, vermillion, and mucosa (limited by the points 6–8–A–e–10–10′ to the gingival sulcus and continue with the points 2′–2–4 finalizing at the point 6) is excised. If there is a significant difference between the nose bases, the amount of this difference should be removed in a triangular shape form the base of the nose at the microform cleft side (A8e). Two rotational incisions are placed at the philtral and central vermillion area: a–b and 3′–1′. Skin should not be elevated at this side in order to prevent ischemia and necrosis of the prolabial skin.

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Fig. 6.89  Flaps for severe bilateral cleft lip deformity (microform + complete bilateral cleft lip). A. xyz triangular flap. B. cd11′ triangular flap. C. Alar component of lateral advancement flap. D. Columellar base flap. E. Area of skin excision. a. Upper medial rotational incision. b. Lower medial rotational incision

(c) Skin flap elevation (Fig. 6.90). The skin is elevated from the underlying muscular plane only in the lateral segment of the complete cleft lip. • Complete cleft side. • Philtral segment. The skin dissection at the philtral area should not be performed to preserve blood supply of this segment. A quadrangular medially based flap is elevated at the subcutaneous level from the base of the columella (columellar base flap). • Lateral segment. A small incision (1 cm) at the pyriform aperture and supraperiosteal dissection over the maxilla is necessary in order to facilitate the proper position of the repaired ala and nostril sill. After this, the lateral advancement flap composed by the upper portion of the lateral lip segment and the base of the ala is elevated. The triangular flaps xyz and cd11′ are finally elevated at the dermal level.

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Fig. 6.90  Area of skin, vermillion, and mucosa resection for severe (microform + complete) bilateral cleft lip

(d) Muscular dissection (Fig. 6.90). Surgical dissection is then performed at the complete side to separate the muscular plane (composed by the levator labii superioris alaeque nasi muscle and two fascicles of orbicularis oris muscle: marginal and peripheral) from the abnormal insertion. (e) Dissection of the mucosa. The mucosa is dissected free from the edge of the muscles for around 5 mm in both sides. At the complete cleft side, two rectangular mucosal flaps are elevated from the cleft margins in a similar way as Millard described for its technique (Fig. 6.91). The medial mucosal flap is raised form the medial cleft lip margin and it is used for oral mucosa repair as a new oral sulcus. The lateral mucosal flap is taken from the lateral cleft lip margin, and it is used to cover the raw posterior surface of the advancement flap and upper lip muscles. Both flaps should be elevated at the muscular level and have at least 1 cm of width to guarantee flap survival. (f) Closure of the mucosa (Figs. 6.91 and 6.92). The cleft lip closure starts with the inner lip mucosa in both sides. • Complete cleft side. The oral mucosa lining is closed before using vicryl 5/0 stitches using the prolabial and lateral mucosa as advancement flaps. • The oral mucosa lining is completed using the medial and lateral mucosal flaps (Fig. 6.92). The lateral (l) and medial (m) mucosal flaps, elevated from the cleft margins, are used to repair the upper segment of the oral side of the upper lip. These flaps are sutured one above the other for covering the oronasal lining (Fig. 6.93). • The triangular vermillion flap (cd11′) is sutured medially into the medial rotational incision (3′–1′) at the complete cleft side. • Microform cleft side. Border-to-border closure (10–2 and 10′–2′ until the gingival sulcus) is done at the microform side using vycril 5/0.

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Fig. 6.91  Severe complete + microform bilateral cleft lip muscular dissection. 1. Columella. 2. Alae. 3. Fascicle of levator labii superioris alaeque nasi muscle. 4 and 5. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 6 and 7. Gum. 8. xyz triangle. 9. cd11′ triangle. 10. Philtral rotational incision. 11. Vermillion rotational incision. 12. Columellar base flap. 13. Microform side skin excision. m: medial mucosal flap. l: lateral mucosal flap

(g) Reconstruction of the upper lip muscles (Fig. 6.94). The reconstruction of the muscular component of the upper lip should be delayed in order to prevent necrosis of the philtral segment. The orbicularis oris muscle is sutured to the subcutaneous tissue of the philtral segment. The levator alaeque nasi is transposed and sutured to the caudal septum to correct the depressed nostril sill using 5/0 PDS at the complete cleft side. (h) Skin closure (Figs. 6.95 and 6.96). Created skin flaps are inset using absorbable (5/0 vicryl) deep dermal sutures and absorbable (7/0 vicryl or 6/0 catgut fast absorbing) skin sutures in a simple interrupted manner. Corner stitches are necessary at the tip of the triangles (xyz and cd11′) Used type of sutures and stitches are described in Fig. 6.97.

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Fig. 6.92  Severe complete + microform bilateral cleft lip oral mucosa closure. 1. Columella. 2. Alae. 3. Fascicle of levator labii superioris alaeque nasi muscle. 4 and 5. Orbicularis oris muscle. a. Peripheral orbicularis oris muscle. b. Marginal orbicularis oris muscle. 6 and 7. Gum. 8. xyz triangle. 9. cd11′ triangle. 10. Philtral rotational incision. 11.Vermillion rotational incision. 12. Columellar base flap. 13. Microform side skin excision. m: medial mucosal flap. l: lateral mucosal flap

6.5 Bilateral Cleft Lip Surgical Protocol Fig. 6.93  Oral mucosa incisions and repair for moderate complete + microform bilateral cleft lip and palate deformity. 1. cd11′ triangle. 2. Vermillion rotational incision. 3. Excisional incision closure. 4. Upper lip muscles. 5. Oral mucosa advancement flap. 6. Frenulum. 7. Frenulum releasing incision. 8. Gum. 9. Vermillion. 10. Red line. 11. Oral mucosa

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Fig. 6.94  Severe complete + microform bilateral cleft lip muscular repair. 1. Nasal columella. 2. Alae. 3. Nasal fascicle of levator labii superioris alaeque nasi muscle. 4. Orbicularis oris muscle at the cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 5. Orbicularis oris muscle at the non-cleft side. a. Marginal orbicularis oris muscle. b. Peripheral orbicularis oris muscle. 6. Nasal septum. 7. xyz triangular flap. 8. cd11′ triangular flap. 9. Medial upper lip rotational incision. 10. Medial vermillion rotational incision. 11. Columellar base flap. 12. Gum. 13. Microform side skin excision

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Fig. 6.95  Severe bilateral cleft lip repair line of skin closure

Fig. 6.96  Skin closure of the primary cheilorhinoplasty repair using the proposed technique in a patient with severe microform + complete bilateral cleft lip

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Fig. 6.97  Severe bilateral cleft lip repair line of skin closure. 1, 2, and 4. Simple interrupted deep dermal sutures using vicryl 5/0. 3 and 5. Corner stitch using vicryl 7/0 or catgut fast absorbing 6/0. The rest of stitches is performed using simple interrupted skin with vicryl 7/0

6.6  B  ilateral Cleft Lip Primary Rhinoplasty: The Surgical Nasal Molding Concept The bilateral cleft lip nose deformity is characterized by the following components: alar cartilage malposition, shortened vestibule of the nose, skeletal deformity, abnormal muscular insertion, and nasal floor deficiency (Fig. 6.98). The main objective of bilateral cleft lip nose repair is the reorientation of the abnormal anatomy and the creation of a symmetrical balanced platform. The use of presurgical orthopedics for bilateral cleft lip nose management is not used in our hospital due to the lack of scientific evidence. Our protocol for bilateral cleft lip nose repair is based on early primary surgery of the nasal deformity at 3 months old during lip surgery. The surgical technique is selected depending on the degree of severity. Main objectives of the primary treatment of the bilateral cleft lip nose deformity are:

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Fig. 6.98  Bilateral cleft lip nose deformity. 1. Absent or short columella. 2. Loss of tip projection. 3. Alar cartilage malposition. 4. Shortened nasal vestibule. 5. Skeletal deformity. 6. Abnormal muscular insertion

1. Alar cartilage reposition for columella and nasal tip repair. The medial reposition of the alar cartilage and columellar lengthening is based on bilateral vestibular lengthening. This is based on the concept proposed by John Mulliken: “the columella is in the nose” [7]. Three techniques (developed by the author) are used with this purpose. The rotational composite flap is used for minor deformities and a modification of the Potter’s method (bilateral V–Y–Z) are used for severe forms [8]. These techniques let us repair the columella, tip projection, alar cartilage malposition, and shortening of the nasal vestibule at the same time. 2. Nasal floor reconstruction. 3. Skeletal deformity repair. The surgical technique for nasal tip repair depends on type of unilateral cleft lip.  ild Bilateral Cleft Lip Nose M Bilateral cleft lip nose mild forms are mostly associated with incomplete cleft lips since there is less tissue deficiency (Fig. 6.99). Mild bilateral cleft nose deformity is considered as a columella height equal or more than 4 mm.

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Fig. 6.99  The mild bilateral cleft lip nose deformity. 1. Short columella. 2. Loss of tip projection. 3. Alar cartilage malposition. 4. Shortened nasal vestibule. 5. Skeletal deformity. 6. Abnormal muscular insertion

The recommended surgical technique for nasal tip repair of mild bilateral cleft lip nose is the bilateral rotational composite flap method, a surgical technique described by the author [9]. This is performed at 3 months old during primary cheiloplasty. The Rotational Composite Flap Technique: Surgical Procedure (Fig. 6.100) The first step is the identification of the caudal margin of the alar cartilage and the intercartilaginous margin in both sides prior to executing any incision. Using a double skin hook and a gentle fingertip traction (with the middle finger of the non-­dominant hand), the surgeon retracts the caudal vestibular skin and present the caudal margin of the alar cartilage itself. The non-hair-bearing area and the palpation of the cartilage edge with the handle of the scalpel are additional landmarks to locate the caudal margin of the alar cartilage. Using the same maneuver, the cephalic margin of the alar cartilage is identified and represents the intercartilaginous border

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Fig. 6.100  Rotational composite flap incisions for mild bilateral cleft lip nose repair. 1. Vestibular rotational composite flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Columella. 5. Alae

Fig. 6.101  Alar cartilage position and rotational composite flap technique. 1. Vestibular rotational composite flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Columella. 5. Alae. 6. Lateral crus. 7. Domus. 8. Medial crus

known as limen nassi. This rotational flap is created as a combination of marginal and small intercartilaginous incision in both sides. The rotational composite flap is designed following the marginal border of the alar cartilage in both sides. Starts at the intercartilaginous border and follows the marginal edge until you reach the nasal columella as illustrated in Figs. 6.100 and 6.101.

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Fig. 6.102  Rotational composite flap elevation. 1. Vestibular rotational composite flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Columella. 5. Alae

Once the incisions are made, the soft tissues are dissected from the surface of the alar cartilage (supra perichondrial plane) using a fine-pointed dissecting scissors and the rotational composite flap is elevated in both sides (Fig. 6.102). This is a medially based composite (skin cartilaginous) vestibular flap. After flap elevation, transcutaneous sutures are used for alar cartilage reposition and repair of the performed incisions (Figs.  6.103 and 6.104). A transcutaneous interdomal suture (transfixion) is placed first in two points. Anterior, between the lowest border of the domus and posterior, between the nasal septum and highest point of the domus at the level of the internal nasal valve using a 5/0 PDS suture. Then the lateral genu of the alar cartilage is elevated using a vertical transcutaneous suture. Using a 5/0 polyglycolic acid sutures through the skin starting inside the nose, coming out at the level of the supra alar crease, returning through the same hole, and coming out inside the nose tying finally the suture. Special care must be paid with the position of this vertical suture since may produce a notch at the level of the soft triangle of the nose. This maneuver moving the composite flap upward and medially creates a lateral triangular defect as illustrated in Fig. 6.102. This defect is closed using the same transcutaneous stitches. Bilateral nasal packing is recommended in all cases to prevent postoperative bleeding inside the operate nostril. The packing is removed the next day. This technique is recommended too for bilateral cleft nose repair after bilateral surgical lip adhesion.

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Fig. 6.103  Rotational composite flap technique closure and transdomal sutures. 1. Vestibular rotational composite flap. 2. Marginal incision. 3. Closure of the lateral defect. 4. Columella. 5. Alae. 6. Lateral crus. 7. Domus. 8. Medial crus. a. Upper interdomal suture. b. Lower interdomal suture

Fig. 6.104  Rotational composite flap technique closure for mild bilateral cleft lip nose repair: pre and postoperative view

 oderate Bilateral Cleft Lip Nose M Bilateral cleft lip nose moderate form (columella height is between 2 and 4 mm) is mostly associated with complete clefts (Fig. 6.105). The recommended surgical technique is the same for these types of cleft lip nose: the V–Y–Z method, a surgical technique described by the author [8]. This is performed at 3 months old during primary cheiloplasty.

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Fig. 6.105  The moderate bilateral cleft lip nose deformity. 1. Short columella. 2. Loss of tip projection. 3. Alar cartilage malposition. 4. Skeletal deformity. 5. Abnormal muscular insertion. 6. Nostril sill deficiency

The Bilateral V–Y–Z Technique: Surgical Procedure (Fig. 6.106) Same recommendations are provided to identify the caudal margin of the alar cartilage and the intercartilaginous margin. The V–Y–Z technique is a combination of the Potter’s concept (V–Y composite advanced flap) and Berkeley’s concept (lateral Z plasty) [10, 11]. The V–Y advanced composite flap is designed following the marginal border of the alar cartilage. Starts at the intercartilaginous border and follows the marginal edge until you reach the nasal columella in both sides as illustrated in Figs. 6.106 and 6.107. The second incision follows the intercartilaginous borders until you reach the internal nasal valve level. The two limbs of the lateral Z-plasty are incised and elevated. Once the incisions are made using a fine-pointed dissecting scissors, the soft tissues are dissected from the surface of the alar cartilage (supra perichondrial plane) in both sides and the V composite flaps are elevated (Fig. 6.108). These

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Fig. 6.106  Bilateral composite V flap and lateral Z plasty incisions for moderate bilateral cleft lip nose repair. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral incisions. 5. Alae. 6. Columella

Fig. 6.107  Alar cartilage position using bilateral V–Y–Z technique. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral incisions. 5. Alae. 6. Columella. 7. Lateral crus. 8. Domus. 9. Medial crus

V form composite flaps are displaced medially and the lateral flaps are transposed in a Z plasty form in both sides. All the performed incisions are closed using transcutaneous stitches. Two transcutaneous (transfixion) interdomal sutures are placed first as described before and then the lateral crus of the alar cartilage is suspended using the same stitches (Figs. 6.109, 6.110, and 6.111). These transcutaneous stitches are

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Fig. 6.108  Composite V flap elevation during bilateral V–Y–Z technique. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral Z plasty. 5. Alae. 6. Columela

Fig. 6.109  Bilateral V–Y–Z technique closure and transdomal sutures. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral Z plasty. 5. Alae. 6. Lateral crus. 7. Columela. 8. Domus. 9. Medial crus. a. Upper interdomal suture. b. Lower interdomal suture

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Fig. 6.110  Bilateral V–Y–Z rhinoplasty for moderate complete bilateral cleft lip nose repair

Fig. 6.111  Bilateral V–Y–Z rhinoplasty for moderate complete bilateral cleft lip nose repair

performed using a 5/0 polyglycolic acid sutures through the skin starting inside the nose, coming out at the level of the supra alar crease, returning through the same hole, and coming out inside the nose tying finally the suture. The use of these sutures in combination with the V–Y–Z method allowed us to obtain the following objectives: (i) reposition the alar cartilage improving tip projection and columellar lengthening; (ii) lengthen the nasal vestibule and prevention of scar contracture using a lateral Z-plasty (the surgical nasal molding concept); and (iii) reduce the space created by surgical dissection preventing the risk of post-­operative bleeding and hematoma formation. Special care must be paid with the position of this vertical suture since may produce a notch at the level of the soft triangle of the nose. Nasal packing is recommended in all cases to prevent postoperative bleeding inside the operate nostril. The packing is removed the next day. Postoperative nostril stenting during 6 months is strongly recommended in this technique in order to prevent vestibular synechia and scar contractures. The rotational composite flap and V–Y–Z methods may be used in combination for asymmetrical bilateral cleft lip cases (incomplete + complete bilateral cleft lip).

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Fig. 6.112  The severe bilateral cleft lip nose deformity. 1. Absence of columella. 2. Loss of tip projection. 3. Alar cartilage malposition. 4. Skeletal deformity. 5. Abnormal muscular insertion. 6. Nostril sill deficiency

 evere Bilateral Cleft Lip Nose S Bilateral cleft lip nose moderate form (columella height is equal or less than 2 mm) is mostly associated with complete clefts (Fig. 6.112). The recommended surgical technique is the same for these types of cleft lip nose: the V–Y–Z method plus skin resection, a surgical technique described by the author. This is performed at 3 months old during primary cheiloplasty. The Bilateral V–Y–Z + Skin Resection Technique: Surgical Procedure (Fig. 6.113) The V–Y–Z technique described for moderate bilateral cleft lip nose is limited to correct the severe forms. The main problem is a wide columella. The V–Y–Z component is performed in a similar form as described for moderate form of bilateral cleft lip nose. The V–Y advanced composite flap is designed following the marginal

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Fig. 6.113  Bilateral V–Y–Z plus skin excision incisions for severe bilateral cleft lip nose repair. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral incisions. 5. Alae. 6. Columella. Blue line: Skin excision area

Fig. 6.114  Alar cartilage position using bilateral V–Y–Z plus skin excision technique. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral incisions. 5. Alae. 6. Columella. 7. Lateral crus. 8. Domus. 9. Medial crus

border of the alar cartilage. Starts at the intercartilaginous border and follows the marginal edge until you reach the nasal columella in both sides as illustrated in Figs. 6.113 and 6.114. The second incision follows the intercartilaginous borders until you reach the internal nasal valve level. The two limbs of the lateral Z-plasty are incised and elevated. Then, a small skin excision (2–3 mm of width) is practiced bilaterally at the level of alar dome. This incision preserves the soft triangle of the

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Fig. 6.115  Composite V flap elevation using bilateral V–Y–Z plus skin excision technique. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral Z plasty. 5. Alae. 6. Columela

nose. This is the main difference with the Tajima inverted U skin excision used by different authors. The area of skin excision is located over the alar rim at the level of the soft triangle. In our experience the scars are more visible using these incisions. The soft triangle of the nose is critical for patency of the external nasal valve. Normal physiology of the nasal airflow may be impaired. After the incisions are made, using a fine-pointed dissecting scissors the soft tissues are dissected from the surface of the alar cartilage (supra perichondrial plane) in both sides and the V composite flaps are elevated (Fig. 6.115). These V form composite flaps are displaced medially and the lateral flaps are transposed in a Z plasty form in both sides. All the performed incisions are closed using transcutaneous stitches in a similar form as I described for the moderate bilateral cleft lip nose (Figs. 6.116, 6.117, 6.118, and 6.119). Bilateral nasal packing is recommended in all cases to prevent postoperative bleeding inside the operate nostrils. The packing is removed during the next day. Bilateral postoperative nostril stenting during 6 months is strongly recommended in this technique in order to prevent vestibular synechia and scar contractures. The rotational composite flap and V–Y–Z plus skin excision methods may be used in combination for asymmetrical bilateral cleft lip cases (incomplete + complete bilateral cleft lip).

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Fig. 6.116  Bilateral V–Y–Z plus skin excision technique closure and transdomal sutures. 1. Vestibular composite V flap. 2. Marginal incision. 3. Intercartilaginous incision. 4. Lateral Z plasty. 5. Alae. 6. Lateral crus. 7. Columela. 8. Domus. 9. Medial crus. a. Upper interdomal suture. b. Lower interdomal suture

Fig. 6.117  Bilateral V–Y–Z plus skin excision rhinoplasty for severe complete bilateral cleft lip nose repair (lip adhesion)

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Fig. 6.118  Bilateral V–Y–Z plus skin excision rhinoplasty for 2 years old severe complete bilateral cleft lip nose repair (late lip adhesion)

Fig. 6.119  The surgical nasal molding concept. Left: Preoperative view. Right: Effect of the vestibular lengthening using the V–Y–Z at the right side of the bilateral cleft with columellar lengthening at the same side (A > a)

 equence of Nasal Stitches of V–Y–Z Procedures S The stitches should be placed as follows (Fig. 6.120): 1. Posterior transfixion interdomal suture. This is placed between the inferior border of upper lateral cartilages, nasal septum, and inferior border of lower lateral cartilages (domes). 2. Anterior transfixion interdomal suture. This is placed between the lowest border of both lower lateral cartilages (domes). These transfixion sutures are done using PDS 5/0. 3. Intercartilaginous transcutaneous suture. Between the superior border of the lower lateral cartilage and inferior border of the upper lateral cartilage. The suture goes through the skin starting inside the nose, coming out at the level of the supra alar crease, returning through the same hole, and coming out inside the nose tying finally the suture. This suture lifts the alar cartilage.

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Fig. 6.120  Bilateral V–Y–Z rhinoplasty sequence of nasal stitches. Red circle: Soft triangle area

4. Anterior skin suture. This suture must be applied between the skin borders of the middle third of the marginal incision. This type and location of stitch prevents the retraction of the soft triangle (red circle). 5. V–Y transcutaneous stitch. This is placed at the posterior border of the V composite advanced flap in a similar form as suture 3. 6 and 7. Transcutaneous stitches. These sutures are located between skin borders of the Z plasty after flaps transposition in a similar form as suture 3. 8. Alar base transcutaneous stitch. This is used for reposition of the alar advancement flap preventing the lateral web commonly observed after primary cleft rhinoplasty. The suture starts at the skin border of the lateral incision then goes through the alae at the level of the lateral alar crease returning through the same hole and coming out inside the nose tying finally the suture. 9. Columellar base transfixion suture. Sutures 3–8 are done using vicryl 5/0. The author does not recommend to use too many sutures because these stitches may affect the blood supply of the alae of the nose and necrosis would occur.

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 asal Floor Reconstruction N In our protocol, the nasal floor is composed by three segments that are repaired at different surgical times (Fig. 6.121). I. Anterior (nostril sill) is repaired at 3 months old during cleft lip repair. II. Middle (primary palate) is repaired during mixed dentition period using local gingival mucoperiosteal flaps and autologous bone graft. III. Posterior (secondary palate) is repaired at 1-year-old using the one flap technique. The anterior segment is the floor of the nasal vestibule, and this is repaired at 3 months old during primary cheiloplasty. This anterior segment of the nasal floor is repaired using two flaps:

Fig. 6.121  Surgical technique for vestibular segment of the nasal floor repair. Flap A (lateral): Alar segment of the lateral advancement cutaneous flap. Flap B (medial): Columellar base flap. The nasal fascicle of levator labii superioris alaeque nasi muscle is used to provide structural support for the vestibular nasal floor

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(a) Medial flap. This is the columellar base flap. A small flap is designed laterally to the base of the columella at the cleft border. This is a 1 × 1 cm cutaneous flap based medially. (b) Lateral flap. This is the alar segment of the lateral advancement cutaneous flap. This flap is composed by the upper portion of the lateral lip segment and the base of the ala. A structural support of the anterior segment of the nasal floor is necessary since there is not skeletal framework due to the cleft. This support is provided by the muscular repair of the upper lip. The nasal fascicle of levator labii superioris alaeque nasi muscle is used to provide support for the vestibular nasal floor. This muscle is sutured to the caudal septum. Nasal packing is used in all cases inside the operated nostril to prevent postoperative bleeding. The packing should be removed 1 day after surgery. Postoperative nostril stenting is used to prevent scar contracture of the vestibular incisions. This is mandatory after using any primary rhinoplasty with vestibular nose incisions. Scar contracture may close (partially or totally) the nostril affecting the normal breathing of the baby.

6.7  Skeletal Reconstruction Main consequences of the unrepaired bone deficiency in patients with bilateral cleft lip are: hyperprojection of the premaxilla, collapse of the cleft segments and maxillary crossbite, and persistence of palate and alveolar fistulas. Scientific evidence including systematic reviews and meta-analysis [12] indicated that primary skeletal repair at early age could lead to maxillary growth inhibition. Primary autologous bone graft during mixed dentition period (7–9 years of age) is used in our hospital for alveolar cleft reconstruction. Panoramic radiograph is used to visualize preoperatively the alveolar clefts and evaluate the eruption of the canine crown (Fig. 6.122). I personally consider a staging protocol for alveolar bone graft observing less associated infection and graft resorption. The alveolar cleft should be closed previously to prevent any salivary contamination of the bone graft and resorption. Orthopedic management of the cleft segments is mandatory at early age for severe forms of bilateral cleft lip and palates (alveolar gap wider than 1 cm). The alveolar cleft is closed using gingivoperiosteal flaps at 5  years old, then the alveolar bone graft is performed during mixed dentition period. Autologous bone graft is used because of its increased success rate in comparison with other materials (80–90%) [13]. The iliac crest is preferred as donor site using a trephine which minimizes skin incisions and surgical dissection with improvement of postoperative condition of the patient [14]. Alternatively, the tibia is used as donor site.

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Fig. 6.122  Panoramic X-ray of a 6-year-old patient with bilateral cleft lip and palate

Surgical Technique (a) Presurgical management: Maxillary arch alignment (the surgical alveolar molding). The presurgical management is often required in patients with severe bilateral cleft lip and palate (alveolar gap wider than 1 cm). The premaxilla must be well aligned with the maxillary segments in order to facilitate the alveolar cleft closure. The best form to correct the position of the premaxilla is the use of presurgical orthopedics at early age (one or second week of life) in combination with the orthopedic effect of the repaired upper lip muscles and primary palatoplasty. In order to proceed with the bone reconstruction, the cleft segments must be well aligned. The maxillary arch alignment can be done using presurgical orthopedics or by action of the upper lip muscular repair (the surgical alveolar molding concept) (Fig. 6.123). The surgical method is the used technique by the author because of many advantages in comparison with the presurgical method. An early defective handling would leave this segment in bad position making difficult the alveolar cleft

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a

b

c

d

Fig. 6.123  The surgical alveolar molding. Maxillary arch alignment obtained by surgical alveolar molding (muscular action done by primary cheiloplasty) in a 1-year-old patient. (a–c) Preoperatory views. (d) Premaxilla and maxillary arch alignment after primary cheiloplasty

closure and skeletal repair. Surgical reposition of the premaxilla at the time of the alveolar cleft closure may be necessary when this segment remains too projected after primary cheiloplasty and palatoplasty. Bone Reconstruction The surgery is performed in two surgical times as follows: First Time: Alveolar Cleft Closure (Figs. 6.124, 6.125, and 6.126) The alveolar cleft is closed at 5 years old. The defect frequently includes oronasal fistulas. These fistulas may be composed by two segments: alveolar and retro-­ premaxillary. The retro-premaxillary fistula is difficult to be closed and should be prevented using an adequate surgical management during primary palatoplasty (see

268 Fig. 6.124 Bilateral alveolar cleft. Line of surgical incision

Fig. 6.125 Bilateral alveolar cleft. Gingivo mucoperiosteal flaps elevation

Fig. 6.126 Unilateral alveolar cleft closure

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6.7 Skeletal Reconstruction

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Chap. 7). The alveolar clefts are repaired using muco perichondrial flaps. The nasal floor is closed using a vomer muco perichondrial flap medially and lateral nasal wall flap raised in the subperiosteal plane laterally. Then, gingivoperiosteal flaps are used to close the oral side of the cleft. The incision is done using a 15 blade scalpel around the alveolar cleft margins and following the dental margins of the gingiva in both sides as in Fig. 6.124. The medial and lateral mucoperiosteal flaps are raised in a subperiosteal plane. The periosteum is scored vertically and horizontally to facilitate the flap mobilization. Closure is then performed using 5–0 vicryl suture. If the retro premaxillary fistula is present, the defect should be closed using palatal mucoperiosteal flaps at the same time. Second Time: Alveolar Bone Graft (Figs. 6.127 and 6.128) (a) Bone graft harvest. The most used donor site is the iliac crest. The skin incision is 2 cm of length and located 2  cm lateral to the anterior superior iliac crest (Fig.  6.127). The iliac crest is preferred as donor site using a trephine which minimizes skin incisions and surgical dissection with improvement of postoperative condition of the patient. Alternatively, the tibia is used as donor site. The surgical dissection through muscles and fascia exposes the iliac crest at this level. Then using a curette, the cancellous bone is harvested. Requirement amount of bone graft is 4–5 cc approximately per each side. Overlaying tissue is closed in three layers. (b) Grafting. The time of bone grafting coordinates with the orthodontist during the mixed dentition period. The closed gingival mucosa over the alveolar cleft is open through a 1  cm incision. The cleft borders are dissected at the subperiosteal

Fig. 6.127  Cancellous bone graft raised from the iliac crest using a trephine designed by SOBRAPAR craniofacial center (Campinas Brasil)

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a

b

c

d

Fig. 6.128  Alveolar cleft repair in a bilateral cleft lip and palate patient (first time). (a) X ray at 6  years old (mixed dentition period) at the bone graft time illustrating the alveolar cleft. (b) Bilateral alveolar cleft (preoperative view). (c) Nasal mucosa closure of the alveolar cleft and elevation of the gingivoperiosteal flap. (d) Postoperative view of the alveolar cleft closure

plane preserving the scar tissue created by the alveolar cleft closure. The integrity of the nasal and oral mucosa must be preserved in order to guarantee the isolation of the graft reducing the probability of contamination and graft resorption. Cancellous bone graft is then placed filling the gap created by dissection of the alveolar clefts. The gingival borders of the incision are finally closed using vicryl 5/0. Dental splint may be used to provide mechanical protection to the healing mucosa during 6 weeks.

6.8  Postoperatory Care Postoperative care is the same as those given for the unilateral cleft lip.

6.9 Case Studies

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6.9  Case Studies Case 1 • Diagnostic: severe primary palate component bilateral cleft lip and palate (Fig. 6.129). a

b

c

d

Fig. 6.129 (a) Preoperatory view of severe bilateral cleft lip and palate. (b) Postoperatory view after bilateral lip adhesion. (c) Position of premaxilla after orthopedic effect of bilateral lip adhesion (4 months later). (d) Postoperatory view after primary cheilorhinoplasty (1 year follow up)

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Case 2 • Diagnostic: severe primary palate component bilateral cleft lip and palate (Fig. 6.130). Case 3 • Diagnostic: mild incomplete bilateral cleft lip and palate (Fig. 6.131). a

b

c

d

Fig. 6.130 (a) Preoperatory view of severe bilateral cleft lip and palate. (b) Preoperatory view of the wide alveolar cleft. (c) Position of premaxilla after orthopedic effect of bilateral lip adhesion (4 months later). (d) Postoperatory view after primary cheilorhinoplasty (10 months follow up)

a

b

Fig. 6.131 (a) Preoperative view. (b) Postoperative view after one year

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Case 4 • Diagnostic: mild complete bilateral cleft lip and palate (Fig. 6.132). Case 5 • Diagnostic: moderate complete bilateral cleft lip and palate (Fig. 6.133). a

b

Fig. 6.132 (a) Preoperative view. (b) Postoperative view after one year

Fig. 6.133 (a) Preoperative view. (b) Postoperative view after one year

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Case 6 • Diagnostic: moderate incomplete + microform bilateral cleft lip (Fig. 6.134). Case 7 • Diagnostic: severe microform + complete bilateral cleft lip and palate (Fig. 6.135).

Fig. 6.134 (a) Preoperative view. (b) Postoperative view after one year

Fig. 6.135 (a) Preoperative view. (b) Postoperative view after one year

6.9 Case Studies

Case 8 • Diagnostic: severe complete bilateral cleft lip and palate (Fig. 6.136).

Fig. 6.136 (a) Preoperative view. (b) Postoperative view after one year

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References 1. Randall P. A lip adhesion operation in cleft lip surgery. Plast Reconstr Surg. 1965;35:371–6. 2. Vyas RM, Kim DC, Padwa BL, Mulliken JB.  Primary premaxillary setback and repair of bilateral complete cleft lip: indications, technique and outcomes. Cleft Palate Craniofac J. 2016;53(3):302–8. 3. Millard R Jr. The cleft craft. The evolution of its surgery I, II and III. 1st ed. Boston: Little Brown. 4. Manchester W.  The repair of the double cleft lip as part of an integrated program. Plast Reconstr Surg. 1970;45:207–16. 5. Spina V, Kamakura L, Lapa F.  Surgical management of bilateral cleft lip. Ann Plast Surg. 1978;1:49. 6. Noordhoff M. Bilateral cleft lip and nasal repair. In: Cohen MS, editor. Masters of surgery, vol. 1. St Louis: Little Brown. p. 566–80. 7. Mulliken J. Principles and techniques of bilateral complete cleft lip repair. Plast Reconstr Surg. 1985;75(4):477–87. 8. Rossell-Perry P, Olivencia-Flores C, Delgado-Jimenez P, Ormeño-Aquino R.  The surgical NAM: a rational treatment for bilateral cleft lip nose deformity and systematic review. Plast Reconstr Surg. GO Accepted for publication. 9. Rossell-Perry P.  Rotational composite flap technique for primary incomplete cleft lip nose. Plastic Reconstructive Surg J. GO Accepted for publication. 10. Potter J. Some nasal tip deformities due to alar cartilage abnormalities. Plast Reconstr Surg. 1954;13(5):358–66. 11. Berkeley W. The cleft lip nose. Plast Reconstr Surg. 1959;23:567. 12. El-Ashmawi N, Elkordy S, Salah Fayed M, El-Beialy A, Attia K. Effectiveness of gingivoperiosteoplasty on alveolar bone reconstruction and facial growth in patients with cleft lip and palate: a systematic review and meta-analysis. Cleft Palate Craniofac J. 2019;56(4):438–53. 13. Stein M, Zhang Z, Fell M, Mercer N, Malic C.  Determining postoperative outcomes after cleft palate repair: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2019;72(1):85–91. 14. Chammas D, Denadai R, Marque F, Buzzo C, Raposo-do-Amaral C, Raposo-do-Amaral C. Assessment of donor área pain in patients with cleft lip and palate undergoing alveolar bone defects repairs using iliac crest autogenous grafting: a prospective randomized comparison of two bone extractors. Rev Bras Cir Plast. 2014;29(3):337–45.

Chapter 7

Cleft Palate Repair

7.1  Cleft Palate Surgical Techniques Despite having abundant scientific evidence, there is no consensus about which surgical protocol provides better surgical outcomes for primary cleft palate repair. We may consider two basic protocols: (a) One stage. This is probably the most used protocol for primary cleft palate repair. The two-flap or one-flap palatoplasty, Von Langenbeck, and Furlow technique are the most used one-stage surgical techniques (Fig. 7.1). Advantages: Lower rate of fistulas have been reported by different authors [1]. Disadvantages: Some authors consider that early closure of hard palate is associated with increased rate of maxillary hypoplasia; however, this is not well supported by the scientific evidence actually [1]. Fig. 7.1  Single-stage repair of a unilateral cleft palate using the two-flap technique (Bardach)

© Springer Nature Switzerland AG 2020 P. Rossell-Perry, Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair, https://doi.org/10.1007/978-3-030-44681-9_7

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(b) Two stage: This protocol includes two models: delayed hard palate closure and delayed soft palate closure. Delayed soft palate closure (Oslo’s protocol) (Fig.  7.2): This protocol was initially proposed by Veau in 1932 and then published by Abyholm from Norway reporting 13% of maxillary hypoplasia. It is known as Oslo’s protocol [2]. The alveolar cleft and hard palate are closed using the vomer flap earlier at 3 months of age during lip repair and the soft palate is repaired later at 1 year of age. Advantages: Lower rate of maxillary hypoplasia. However, there is no consensus and is not supported by available scientific evidence actually. Disadvantages: Increased rate of palatal fistulas. Some studies reported increased rate of velopharyngeal insufficiency [3–5]. Delayed hard palate closure (Gothenburg’s protocol) (Fig.  7.3): Hermann Schweckendiek a German ENT popularized the twostage cleft palate repair in Europe in 1944 closing the soft palate at early age and hard palate around 15 years of age. Later, Malek from France and Friede from Sweden published a similar protocol closing the hard palate earlier avoiding speech problems associated with delayed hard palate closure [6, 7]. Primary staphylorrhaphy is performed during lip repair at 3 months of age. Hard palate closure is done at 1 year of age using the vomer flap. Advantages: Lower rate of maxillary hypoplasia not supported by scientific evidence. The cleft in the hard palate is reduced then minimal hard palate dissection is required using this technique. However, this advantage is only observed when the patient is operated before 6  months of age. Disadvantages: Increased rate of palatal fistulas [1].

Fig. 7.2  Two-stage palatoplasty of a unilateral cleft palate using the soft palate delayed closure (Oslo’s protocol)

7.2 Author’s Surgical Technique (Tables 7.1 and 7.2)

279

Fig. 7.3  Two-stage palatoplasty of a bilateral cleft palate using the hard palate delayed closure (Gothenburg’s protocol)

7.2  Author’s Surgical Technique (Tables 7.1 and 7.2) I started 25 years ago repairing the cleft palate deformity using the two-flap technique for all types of cleft palate based on Veau’s classification. A single-stage operation allowed me to increase flexibility and mobility of the mucoperiosteal flaps. Reported increased rate of fistulas associated with two-stage protocols is probably related with the presence of scar tissue during the second time of repair. However, during the time, I observed that extended tissue dissection and bilateral relaxing incisions weren’t necessary for any type of cleft palate. A new estimation of the cleft palate severity was necessary, and it was proposed using a new diagram for cleft description (the clock diagram) [8]. This classification based on cleft severity uses the cleft palate index [9]. Additionally, blood supply of the congenital malformed tissues of the cleft palate is not constant, and elevation of monopedicled flaps is not always safe. Severe complications such as mucoperiosteal flap necrosis have been reported after cleft palate repair and the hypoplastic cleft side is often affected [10–12]. Preservation of the blood supply of the cleft side reducing the use and extension of relaxing incisions is proposed as a form to prevent this type of complications. A more individualized form of cleft palate management is proposed by the author with emphasis on blood supply preservation of the hypoplastic tissues (cleft side). This strategy has been described as the Lima Protocol for primary cleft palate management. One-flap and Von Langenbeck palatoplasties are good examples of preservation of blood supply for the cleft side of the cleft palate [13]. Actually I am not performing two-flap palatoplasty for any type of cleft palate. Along these 25 years, the uvular repair was performed using the conventional technique with non-­desirable outcomes. Use of one hemi-uvula was initially proposed by Carlos Navarro in Peru and modified later by the author [14, 15]. The proposed technique has been studied observing better aesthetic and functional results. Surgical outcomes using the presented protocol have been published on indexed journals by the author observing acceptable results [15, 16].

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Table 7.1  The Lima Surgical Protocol for primary cleft palate repair Incomplete cleft palate Vean I: Furlow technique Vean II: Mild: Furlow technique or minimal incision technique Moderate: Hybrid technique Severe: Von Langenbeck technique Unilateral cleft palate Mild: Minimal incision or one-flap technique at the non-cleft side Moderate: One-flap technique at the non-cleft side Severe: Hybrid palatoplasty: One-flap technique at the non-cleft side plus relaxing incision at the cleft side Bilateral cleft palate Mild: Hybrid technique Moderate: Von Langenbeck technique Severea: Before 6 months of age: Delayed hard palate closure (uranorraphy at 1 year). After 6 months of age: Hybrid palatoplasty: One-flap technique combined with relaxing incision The strategy in this type is to transform the severe form in a moderate or mild form. The soft palate closure may change the width of the cleft if this is repaired before 6 months of age. Then the hard palate can be closed using Von Langenbeck technique at 1 year of age. If the soft palate closure is done after 6 months of age, the width of the cleft is not changed and a hybrid palatoplasty is required to close the cleft without palatal fistulas

a

Table 7.2  A single surgeon’s surgical outcomes using the author’s protocol for cleft palate repair Type of cleft palate No. of studied patients Palatal fistula Velopharyngeal insufficiency Facial growth

Study A Study Ba Unilateral All types 152 30 by group 8.60% — 9.90% 6.07% —

Study C Study D Study Ea Unilateral Bilateral Unilateral 120 90 72 by group 6.60% 5.83% 7.77%

Study F Unilateral 28 vs. 32 6.25% 3.10%

2.8b

Randomized clinical trial Atack-5-year-old’s index A: Rossell-Perry et al. [9] B: Rossell-Perry et al [15] C: Rossell-Perry et al. [20] D: Rossell-Perry eta l. [16] E: Rossell-Perry et al. [2] F: Rossell-Perry [5] a

b

The main contributions of the proposed author’s surgical protocol are: (a) More individualized management of the cleft palate deformity (b) Closure of the cleft palate under minimal tension using lateral relaxing incisions as necessary (c) Prevention of severe complications improving blood supply of the palatal flaps (d) Conservative intravelar veloplasty without tensor veli palatini tendon transection (e) Good aesthetic and functional repair of the uvula using the unilateral uvuloplasty

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7.3  Presurgical Considerations Due to the characteristics of this operation in which it is required to work inside the mouth, being a limited space, small and less illuminated, patient’s position acquires special importance. Proper exposure of the surgical field and patient positioning are essential to operative success. Surgeon’s position (sitting or standing) does not represent a demonstrated advantage and is more of a personal preference. Extension of the neck is common during cleft palate repair, and use of pediatric head and shoulder positioning device is necessary (Fig. 7.4). I use to operate the patient in a supine position with the head on an adjustable rest and a roll placed under the shoulders with the neck in extension. A severe complication (posterior fossa infarction) related to this position has been reported before during cleft palate repair [17]. Duration of surgical procedure and hyper-extension of the neck should be well considered in order to prevent rare (but severe) complications like this. This position facilitates the application of the Dingman mouth gag (See Chap. 4). Once the patient is in proper position and the mouth gag applied, anesthetic infiltration is performed. Under loupe magnification and adequate illumination, anatomical landmarks of the cleft palate are identified to proceed with the surgery. Palatal markings are difficult to be performed and usually not necessary. The surgical incisions follow the anatomical landmarks of the cleft palate. The surgery is initiated with identification of these anatomical references and then infiltration with local anesthetic at the level of the top of the patient’s head. The injection of local anesthetic is performed at the submucosal level. Maximal dose of 1% xylocaine is 1 cc per kg or 0.5 cc per kg with 2% xylocaine. 0.1  ml of 1:200,000 epinephrine is safe to be used in combination with the xylocaine. Fig. 7.4 Preoperative position of the patient in a supine position with the neck in extension

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Fig. 7.5  Greater palatine nerve block for unilateral cleft palate repair

Greater palatine nerve block on both sides is done during anesthetic infiltration for cleft palate repair (Fig. 7.5). Local anesthesia is completed with field infiltration around the hard and soft palate. Infiltration of the mucosa of the vomer should be carefully performed to prevent bleeding from the nasal septum. Five to seven minutes must be allowed after the injection to obtain a proper effect.

7.4  The Lima Cleft Palate Surgical Protocol 7.4.1  Submucous Cleft Palate This is a minor form of incomplete cleft palate. It is characterized by a triad: Bifid uvula, translucent zone in soft palate, and hard palate notch. Not all the submucous cleft palate patients have speech disorders. The surgery is indicated for patients with anatomical findings (classic triad) and articulation errors and/or velopharyngeal insufficiency.

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Markings The used technique for this type of cleft palate is a modification of Furlow technique (double opposing Z-plasty) described by Randall [18]. The design of surgical incisions is based on the identification of anatomical landmarks of the cleft palate previously described (Fig. 7.6). The double Z plasty is composed by two types of flaps, as follows: (a) Mucosal flaps: Oral (A) and nasal (C) (both anteriorly based). Oral mucosal flap: A triangular anteriorly based flap is designed starting at the base of the uvula and following the midline laterally to the translucent zone. Then a lateral marking of the oral triangular mucosal flap starts at the base of the uvula and finishes at a point located at the intersection of the midpoint of the width of the hemi

Fig. 7.6  The submucous cleft palate. 1. Hard palate. 2. Soft palate. A. Hard palate notch. B. Translucent zone. C. Bifid uvula

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palate with the midpoint of the height of the soft palate (distance between the maxillary tuberosity level and uvular base level). This is the point X (Figs. 7.7 and 7.8). Nasal mucosal flap: This triangular flap is designed following the base of the previously elevated oral myomucosal flap (B) (Figs. 7.7 and 7.8).

Fig. 7.7  Furlow palatoplasty plus unilateral uvuloplasty for submucous cleft palate repair. A. Oral mucosa flap. B.  Oral myomucosal flap. C.  Nasal mucosa flap. D.  Nasal myomucosal flap. TZ: Translucent zone. Upper left: Surgical design of oral mucosa flap identifying the point X. Upper right: Oral mucosa flap elevation and surgical design of oral myomucosal flap. Lower left: Oral myomucosal flap elevation and surgical design for nasal mucosa flap. Lower right: Nasal mucosa flap elevation for surgical design of nasal myomucosal flap

7.4 The Lima Cleft Palate Surgical Protocol

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a

b

c

d

Fig. 7.8  Modified Furlow technique for submucous cleft palate repair. (a) Point X and surgical design for flap A. (b) Flap A elevation and subperiosteal dissection of its base. (c) Flap A transposition and point Y identification. (d) Surgical incision for flap B creation. A: Oral mucosal flap. B: Oral myomucosal flap. C: Area of nasal myomucosal flap

(b) Myomucosal flaps: Oral (B) and nasal (D) (both posteriorly based). The two posteriorly based flaps are elevated with the palate muscle. Oral myomucosal flap: This flap is designed intraoperatively. The marking of the incision line is located after transposition of the elevated oral mucosal flap over the opposite side of the soft palate (Fig. 7.7). This maneuver guarantees that the oral mucosa Z plasty can be closed without additional relaxing incisions or raw surfaces. Nasal myomucosal flap: This myomucosal flap is designed after transposition of the nasal mucosa flap over the opposite side making easier the nasal mucosa repair. Central translucent zone and one hemi-uvula are excised in this type of cleft palate.

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The proposed author’s modification of the Furlow technique is characterized by: (a) Smaller size of the triangular flaps. This modification makes easier the surgical closure without back cuts, relaxing incisions, and raw surfaces. (b) A different angle of the oral mucosal flap. The angle of the triangular flap is more than the 60 degrees described by Furlow (closer to 90 degrees). This design provides better blood supply to the tip of the flap. (c) The tendon of the tensor veli palatini is preserved during myomucosal flaps dissection. A conservative intravelar veloplasty is performed. (d) Uvular repair using unilateral uvuloplasty (see Sec. 7.7 unilateral uvuloplasty in this chapter). Surgical procedure. This is the surgical sequence of the proposed technique for submucous cleft palate. A Dingman mouth gag and a small throat pack are inserted with the patient in supine position and the neck in extension. Xylocaine 2% (0.5 cc per kg) with 0.1 ml of 1:200,000 epinephrine is injected as I described previously in this chapter. (a) Surgical incisions and tissue excision. A full thickness mucosal incision is performed following the described markings perpendicular to the soft palate plane using a scalpel No 7 with a 15 blade or 12 C if this is available. Midline incision is practiced following the central translucent zone borders starting at the base of the uvula and finishing at the hard palate border. The uvular incisions are performed according to the unilateral uvuloplasty technique. The translucent zone tissue and hemi-uvula of the right side of the patient are then excised. Finally, starting at the uvular base of the right side, a full thickness mucosal incision is done finishing at the point X previously described (see markings) (Figs. 7.7 and 7.8). The oral mucosal flap (A) is created between these two incisions. (b) Oral mucosal flap elevation. The oral mucosa triangular flap is elevated from the underlying muscular plane doing a sharp dissection using scalpel or fine scissors (Figs. 7.7 and 7.8). The dissection at the base level of the flap is critical. The oral mucosa of the hard palate is thinner and more adherent making the surgical dissection more difficult. Careful dissection is recommended in order to preserve the blood supply of the flap. A subperiosteal dissection using a fine periosteal elevator is necessary for flap elevation at this level. This maneuver makes easier this flap transposition. This flap is the key point of the technique since it is used as a reference to design the other flaps.

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(c) Oral myomucosal flap incision and elevation. The oral myomucosal flap (B) is designed doing the oral mucosa flap (A) elevation and transposition as in Figs.  7.7 and 7.8. This transposition identifies the point Y. A full thickness mucosal and muscle incision is done following this marking. The palatine aponeurosis is sectioned, and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved. Then the flap B is elevated from the underlying nasal mucosa doing a blunt dissection. The base of this flap is a line between the base of the uvula and point Y. (d) Nasal mucosa flap incision. The nasal mucosa flap (C) is designed between the midline incision and the line between uvular base and point Y (Figs. 7.7 and 7.10). A full thickness incision is performed following this line. A small subperiosteal dissection of the hard palate may be necessary at the base of this flap in order to facilitate its transposition to the opposite side. Special attention must be considered during this maneuver to preserve its blood supply. (e) Nasal myomucosal flap incision. The nasal myomucosal flap (D) is designed doing the nasal mucosa flap (C) transposition as in Figs. 7.7 and 7.10. A full thickness muscle and nasal mucosa incision is done following this marking. The palatine aponeurosis is sectioned, and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved in a similar form as flap B. (f) Muscular repair (Figs. 7.9, 7.10, and 7.11). After the elevation of the flaps, the muscular repair is performed. The velopharyngeal sphincter reconstruction is started doing the uvular repair using the proposed technique in this chapter. Then the muscular repair starts with the transposition of the flap D, its muscular component is sutured to the tendon-aponeurotic system attached to the hamulus of the opposite side. The medial mucosal border of the flap D is sutured to the nasal mucosa at the base of the oral myomucosal flap (B). After this, the oral myomucosal flap is transposed doing an overlapping. The muscular component of this flap is sutured to the hamulus in a similar form as flap D. Some stitches may be used between the muscular components of these flaps. Finally, the oral mucosal border of the flap B is sutured to the incision practiced between the base of the uvula and point X.

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Fig. 7.9  Furlow palatoplasty plus unilateral uvuloplasty for submucous cleft palate repair. A. Oral mucosa flap. B. Oral myomucosal flap. C. Nasal mucosa flap. D. Nasal myomucosal flap. Upper left: Nasal mucosa flap upper border sutured. Upper right: Nasal myomucosal flap transposition. Lower left: Oral myomucosal flap transposition. Lower right: Oral mucosa flap transposition

(g) Final closure (Figs. 7.11 and 7.12). The upper half of the soft palate is repaired using the mucosal flaps A and C. The C flap is transposed first closing the gap between the flap D (transposed before) and the base of flap A. Simple interrupted vycril 5/0 sutures are used with this purpose. Then, the oral mucosa flap (A) is finally transposed and sutured using simple interrupted stitches. A corner stitch is recommended to be used at the tip of this flap.

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a

b

c

d

Fig. 7.10  Modified Furlow technique for submucous cleft palate repair. (a) Elevation of the B flap (oral myomucosal flap). (b) Incision of the nasal mucosa at the base of the B flap creating the C flap and its transposition. (c) Flap D (nasal myomucosal) transposition after its creation. (d) Upper half of the soft palate nasal mucosa closure using the C flap. A: Oral mucosal flap. B: Oral myomucosal flap. C: Nasal mucosal flap. D: Nasal myomucosal flap

(h) Uvular repair (Fig. 7.9). The uvular repair is performed using the unilateral uvuloplasty for all types of cleft palate. Description of this technique is done in this chapter.

7.4.2  Incomplete Cleft Palate This type of cleft palate involves only the secondary palate. There are two types of incomplete cleft palate based on Veau’s classification:

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a

b

c

d

Fig. 7.11  Modified Furlow technique for submucous cleft palate repair. (a) Lower half of the nasal mucosa repair using the transposed nasal myomucosal flap (D flap). (b) Uvular repair and nasal mucosa repair using flaps C and D. (c) Flap B transposition soft palate muscular repair. (d) Final closure of the oral mucosa. A: Oral mucosal flap. B: Oral myomucosal flap. C: Nasal mucosal flap. D: Nasal myomucosal flap

• Veau I: The cleft affects only the soft palate. • Veau II: The cleft involves the hard (secondary palate) and soft palate. All the Veau I type of cleft palate are repaired in a similar form as I described for submucous cleft palate. In fact, the submucous cleft palate deformity is a Veau I type. Based on author’s classification of severity, we may consider three types of incomplete cleft palate: 7.4.2.1  The Mild Incomplete Cleft Palate Deformity It is defined as Veau I or II cleft palate with cleft palate index less than 0.20 (Fig. 7.13). Markings. The used technique for this type of cleft palate is a modification of Furlow technique (double opposing Z-plasty) [18]. The description of the technique

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Fig. 7.12  Three submucous cleft palate cases repaired using the modified Furlow technique

for this type of cleft is similar to the method used for submucous cleft palate (Figs. 7.14 and 7.15). (a) Mucosal flaps: Oral (A) and nasal (C) (both anteriorly based). Oral mucosal flap: A triangular anteriorly based flap is designed starting at the base of the uvula and following the cleft borders. Then a lateral marking of the oral mucosal flap starts at the base of the uvula and finishing at point X (located in the

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Fig. 7.13  Mild incomplete cleft palate

same position as described for submucous cleft palate). Nasal mucosal flap: This triangular flap is designed following the base of the previously elevated oral myomucosal flap. (b) Myomucosal flaps: Oral (B) and nasal (D) (both posteriorly based). The two posteriorly based flaps are elevated with the palate muscle. Oral myomucosal flap: This flap is designed intraoperatively. The marking of the incision line is located after transposition of the elevated oral mucosal flap over the opposite side of the soft palate. Nasal myomucosal flap: This myomucosal flap is designed after transposition of the nasal mucosa flap. The midline marking follows the cleft borders and finishes at the posterior border of the hard palate. One hemi-uvula is excised in this type of cleft palate (unilateral uvuloplasty). Surgical procedure (Figs. 7.14, 7.15, and 7.16): This is the surgical sequence of the proposed technique for mild incomplete cleft palate. A Dingman mouth gag and a small throat pack are inserted with the patient in supine position and the neck in extension. Xylocaine 2% (0.5 cc per kg) with 0.1 ml of 1:200,000 epinephrine is injected as I described previously in this chapter.

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Fig. 7.14  Furlow palatoplasty for mild incomplete cleft palate repair. A. Oral mucosa flap. B. Oral myomucosal flap. C. Nasal mucosa flap. D. Nasal myomucosal flap. Upper left: Surgical design of oral mucosa flap identifying the point X. Uvular excision. Upper right: Oral mucosa flap elevation and surgical design of oral myomucosal flap. Lower left: Oral myomucosal flap elevation and surgical design for nasal mucosa flap. Lower right: Nasal mucosa flap elevation for surgical design of nasal myomucosal flap

(a) Surgical incisions and hemi-uvular excision. A full thickness mucosal incision is performed following the described markings perpendicular to the soft palate plane using a scalpel No 7 with a 15 blade or 12 C if this is available. Midline incision is practiced following the cleft borders starting at the base of the uvula and finishing at the hard palate border.

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Fig. 7.15  Furlow palatoplasty plus unilateral uvuloplasty for mild incomplete cleft palate repair. A. Oral mucosa flap. B. Oral myomucosal flap. C. Nasal mucosa flap. D. Nasal myomucosal flap. Upper left: Nasal mucosa flap upper border sutured. Upper right: Nasal myomucosal flap transposition. Unilateral uvuloplasty. Lower left: Oral myomucosal flap transposition. Lower right: Oral mucosa flap transposition

Then, a full thickness mucosal incision is done starting at the base of the uvula and finishing at the point X previously described (see markings) (Figs.  7.14 and 7.16). The oral mucosal flap (A) is created between these two incisions. One hemi-­ uvula (the smaller one) is excised according to the unilateral uvuloplasty technique at this time. (b) Oral mucosal flap elevation. The oral mucosa triangular flap is elevated from the underlying muscular plane. A subperiosteal dissection using a fine periosteal elevator is necessary for flap elevation at this level. Preservation of the flap integrity at this level is mandatory. As I

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a

b

c

d

Fig. 7.16  Furlow technique for mild incomplete cleft palate. (a) Oral mucosal flap. (b) Oral myomucosal flap. (c) Nasal mucosal flap. (d) Nasal myomucosal flap. a. Muscular component of myomucosal flap. b. Mucosal component of myomucosal flap. U.  Uvula. X.  Point for oral mucosa flap design

mentioned before for submucous cleft palate repair, this flap is the key point of the technique since it is used as a reference to design the other flaps. (c) Oral myomucosal flap incision and elevation. The oral myomucosal flap (B) is designed after oral mucosa flap (A) elevation and transposition as in Fig. 7.14. This transposition identifies the point Y. A full thickness mucosal and muscle incision is done following this marking. The palatine aponeurosis is sectioned, and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved doing a conservative intravelar veloplasty. Then the flap B is elevated from the underlying nasal mucosa doing a blunt dissection. The base of this flap is a line between the base of the uvula and point Y. (d) Nasal mucosa flap incision. The nasal mucosa flap (C) is designed between the midline incision and the line between uvular base and point Y (Fig. 7.14). A full thickness incision is performed following this line.

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A small subperiosteal dissection of the hard palate may be necessary at the base of this flap in order to facilitate its transposition to the opposite side. (e) Nasal myomucosal flap incision. The nasal myomucosal flap (D) is designed doing the nasal mucosa flap (C) transposition as in Fig. 7.14. A full thickness muscle and nasal mucosa incision is done following this marking. The palatine aponeurosis is sectioned, and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved in a similar form as flap B. (f) Muscular repair (Figs. 7.15 and 7.16). The muscular velar repair is performed in the same form as I described for the submucous cleft palate. This is a non-radical intravelar veloplasty (see description in this chapter). (g) Final closure (Figs. 7.15, 7.16, and 7.17). The cleft palate closure is completed repairing the upper half of the soft palate using the mucosal flaps (A and C) as I describe before. (h) Uvular repair (Fig. 7.15). The uvular repair is performed using the unilateral uvuloplasty for all types of cleft palate. Description of this technique is done in this chapter. An alternative surgical technique for mild incomplete cleft palate is the minimal incision technique. This technique uses a midline closure without lateral relaxing incisions, and it is used by the author only for mild forms of incomplete cleft palate. Markings (Fig. 7.18): The design of the surgical incisions is done following the cleft margins. The uvular repair is designed using the unilateral uvuloplasty method. Surgical procedure: This is the surgical sequence of the minimal incision technique for mild incomplete cleft palate. (a) Medial surgical incisions and hemi-uvular excision. A full thickness mucosal incision is performed following the cleft margins using a scalpel No 7 with a 15 blade or 12 C. This incision is practiced starting at the base of the uvula and finishing at the hard palate border. One hemi-uvula (the smaller one) is excised according to the unilateral uvuloplasty technique at this time. (b) Oral mucosal elevation. The oral mucosa is elevated from the hard palate and underlying muscular plane. A subperiosteal dissection using a fine periosteal elevator is necessary for flap elevation at the posterior border of the hard palate in both sides. A combination of sharp and blunt dissection is practiced gently between the oral mucosa and the underlying muscular plane in both sides.

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Fig. 7.17  Three mild incomplete cleft palate cases repaired using the modified Furlow technique

Care must be taken to avoid damage to the greater palatine vessels during lateral dissection. This maneuver prevents the development of palatal fistulas at this level. (c) Nasal mucosa elevation and closure. After oral mucosa elevation, the nasal mucosa and the attached muscular plane is exposed.

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Fig. 7.18  Minimal incision technique for mild incomplete cleft palate

The nasal mucosa can be closed without tension using a vicryl 5/0 after uvular repair using the unilateral uvuloplasty. (d) Intravelar veloplasty. The soft palate muscular repair is performed using a conservative intravelar veloplasty. The palatine aponeurosis is sectioned and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved. Multiple interrupted 5/0 PDS sutures are used to approximate the muscles from both sides of the cleft. (e) Oral mucosa closure (Fig. 7.19). The cleft palate closure is completed repairing the oral mucosa without tension using simple interrupted vycril 5/0 sutures for this purpose.

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Fig. 7.19  Minimal incision technique for mild incomplete cleft palate

7.4.2.2  The Moderate Incomplete Cleft Palate Deformity It is defined as Veau II cleft palate with cleft palate index between 0.20 and 0.40 (Fig. 7.20). Markings (Figs. 7.21 and 7.22): The used technique for this type of cleft palate is a hybrid palatoplasty. By definition, a hybrid palatoplasty combines two types of surgical techniques. In this case, the technique for moderate incomplete cleft palate

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Fig. 7.20  Moderate incomplete cleft palate

combines the modified Furlow palatoplasty with unilateral relaxing incision in order to reduce tension of the closure and the development of palatal fistulas. The midline marking follows the cleft borders and finishes at the posterior border of the hard palate. (a) Mucosal flaps: Oral (A) and nasal (C) (both anteriorly based). These mucosal flaps are equally designed as it was described for the submucous and mild incomplete cleft palates. (b) Myomucosal flaps: Oral (B) and nasal (D) (both posteriorly based). These myomucosal flaps are equally designed as it was described for the submucous and mild incomplete cleft palates. (c) Lateral relaxing incision. This incision is designed starting 1 cm posterior to maxillary tuberosity and follows the junction between palatal mucous membrane and gingival mucous membrane to approximately 1  cm anterior to the most anterior extent of the cleft. One hemi-uvula is excised in this type of cleft palate (unilateral uvuloplasty). Surgical procedure: This is the surgical sequence of the proposed technique for moderate incomplete cleft palate. A Dingman mouth gag and a small throat pack are

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Fig. 7.21  Furlow palatoplasty plus relaxing incision for moderate incomplete cleft palate repair. A. Oral mucosa flap. B. Oral myomucosal flap. C. Nasal mucosa flap. D. Nasal myomucosal flap. Upper left: Surgical design of oral mucosa flap identifying the point X. Upper right: Oral mucosa flap elevation and surgical design of oral myomucosal flap. Lower left: Oral myomucosal flap elevation and surgical design for nasal mucosa flap. Lower right: Nasal mucosa flap elevation for surgical design of nasal myomucosal flap

inserted with the patient in supine position and the neck in extension. Local anesthetic is injected as I previously described. (a) Surgical incisions and hemi-uvular excision. A full thickness mucosal incision is performed following the described markings perpendicular to the soft palate plane using a scalpel No 7 with a 15 blade or 12 C if this is available. Midline incision is practiced following the cleft borders starting at the base of the uvula and finishing at the hard palate border (Fig. 7.23).

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Fig. 7.22  Furlow palatoplasty plus relaxing incision for moderate incomplete cleft palate repair. A. Oral mucosa flap. B. Oral myomucosal flap. C. Nasal mucosa flap. D. Nasal myomucosal flap. Upper left: Nasal mucosa flap upper border sutured. Upper right: Nasal myomucosal flap transposition. Unilateral uvuloplasty. Lower left: Oral myomucosal flap transposition. Black line (lateral relaxing incision) Lower right: Oral mucosa flap transposition and lateral raw surface

Then, a full thickness mucosal incision is done starting at the base of the uvula and finishing at the point X previously described (see markings). The oral mucosal flap (A) is created between these two incisions. The relaxing incision is practiced at the same side through cautery, the underlying muscular aponeurotic plane and the greater palatine pedicle are exposed (Fig. 7.23). One hemi-­ uvula (the smaller one) is excised according to the unilateral uvuloplasty technique at this time (Fig. 7.23b). (b) Oral mucosal flap elevation. The oral mucosa triangular flap is elevated from the underlying muscular plane. A subperiosteal dissection using a fine periosteal elevator is necessary

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a

b

c

d

Fig. 7.23  Furlow palatoplasty plus relaxing incision for moderate incomplete cleft palate repair. (a) Moderate incomplete cleft palate (preoperative view). (b) Marginal and lateral incisions. (c) Greater palatine pedicle dissection. (d) Mucoperiosteal flap elevation

for flap elevation at this level (Fig. 7.23d). This is performed around the hard palate and greater palatine foramen to facilitate the neurovascular bundle mobilization (Fig. 7.23c). The dissection of the greater palatine pedicle is completed through blunt dissection. Care should be taken to avoid any blind dissection of this area in order to avoid injury of the greater palatine artery. The dissection of the oral mucosal flap is extended laterally and connects with the lateral relaxing incision. (c) Oral myomucosal flap incision and elevation. The oral myomucosal flap (B) is designed after oral mucosa flap (A) elevation and transposition as in Fig. 7.24a. This transposition identifies the point Y. A full thickness mucosal and muscle incision is done following this marking. The palatine aponeurosis is sectioned and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved doing a conservative intravelar veloplasty.

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a

b

c

d

e

f

Fig. 7.24  Furlow palatoplasty plus relaxing incision for moderate incomplete cleft palate repair. (a) Oral mucosa flap. (b) Oral mucosa incision at the left side. (c) Myomucosal flap elevation at the right side. (d) Unilateral uvuloplasty. (e) Nasal mucosa closure and muscular repair. (f) Final closure

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Then the flap B is elevated from the underlying nasal mucosa doing a blunt dissection. (d) Nasal mucosa flap incision. The nasal mucosa flap (C) is designed between the midline incision and the line between uvular base and point Y. A full thickness incision is performed following this line. A small subperiosteal dissection of the hard palate may be necessary at the base of this flap in order to facilitate its transposition to the opposite side. (e) Nasal myomucosal flap incision. The nasal myomucosal flap (D) is designed doing the nasal mucosa flap (C) transposition as in Fig. 7.24. A full thickness muscle and nasal mucosa incision is done following this marking. The palatine aponeurosis is sectioned, and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved in a similar form as flap B. (f) Muscular repair (Fig. 7.24e). The muscular velar repair is performed in the same form as I described for the submucous cleft palate. This is a non-radical intravelar veloplasty (see description in this chapter). (g) Final closure (Figs. 7.24f and 7.25). The cleft palate closure is completed repairing the upper half of the soft palate using the mucosal flaps (A and C) as I describe before. A lateral raw surface is necessary in order to prevent palatal fistulas development. (h) Uvular repair. The uvular repair is performed using the unilateral uvuloplasty. 7.4.2.3  The Severe Incomplete Cleft Palate Deformity It is defined as Veau II cleft palate with a cleft palate index greater than 0.40 (Fig. 7.26). The used technique for this type of cleft palate is the Von Langenbeck method [19]. This technique uses two lateral relaxing incisions, and it is recommended by the author for severe forms of incomplete cleft palate reducing the rate of postoperative fistulas. This type of primary palatoplasty allows us to repair the cleft palate without tension and provides additional blood supply to the mucoperiosteal flaps.

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Fig. 7.25  Hybrid technique for moderate incomplete cleft palate (Veau II)

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Fig. 7.26  Severe incomplete cleft palate

Markings: The design of the surgical incisions is done following the cleft margins to the anterior border of the hard palate as in Fig. 7.27. Relaxing incisions are designed in both sides of the palate. These incisions are located starting 1 cm posterior to maxillary tuberosity and follow the junction between palatal mucous membrane and gingival mucous membrane to approximately 1 cm anterior to the most anterior extent of the cleft. The uvular repair is designed using the unilateral uvuloplasty method (Fig. 7.27). Surgical procedure: This is the surgical sequence of the Von Langenbeck technique for severe incomplete cleft palate. (a) Medial and lateral surgical incisions and hemi-uvular excision. A full thickness mucosal incision is performed following the cleft margins using a scalpel No 7 with a 15 blade or 12 C. This incision is practiced starting at the base

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Fig. 7.27  Von Langenbeck technique for severe incomplete cleft palate. Upper left: Medial incisions design. Upper right: Lateral relaxing incisions and nasal mucosa closure using the anterior triangular flap and lateral nasal mucosa flaps. Release of the abnormal muscular insertion is performed. Unilateral uvuloplasty is completed. Lower: Muscular repair and oral mucosa closure is performed. X: Greater palatine artery

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of the uvula and finishing anteriorly to a point approximately 10 mm anterior to the anterior margin of the cleft. This incision creates an anterior oral mucosa triangular flap used for nasal mucosa closure (Fig. 7.28). The lateral relaxing incisions are practiced in both sides through cautery; the underlying muscular aponeurotic plane, the greater palatine pedicle, and hard palate are exposed. One hemi-uvula (the smaller one) is excised according to the unilateral uvuloplasty technique (Fig. 7.28b). (b) Oral mucosal elevation. The oral mucosa is elevated from the underlying muscular plane (Fig. 7.28c). A combination of sharp and blunt dissection is practiced gently between the oral a

b

c

d

Fig. 7.28  The Von Langenbeck technique for severe incomplete cleft palate. (a) Severe incomplete cleft palate. (b) Right uvula excision based on unilateral uvuloplasty technique. Medial and lateral incisions. (c) Oral mucosa dissection. (d) Nasal mucosa dissection and closure

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mucosa and the underlying muscular plane of the soft palate. At the level of the hard palate, the oral mucosa is elevated in the subperiosteal plane. This dissection is performed through the medial and lateral incisions connecting them. A fine periosteal elevator is necessary for greater palatine pedicle dissection. The greater palatine foramen is located approximately 1 cm from the gingiva and 1 cm anterior to the posterior border or the hard palate in both sides. The oral mucosa is finally elevated after greater palatine pedicle release performed through the lateral relaxing incisions under direct vision (Fig. 7.29d, e). Care must be taken to avoid damage to the greater palatine vessels during these lateral dissections. Dissection and medial mobilization of the greater palatine pedicle is critical to guarantee closure of the cleft without tension. (c) Nasal mucosa elevation and closure. At the medial border of the cleft, the nasal mucosa is elevated from the nasal surface of the hard palate using a fine curved periosteal elevator. The extension of this dissection depends on the width of the cleft palate. The nasal mucosa can be closed without tension using a vicryl 5/0 after uvular repair using the unilateral uvuloplasty (Fig. 7.28d). Closure should be completed from the base of the preserved uvula to the anterior ends of the cleft. The anterior portion of the nasal mucosa is closed doing a posterior reflection of the anterior triangular flap (composed of oral mucosa) from the hard palate (primary palate). This method decreases the rate of anterior postoperative fistulas and the need to extend the surgical dissection of the nasal mucosa at that level. Vomer flap is not used for nasal mucosa repair in this type of cleft palate. (d) Intravelar veloplasty (Fig. 7.29a–c). The soft palate muscular repair is performed using a conservative intravelar veloplasty. The palatine aponeurosis is sectioned, and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved. Multiple interrupted 5/0 PDS sutures are used to approximate the muscles from both sides of the cleft (Fig. 7.44). (e) Oral mucosa closure (Figs. 7.29f and 7.30). The cleft palate closure is completed repairing the oral mucosa without tension using simple interrupted vycril 5/0 sutures for this purpose. Lateral raw surfaces are necessary in order to prevent palatal fistulas development. (f) Uvular repair. The uvular repair is performed using the unilateral uvuloplasty.

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a

b

c

d

e

f

Fig. 7.29  The Von Langenbeck technique for severe incomplete cleft palate. (a) Muscular dissection using non-radical intravelar veloplasty. (b) Muscular elevation and retroposition using the non-radical intravelar veloplasty. (c) Muscular repair using the non-radical intravelar veloplasty. (d) Greater palatine pedicle dissection through lateral incision (left). (e) Greater palatine pedicle dissection through lateral incision (right). (f) Final oral mucosa closure

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Fig. 7.30  Von Langenbeck technique for severe incomplete cleft palate

7.4.3  Unilateral Cleft Palate This type of cleft palate involves the primary and secondary palates unilaterally. Based on author’s classification of severity, we may consider three types of unilateral cleft palate:

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Fig. 7.31  Mild unilateral cleft palate

7.4.3.1  The Mild Unilateral Cleft Palate Deformity It is defined as Veau III cleft palate with cleft palate index is less than 0.20 (Fig. 7.31). The used technique for this type of cleft palate is a hybrid palatoplasty. The technique for mild unilateral cleft palate is a modification of the minimal incision technique using a lateral relaxing incision in order to reduce tension of the closure. Markings (Fig. 7.32): The midline marking follows the cleft borders bilaterally. A relaxing incision is designed at the non-cleft side of the palate. This incision is located starting 1  cm posterior to maxillary tuberosity and follows the junction between palatal mucous and gingival mucous membrane. Surgical procedure: This is the surgical sequence of the hybrid technique for mild unilateral cleft palate.

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a

b

c

Fig. 7.32  The hybrid palatoplasty for mild unilateral cleft palate. (a) Surgical incisions. (b) Nasal mucosa closure and elevation of bipedicled mucoperiosteal flap + unilateral uvuloplasty. (c) Non-­ radical intravelar veloplasty and final oral mucosa closure

(a) Medial surgical incisions and hemi-uvular excision (Fig. 7.33). A full thickness mucosal incision is performed following the cleft margins using a scalpel No 7 with a 15 blade or 12 C. This incision is practiced starting at the base of the uvula and finishing at the alveolar cleft border. One hemi-uvula (the smaller one) is excised according to the unilateral uvuloplasty technique at this time.

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a

b

c

d

e

f

Fig. 7.33  The hybrid palatoplasty for mild unilateral cleft palate. Oral mucosa incisions. (a) Mild unilateral cleft palate. (b) Left uvula excision based on unilateral uvuloplasty technique. (c) Preserved uvula incision. (d) Cleft side margin incision. (e) Non-cleft side margin incision. (f) Lateral relaxing incision performed using cautery

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(b) Lateral relaxing incision (Fig. 7.33f). A lateral relaxing incision is practiced at the non-cleft side through cautery. The incision is extended to the posterior border of the alveolar cleft level. (c) Oral mucosal elevation (Fig. 7.34). The oral mucosa is elevated from the hard palate and underlying muscular plane. A subperiosteal dissection using a fine periosteal elevator is necessary for oral mucosa elevation. This dissection is performed through the medial and relaxing incision at the non-­ cleft side and through the medial incision at the cleft side. The greater palatine foramen is located approximately 1  cm from the gingiva and 1  cm anterior to the posterior border or the hard palate in both sides (Fig.  7.37). The oral mucosa is finally elevated after greater palatine pedicle release performed through the lateral relaxing incisions under direct vision (Fig. 7.37).

a

b

c

d

Fig. 7.34  The hybrid palatoplasty for mild unilateral cleft palate. Oral mucosa elevation. (a) Mucoperiosteal elevation from the cleft side. (b) Oral mucosa elevation from the cleft side soft palate. (c) Subperiosteal flap elevation of the oral mucosa from the non-cleft side. (d) Soft palate oral mucosa elevation from the non-cleft side

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Skeletonization of this pedicle is essential to prevent development of palatal fistulas. A combination of sharp and blunt dissection is practiced gently between the oral mucosa and the underlying muscular plane in both sides. Care must be taken to avoid damage to the greater palatine vessels during lateral dissection in both sides. (d) Nasal mucosa elevation and closure (Fig. 7.35). At the medial border of the cleft, the nasal mucosa is elevated from the nasal surface of the hard palate using a fine curved periosteal elevator. The nasal mucosa of the vomer is elevated from the non-cleft side using a periosteal elevator. The nasal mucosa can be closed without tension using a vicryl 5/0 after uvular repair. Closure should be completed from the base of the preserved uvula to the posterior border of the alveolar cleft.

a

b

c

d

Fig. 7.35  The hybrid palatoplasty for mild unilateral cleft palate. Nasal mucosa elevation and repair. (a): Nasal mucosa (vomer) elevation from the non-cleft side. (b) Nasal mucosa elevation from the cleft side. (c) Unilateral uvuloplasty. (d) Nasal mucosa closure and bipedicled flap elevation

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(e) Intravelar veloplasty (Fig. 7.36). The soft palate muscular repair is performed using a conservative intravelar veloplasty. The palatine aponeurosis is sectioned and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved. Multiple interrupted 5/0 PDS sutures are used to approximate the muscles from both sides of the cleft.

a

b

c

d

Fig. 7.36  The hybrid palatoplasty for mild unilateral cleft palate. Intravelar veloplasty. (a) Non-­ radical intravelar veloplasty at the cleft side. (b) Muscular elevation from the cleft side. (c) Muscular elevation at the non-cleft side. (d) Muscular repair

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a

b

c

d

Fig. 7.37  The hybrid palatoplasty for mild unilateral cleft palate. (a) Surgical dissection of the greater palatine pedicle. (b) Lateral fibrous attachment release to the greater palatine pedicle and its skeletonization. (c) Flap mobilization after vascular pedicle release. (d) Postoperative view

(f) Oral mucosa closure (Figs. 7.37 and 7.38). The cleft palate closure is completed repairing the oral mucosa without tension using simple interrupted vycril 5/0 sutures for this purpose. (g) Uvular repair. The uvular repair is performed using the unilateral uvuloplasty.

320

Fig. 7.38  Hybrid palatoplasty for mild unilateral cleft palate

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Fig. 7.39  Moderate unilateral cleft palate

7.4.3.2  The Moderate Unilateral Cleft Palate Deformity It is defined as Veau III cleft palate with cleft palate index between 0.20 and 0.40 (Fig. 7.39) The used technique for this type of cleft palate is the one flap palatoplasty. This is a technique developed by the author [20]. A clinical trial study observed similar rate of oronasal fistulas comparing this technique with the two-flap method in patients with unilateral cleft palate [21]. This technique uses the non-cleft side for cleft palate repair. The flap is bigger and well vascularized in comparison with the non-cleft side. Markings (Fig. 7.40): The midline marking follows the cleft borders bilaterally. A monopedicled mucoperiosteal flap is designed at the non-cleft side of the palate. This incision is located starting 1 cm posterior to maxillary tuberosity and follows along the edge of palate, over the gingiva and just medial to the line of dental eruption, as in the alveolar extension palatoplasty of Carstens until the posterior border of the alveolar cleft [22]. At this level, the lateral incision is connected with the medial incision. A 1-cm lateral extension over soft palate was needed to prevent any tension on midline closure at this level.

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Fig. 7.40  The one-flap palatoplasty for moderate unilateral cleft palate. Upper left: Surgical incisions and unilateral uvula excision. Upper right: 1. Hard palate. 2. Incisive foramen. 3. Palatal spine. 4. Greater palatine artery. 5. Mucoperiosteal flap. 6. Subperiosteal dissection at the cleft side. 7. Nasal mucosa closure. 8. Muscular non-radical intravelar veloplasty. 9. Unilateral uvuloplasty for uvular repair. Lower left: Intravelar veloplasty non-radical muscular repair. Lower right: Final oral mucosa closure

Surgical procedure: This is the surgical sequence of the one-flap technique for moderate unilateral cleft palate. (a) Surgical incisions and hemi-uvular excision (Fig. 7.41). A full thickness mucosal incision is performed following the cleft margins using a scalpel No 7 with a 15 blade or 12 C.

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a

b

c

d

e

f

Fig. 7.41  The one-flap palatoplasty for moderate unilateral cleft palate. Oral mucosa incisions. (a) Moderate unilateral cleft palate. (b) Right uvula excision based on unilateral uvuloplasty technique. (c) Preserved uvula and non-cleft side margin incision. (d) Cleft side margin incision. (e) Mucoperiosteal flap incision performed using cautery. (f) Final oral mucosa incisions

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This incision is practiced starting at the base of the uvula and finishing at the alveolar cleft border. One hemi-uvula (the smaller one) is excised according to the unilateral uvuloplasty technique at this time. A lateral relaxing incision is practiced at the non-cleft side through cautery and connected anteriorly with the medial incision. (b) Oral mucosal elevation (Fig. 7.42). The oral mucosa is elevated from the hard palate and underlying muscular plane in both sides. A subperiosteal dissection using a fine periosteal elevator is necessary for oral mucosa elevation. The mucoperiosteal flap is elevated at the subperiosteal level from the noncleft side. After the initial elevation of the mucoperiosteal flap, the anatomy of the hard palate is easily observed. The first element to be identified is a prominent palatal spine (could be one to three) projected few millimeters over the greater palatine vessels. During the cleft palate repair, the palatine spines are the most

a

b

c

d

Fig. 7.42  The one-flap palatoplasty for moderate unilateral cleft palate. Oral mucosa elevation. (a) Mucoperiosteal flap elevation from the non-cleft side. (b) Oral mucosa elevation from the non-­ cleft side soft palate. (c) Subperiosteal elevation of the oral mucosa from the cleft side. (d) Oral soft palate mucosa elevation from the cleft side

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important point of reference to locate the greater palatine pedicle and avoid its injury. The greater palatine foramen is located approximately 1 cm from the gingiva and 1  cm anterior to the posterior border or the hard palate in both sides (Figs. 7.45 and 7.46). After identification of the greater palatine pedicle covered by periosteum, the dissection continues medially and laterally from the foramen. Medially the dissection is easier over the palatine bone and special attention should be paid at the soft palate level with the soft palate pits. Laterally the mucosa is firmly attached to the bone structures and represents the posterior alveolar ridge dimple. The dissection at this level is difficult and put in risk of injury to the greater foramen vessels. The oral mucosa is finally elevated after greater palatine pedicle release performed through the lateral relaxing incisions under direct vision (Figs.  7.45 and 7.46). A combination of sharp and blunt dissection is practiced gently between the oral mucosa and the underlying muscular plane in both sides. Lesser palatine vessels are located behind the palatine bone and should be cauterized to prevent bleeding. (c) Nasal mucosa elevation and closure (Fig. 7.43). a

b

c

d

Fig. 7.43  The one flap palatoplasty for moderate unilateral cleft palate. (a) Nasal mucosa elevation from the cleft side. (b) Nasal mucosa (vomer) elevation from the non-cleft side. (c) Unilateral uvuloplasty. (d) Nasal mucosa closure

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At the medial border of the cleft, the nasal mucosa is elevated from the nasal surface of the hard palate using a fine curved periosteal elevator. The extension of this dissection depends on the width of the cleft palate. The nasal mucosa is elevated from the nasal surface of the hard palate at the cleft side, and the mucosa of the vomer is elevated from the non-cleft side. The nasal mucosa can be closed without tension using a vicryl 5/0 after uvular repair. Mucosal closure should be completed from the base of the preserved uvula to the posterior border of the alveolar cleft. (d) Intravelar veloplasty (Fig. 7.44). The soft palate muscular repair is performed using a conservative intravelar veloplasty. The palatine aponeurosis is sectioned, and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved. Multiple interrupted 5/0 PDS sutures are used to approximate the muscles from both sides of the cleft (Fig. 7.44).

a

b

c

d

Fig. 7.44  The one-flap palatoplasty for moderate unilateral cleft palate. Intravelar veloplasty. (a) Non-radical intravelar veloplasty at the non-cleft side. (b) Muscular elevation from the non-cleft side. (c) Muscular elevation at the cleft side. (d) Muscular repair

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(e) Oral mucosa closure (Fig. 7.47). The cleft palate closure is completed repairing the oral mucosa without tension using simple interrupted vycril 5/0 sutures for this purpose. The anterior portion of the oral mucosa is closed in a border to border form with the cleft side. The mucoperiosteal flap closes the alveolar cleft floor (Fig. 7.46). Carefully hemostasis should be done through the lateral raw surface. (f) Uvular repair (Fig. 7.43C). The uvular repair is performed using the unilateral uvuloplasty.

a

b

c

d

Fig. 7.45  The one-flap palatoplasty for moderate unilateral cleft palate. Greater palatine artery dissection. (a) Surgical dissection of the greater palatine pedicle (lateral release using cautery). (b) Lateral fibrous attachment release to the greater palatine pedicle. (c) Flap mobilization after vascular pedicle release. (d) Medial flap mobilization after pedicle release

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a

c

b

d

Fig. 7.46  Greater palatine pedicle skeletonization and anterior portion of the oral mucosa closure. (a) Mucoperiosteal flap incisions. (b) Greater palatine pedicle dissection from its foramen. (c) Skeletonization and displacement of the greater palatine pedicel. (d) 1. Mucoperiosteal flap. 2. Cleft side. 3. Gum. 4. Alveolar cleft

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Fig. 7.47  The one-flap palatoplasty for moderate unilateral cleft palate

7.4.3.3  The Severe Unilateral Cleft Palate Deformity It is defined as Veau III cleft palate with a cleft palate index greater than 0.40 (Fig. 7.48). The technique for severe unilateral cleft palate is the one-flap palatoplasty using a lateral relaxing incision at the cleft side in order to reduce tension of the closure.

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Markings (Fig. 7.49): The midline marking follows the cleft borders bilaterally. A monopedicled mucoperiosteal flap is designed at the non-cleft side of the palate in a similar for as the author described for the moderate unilateral cleft palate. This incision is located starting 1 cm posterior to maxillary tuberosity and follows along the edge of palate, over the gingiva and just medial to the line of dental eruption, as in the alveolar extension palatoplasty of Carstens until the posterior border of the alveolar cleft [22]. At this level, the lateral incision is connected with the medial incision. A 1-cm lateral extension over soft palate was needed to prevent any tension on midline closure at this level. A small lateral relaxing incision is located at the cleft side starting 1 cm posterior to maxillary tuberosity and following the junction between palatal and gingival mucosa. Surgical procedure: This is the surgical sequence of the surgical technique for severe unilateral cleft palate. (a) Surgical incisions and hemi-uvular excision (Fig. 7.50). A full thickness mucosal incision is performed following the cleft margins using a scalpel No 7 with a 15 blade or 12 C. This incision is practiced starting at the base of the uvula and finishing at the alveolar cleft border. One hemi-uvula (the smaller one) is excised according to the unilateral uvuloplasty technique at this time. Lateral relaxing incisions are practiced in both sides through cautery following the surgical markings. (b) Oral mucosal elevation (Fig. 7.51). A subperiosteal dissection using a fine periosteal elevator is necessary for oral mucosa elevation in both sides. The mucoperiosteal flap is elevated at the subperiosteal level from the non-cleft side. The greater palatine foramen is located approximately 1 cm from the gingiva and 1 cm anterior to the posterior border or the hard palate in both sides (Fig. 7.54). After identification of the greater palatine pedicle covered by periosteum, the dissection continues medially and laterally from the foramen. The oral mucosa is finally elevated after greater palatine pedicle release performed under direct vision (Fig. 7.54). Oral mucosa is elevated at the cleft side through the medial incision and the small relaxing incision.

7.4 The Lima Cleft Palate Surgical Protocol

Fig. 7.48  Severe unilateral cleft palate

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Fig. 7.49  The one-flap palatoplasty for severe unilateral cleft palate. Upper left: Surgical incisions and unilateral uvula excision. Upper right: 1. Hard palate. 2. Incisive foramen. 3. Palatal spine. 4. Greater palatine artery. 5. Mucoperiosteal flap. 6. Subperiosteal dissection at the cleft side. 7. Nasal mucosa closure. 8. Muscular non-radical intravelar veloplasty. 9. Unilateral uvuloplasty for uvular repair. 10. Lateral relaxing incision at the cleft side. Lower: Final oral mucosa closure

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a

b

c

d

e

f

Fig. 7.50  The hybrid palatoplasty for severe unilateral cleft palate. Oral mucosa incisions. (a) Severe unilateral cleft palate. (b) Left uvula excision based on unilateral uvuloplasty technique. (c) Preserved uvula and cleft side margin incision. (d) Non-cleft side margin incision. (e) Cleft side margin incision. (f) Final view showing bilateral marginal incisions and lateral mucoperiosteal flap incision using cautery

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a

b

c

d

Fig. 7.51  The hybrid palatoplasty for severe unilateral cleft palate. Oral mucosa elevation. (a) Mucoperiosteal flap elevation from the non-cleft side. (b) Oral mucosa elevation from the non-­ cleft side soft palate. (c) Subperiosteal elevation of the oral mucosa from the cleft side. (d) Oral soft palate mucosa elevation from the cleft side

The greater palatine pedicle must be dissected under direct visualization in the same form as the author described for the non-cleft side. A combination of sharp and blunt dissection is practiced gently between the oral mucosa and the underlying muscular plane in both sides. (c) Nasal mucosa elevation and closure (Fig. 7.52). At the medial border of the cleft, the nasal mucosa is elevated from the nasal surface of the hard palate using a fine curved periosteal elevator. The nasal mucosa is elevated from the nasal surface of the hard palate at the cleft side and the mucosa of the vomer is elevated from the non-cleft side. The nasal mucosa can be closed without tension using a vicryl 5/0 after uvular repair. Closed should be complete from the base of the preserved uvula to the posterior border of the alveolar cleft.

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(d) Intravelar veloplasty (Fig. 7.53). The soft palate muscular repair is performed using a conservative intravelar veloplasty. The palatine aponeurosis is sectioned, and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved. Multiple interrupted 5/0 PDS sutures are used to approximate the muscles from both sides of the cleft. (e) Oral mucosa closure (Figs. 7.54 and 7.55). The cleft palate closure is completed repairing the oral mucosa without tension using simple interrupted vycril 5/0 sutures for this purpose. Carefully hemostasis should be done through the lateral raw surfaces.

(f) Uvular repair (Fig. 7.52c). The uvular repair is performed using the unilateral uvuloplasty.

a

b

c

d

Fig. 7.52  The hybrid palatoplasty for severe unilateral cleft palate. (a) Nasal mucosa elevation from the cleft side. (b) Nasal mucosa (vomer) elevation from the non-cleft side. (c) Unilateral uvuloplasty. (d) Nasal mucosa closure

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a

b

c

d

Fig. 7.53  The hybrid palatoplasty for severe unilateral cleft palate. Intravelar veloplasty. (a) Non-­ radical intravelar veloplasty at the non-cleft side. (b) Muscular elevation from the non-cleft side. (c) Muscular elevation at the cleft side. (d) Muscular repair

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a

b

c

d

Fig. 7.54  The hybrid palatoplasty for severe unilateral cleft palate. (a) Surgical dissection of the greater palatine pedicle (lateral release using cautery). (b) Lateral fibrous attachment release to the greater palatine pedicle. (c) Flap mobilization after vascular pedicle skeletonization. (d) Lateral relaxing incision at the cleft side and final closure

338

Fig. 7.55  The hybrid palatoplasty for severe unilateral cleft palate

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7.4.4  Bilateral Cleft Palate This type of cleft palate involves the primary and secondary palate bilaterally. Rate of complications is higher in this type of cleft palate. Based on author’s classification of severity, we may consider three types of bilateral cleft palate: 7.4.4.1  The Mild Bilateral Cleft Palate Deformity It is defined as Veau IV cleft palate with cleft palate index less than 0.20 (Fig. 7.56). The used technique for this type of cleft palate is a hybrid palatoplasty. Markings (Figs. 7.57 and 7.58): The midline marking follows the cleft borders bilaterally. A relaxing incision is designed at one side of the palate (right or left). This incision is located starting 1 cm posterior to maxillary tuberosity and follows the junction between palatal mucous and gingival mucous membrane to within 1 centimeter from the cleft. The uvular repair is designed using the unilateral uvuloplasty method [15]. Surgical procedure: This is the surgical sequence of the surgical technique for mild bilateral cleft palate. (a) Medial surgical incisions and hemi-uvular excision (Fig. 7.59). A full thickness mucosal incision is performed following the cleft margins using a scalpel No 7 with a 15 blade or 12 C. This incision is practiced starting at the base of the uvula and finishing at the alveolar cleft border. One hemi-uvula (the smaller one) is excised according to the unilateral uvuloplasty technique at this time. (b) Lateral relaxing incision (Fig. 7.59). A lateral relaxing incision is practiced at one side through cautery. The incision is extended to the level of the posterior border of the alveolar cleft. (c) Oral mucosal elevation (Fig. 7.59). The oral mucosa is elevated from the hard palate and underlying muscular plane. A subperiosteal dissection using a fine periosteal elevator is necessary for oral mucosa elevation at the hard palate. A combination of sharp and blunt dissection is practiced gently between the oral mucosa and the underlying muscular plane in both sides. The greater palatine pedicle release is performed through the lateral relaxing incision under direct vision (Fig. 7.61c). The pedicle must be released from the foramen as much as necessary to allow medial displacement of the mucoperiosteal flaps without tension.

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Fig. 7.56  Mild bilateral cleft palate

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7.4 The Lima Cleft Palate Surgical Protocol Fig. 7.57  The hybrid palatoplasty for mild bilateral cleft palate. (a) Surgical incisions. (b) nasal mucosa and premaxillary flaps

a

b

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a

b

c

Fig. 7.58  The hybrid palatoplasty for mild bilateral cleft palate. (a) Nasal mucosa closure. (b) Unilateral mucoperiosteal flap elevation + non-radical intravelar veloplasty. (c) Final oral mucosa closure

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a

b

c

d

Fig. 7.59  The hybrid palatoplasty for mild bilateral cleft palate. Oral mucosa elevation. (a) Mild bilateral cleft palate. (b) Unilateral uvular excision and marginal cleft incisions. (c) Oral mucosa dissection (left side). (d) Oral mucosa dissection (right side)

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a

b

c

d

Fig. 7.60  The hybrid palatoplasty for mild bilateral cleft palate. Nasal mucosa elevation and repair. (a) Nasal mucosa elevation (left side). (b) Nasal mucosa elevation (right side). (c) Uvular repair using the unilateral uvuloplasty. (d) Nasal mucosa repair using the premaxillary flap

(d) Nasal mucosa elevation and closure (Fig. 7.60a, b). At the medial border of the cleft, the nasal mucosa is elevated from the nasal surface of the hard palate using a fine curved periosteal elevator. Using cautery, a posteriorly based mucoperiosteal flap is elevated from the premaxilla. The anterior portion of the nasal mucosa is closed doing a posterior reflection of this flap from the premaxilla (Fig. 7.60a, b). Closure should be completed from the base of the preserved uvula to the posterior border of the alveolar cleft using a vicryl 5/0. (e) Intravelar veloplasty (Fig. 7.61a, b). The soft palate muscular repair is performed using a conservative intravelar veloplasty.

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The palatine aponeurosis is sectioned, and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved. Multiple interrupted 5/0 PDS sutures are used to approximate the muscles from both sides of the cleft. (f) Oral mucosa closure (Figs. 7.61d and 7.62). The cleft palate closure is completed repairing the oral mucosa without tension using simple interrupted vycril 5/0 sutures for this purpose. (g) Uvular repair (Fig. 7.60c). The uvular repair is performed using the unilateral uvuloplasty.

a

b

c

d

Fig. 7.61  The hybrid palatoplasty for mild bilateral cleft palate. (a) Abnormal muscular insertion after nasal mucosa closure. (b) Non-radical intravelar veloplasty. (c) Greater palatine pedicle dissection. (d) Oral mucosa closure using a bipedicled flap

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Fig. 7.62  The hybrid palatoplasty for mild bilateral cleft palate

7.4.4.2  The Moderate Bilateral Cleft Palate Deformity It is defined as Veau IV cleft palate with cleft palate index between 0.20 and 0.40 (Fig. 7.63). The used method for this type of cleft palate is the Von Langenbeck technique. This technique uses bipedicled flaps and two lateral relaxing incisions. It is recommended by the author for moderate forms of bilateral cleft palate. Use of bipedicled flaps increases the blood supply preventing flap necrosis and the relaxing incisions reduces the development of postoperative palatal fistulas. Markings (Figs. 7.64 and 7.65): The design of the surgical incisions is done following the cleft margins to the anterior border of the hard palate as in Fig. 7.64.

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Relaxing incisions are designed in both sides of the palate. These incisions are located starting 1 cm posterior to maxillary tuberosity, then curves anteriorly where soft palate joins maxillary tuberosity and is carried forward at the junction between palatal mucous membrane and gingival mucous membrane to within 1 centimeter from the cleft. A transverse incision is designed along the incisors line of eruption and then continues posteriorly to create a posteriorly based premaxillary flap (Figs.  7.66 and 7.67). The uvular repair is designed using the unilateral uvuloplasty method. Surgical procedure: This is the sequence of the Von Langenbeck technique for moderate bilateral cleft palate. (a) Medial surgical incisions and hemi-uvular excision (Fig. 7.68). A full thickness mucosal incision is performed following the cleft margins using a scalpel No 7 with a 15 blade or 12 C. These incisions are practiced starting at the base of the uvula and finishing anteriorly. The relaxing incision is practiced in both sides using cautery following the described surgical markings. Through medial and lateral incisions the underlying muscular aponeurotic plane, the greater palatine pedicle and hard palate are exposed. One hemi-uvula (the smaller one) is excised according to the unilateral uvuloplasty technique. (b) Oral mucosal elevation (Fig. 7.69). The oral mucosa is elevated from the underlying muscular plane. A combination of sharp and blunt dissection is practiced gently between the oral mucosa and the underlying muscular plane of the soft palate. Using curved scissors, the oral mucous membrane is dissected in the plane just deep to the mucous glands exposing the abnormally inserted muscles in both sides. At the level of the hard palate, the oral mucosa is elevated in the subperiosteal plane. This dissection is performed through the medial and lateral incisions connecting them. The greater palatine pedicle is bilaterally dissected. Through the relaxing incisions, under direct vision and using a fine elevator, the greater palatine vascular bundle is carefully stretched from the foramen (Fig. 7.69a).

348

Fig. 7.63  Moderate bilateral cleft palate

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7.4 The Lima Cleft Palate Surgical Protocol Fig. 7.64  The Von Langenbeck technique for moderate unilateral cleft palate. (a) Surgical markings. Cleft marginal and lateral relaxing incisions. Premaxilla incision. (b) Unilateral uvuloplasty + nasal mucosa and premaxila flaps elevation

a

b

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a

b

c

Fig. 7.65  The Von Langenbeck technique for moderate unilateral cleft palate. (a) Nasal mucosa closure using premaxilla and nasal mucosa flaps. Unilateral uvuloplasty. (b) Bilateral bipedicled flaps elevation. Non-radical intravelar veloplasty. (c) Oral mucosa closure

7.4 The Lima Cleft Palate Surgical Protocol

Fig. 7.66  Presurgical design of the premaxillary flap (P) for anterior nasal mucosa repair

Fig. 7.67  Subperiosteal elevation of the premaxillary flap (P) and posterior reflection

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a

b

c

d

e

f

Fig. 7.68  The Von Langenbeck technique for moderate bilateral cleft palate. Oral mucosa incision. (a) Moderate bilateral cleft palate. (b) Unilateral uvular excision. (c) Preserved uvular incision. (d) Cleft margin incisions. (e, f) Lateral relaxing incisions

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a

b

c

d

Fig. 7.69  The Von Langenbeck technique for moderate unilateral cleft palate. (a) Hard palate oral mucosa dissection (right). (b) Soft palate oral mucosa dissection (right). (c) Hard palate oral mucosa dissection (left). (d) Soft palate oral mucosa dissection (left)

The greater palatine pedicle must be released from the foramen as much as necessary to allow medial displacement of the mucoperiosteal flaps without tension. Care must be taken to avoid damage to the greater palatine vessels during these lateral dissections. (c) Nasal mucosa elevation and closure. Through the cleft margin, the mucous membrane is dissected from the nasal surface of the hard palate using a curve fine periosteal elevator. The extension of this dissection is in direct relation with the width of the cleft (Fig. 7.70). If these flaps are not enough for nasal mucosa closure, vomer flaps are required (Fig. 7.70). Using cautery a posteriorly based mucoperiosteal flap is elevated from the premaxilla. The anterior portion of the nasal mucosa is closed doing a posterior reflection of this flap from the premaxilla. The flap is elevated in the subperiosteal plane (Figs. 7.66 and 7.67).

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This method decreases the rate of anterior postoperative fistulas. Finally, the nasal mucosa closure can be completed without tension along the cleft using a vicryl 5/0 after uvular repair using the unilateral uvuloplasty. (d) Intravelar veloplasty (Fig. 7.71). The soft palate muscular repair is performed using a conservative intravelar veloplasty. The palatine aponeurosis is sectioned, and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved. Multiple interrupted 5/0 PDS sutures are used to approximate the muscles from both sides of the cleft. (e) Oral mucosa closure (Figs. 7.71 and 7.72). The cleft palate closure is completed repairing the oral mucosa without tension using simple interrupted vycril 5/0 sutures for this purpose. Control of bleeding is done through the lateral raw surfaces using cautery. (f) Uvular repair. The uvular repair is performed using the unilateral uvuloplasty. a

b

c

d

Fig. 7.70  The Von Langenbeck technique for moderate unilateral cleft palate. Nasal mucosa dissection. (a) Nasal mucosa dissection (right). (b) Nasal mucosa dissection (left). (c) Vomer flaps elevation. (d) Final nasal mucosa dissection

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a

b

c

d

e

f

Fig. 7.71  The non-radical intravelar technique for moderate bilateral cleft palate. (a) Nasal mucosa closure and muscular dissection (left side). (b) Muscular retroposition (left side). (c) Muscular dissection (right side). (d) Muscular retroposition (right side). (e) Non-radical intravelar veloplasty repair. (f) Final oral mucosa closure

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Fig. 7.72  The Von Langenbeck technique for moderate unilateral cleft palate

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7.4.4.3  The Severe Bilateral Cleft Palate Deformity It is defined as Veau IV cleft palate with a cleft palate index greater than 0.40 (Fig. 7.73). This type represents the most hypoplastic form of the cleft palates. Congenital hypoplasia is present in both sides and affects hard, soft tissues, and neurovascular bundles. Rate of complications like fistulas, velopharyngeal insufficiency, mucoperiosteal flaps necrosis, and maxillary hypoplasia are increased in this type of cleft palate [1, 9, 23, 24]. Based on these characteristics, a more individualized treatment is required to prevent these non-desirable outcomes. Bilateral bipedicled flaps and lateral relaxing incisions are recommended; however, the anterior segment of the cleft is extremely difficult and requires a strategy to achieve a complete closure of the cleft without tension. The surgical protocol used for severe bilateral cleft palate is: (a) Early use of presurgical orthopedics. Nasoalveolar molding may improve the premaxilla position and reduces the width of the cleft transforming a severe type into a moderate or mild type of cleft palate. Then, a Von Langenbeck technique can be used safely for cleft palate repair at 1 year of age. This is the best form of treatment for severe bilateral cleft palate however requires an early intervention (second week of life). (b) An alternative to the orthopedics is the primary surgery. Delayed hard palate closure in combination with bilateral lip adhesion is used before 6 months of age. This method modifies the severity of the cleft, improving the premaxilla position and reducing the width of the cleft. Hard palate closure can be achieved without tension using Von Langenbeck technique at 1 year of age. (c) If the patient arrives for surgery later than 6 months of age. After 6 months of age, the delayed hard palate closure doesn’t change the position of the cleft segments and its use at this time only makes more difficult the cleft palate closure increasing the risk of palatal fistulas. In this situation, the severe bilateral cleft palate is repaired using a hybrid palatoplasty. This strategy represents a combination of the strengths of the one- and two-stage protocols. This is the philosophy of the Lima Cleft Palate Surgical Protocol [13].

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Fig. 7.73  Severe bilateral cleft palate

Delayed Hard Palate Closure for Severe Bilateral Cleft Palate Repair This is a two-stage strategy for cleft palate repair. The first stage is a soft palate closure performed before 6 months of age (ideally 3–4 months) in combination with bilateral lip adhesion. The second stage is practiced at 1 year of age using the Von Langenbeck concept for hard palate closure. The objective of this method is the transformation of a wider cleft into a narrower cleft in order to facilitate its closure using a more conservative surgical technique. Based on the protocol proposed by the author (the Lima Protocol for cleft palate repair), the use of bipedicled flaps is recommended to prevent postoperative complications. First Stage Markings (Fig. 7.74): Starting in the hamulus region and from there anteriorly to the maxillary tuberosity. Then, a line is drawn along the border between the hard and soft palate. This line is then continuing 90 degrees posteriorly following the cleft

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359

margin to the base of the uvula. A triangular vomer flap is drawn posteriorly based as wide and long as required to repair the defect in the nasal mucosa. Surgical technique: Starting laterally the oral mucosa is incised along the drawn lines, and then using blunt and sharp dissection, the soft palate is elevated from the underlying muscular plane in both sides. The vomer flap is elevated subperiostally and turned posteriorly. The nasal mucosa is repaired starting with the uvular repair using the unilateral uvuloplasty technique. Then, the lateral mucosal flaps and the vomer flap are sutured together using 5/0 vycril mattress sutures. After suturing the nasal mucosa layer, the velar muscles are dissected and repaired. Muscular insertions to the hard palate and palatal aponeurosis are incised and separated preserving the tensor veli palatini tendon (non-radical intravelar veloplasty). Then, the muscles are dissected from the nasal mucosa and mobilized posteriorly to be finally sutured in the midline using two or three absorbable mattress sutures. The oral mucosa is finally performed and lateral raw surfaces are left without cover. The most anterior part of the oral mucosa flaps are sutured covering the raw surface of the vomer flap. Second Stage Markings: The design of the surgical incisions is done following the residual cleft margins to the anterior border of the hard palate as in Fig. 7.74. Relaxing incisions are designed in both sides of the palate. These incisions are located starting 1 cm posterior to maxillary tuberosity, then curves anteriorly where soft palate joins maxillary tuberosity and is carried forward at the junction between palatal mucous membrane and gingival mucous membrane to within 1 centimeter from the cleft. A transverse incision is designed along the incisors line of eruption and then continues posteriorly to create a posteriorly based premaxillary flap. Surgical technique (Figs.  7.75 and 7.76): A full thickness mucosal incision is performed following the residual cleft margins using a scalpel. The lateral relaxing incisions are practiced in both sides using cautery following the described surgical markings. Through medial and lateral incisions, the greater palatine pedicle is bilaterally dissected. The greater palatine pedicle must be released from the foramen as much as necessary to allow medial displacement of the mucoperiosteal flaps without tension. Through the residual cleft margin, the mucous membrane is dissected from the nasal surface of the hard palate using a curve fine periosteal elevator. The nasal mucosa closure can be completed using the lateral flaps and the premaxillary flap using a vicryl 5/0. The cleft palate closure is completed repairing the oral mucosa without tension using simple interrupted vycril 5/0 sutures for this purpose. Lateral raw surfaces are left without cover bilaterally. Control of bleeding is done through the lateral raw surfaces using cautery.

7  Cleft Palate Repair

360

a

b

c

Fig. 7.74  Delayed hard palate closure. (a) Surgical incisions for soft palate closure before 6  months of age. (b) Soft palate closure and cleft width reduction. (c) Final closure using Von Langenbeck concept

7.4 The Lima Cleft Palate Surgical Protocol

361

a

b

c

d

e

f

Fig. 7.75  Delayed hard palate closure technique for severe bilateral cleft palate repair. (a) Severe bilateral cleft palate. (b) Nasal mucosa repair using the soft palate and vomer flaps. (c–e) Non-­ radical intravelar veloplasty. (f) Oral mucosa closure of the soft palate repair

7  Cleft Palate Repair

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a

b

c

d

Fig. 7.76  Delayed hard palate closure technique for severe bilateral cleft palate repair. (a) Severe bilateral cleft palate. (b) Nasal mucosa repair using the soft palate and vomer flaps. (c) Soft palate repair after 8 months. (d) Final oral mucosa closure using Von Langenbeck principle

The Hybrid Palatoplasty for Severe Bilateral Cleft Palate Repair After 6 months of age, the chance of transforming a severe type into a moderate or mild type of cleft palate is minimal. Use of bipedicled flaps (based on Von Langenbeck concept) is not possible to be used in this type of cleft palate since the closure of the anterior portion of the cleft is difficult to be performed and the risk of anterior fistula is increased. This is the reason why the use of one monopedicled flap with more mobility is required to guarantee complete closure of the cleft palate.

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363

Markings: The design of the surgical incisions is done following the cleft margins to the anterior border of the hard palate as in Fig. 7.77. Relaxing incisions are designed in both sides of the palate. These incisions are located starting 1 cm posterior to maxillary tuberosity, then curves anteriorly where soft palate joins maxillary tuberosity and is carried forward at the junction between palatal mucous membrane and gingival mucous membrane to within 1 centimeter from the cleft (Fig. 7.77). In one side, medial and lateral incisions are connected to design a monopedicled flap. The uvular repair is designed using the unilateral uvuloplasty method. Surgical procedure: This is the sequence of the hybrid palatoplasty for severe bilateral cleft palate. (a) Medial surgical incisions and hemi-uvular excision (Fig. 7.78). A full thickness mucosal incision is performed following the cleft margins using a scalpel No 7 with a 15 blade or 12 C. These incisions are practiced starting at the base of the uvula and finishing anteriorly. The relaxing incision is practiced in both sides using cautery following the described surgical markings. One hemi-uvula (the smaller one) is excised according to the unilateral uvuloplasty technique. (b) Oral mucosal elevation (Figs. 7.79 and 7.80). At the level of the hard palate, the oral mucosa is elevated in the subperiosteal plane. This dissection is performed through the medial and lateral incisions connecting them. A combination of sharp and blunt dissection is practiced gently between the oral mucosa and the underlying muscular plane of the soft palate in both sides. The greater palatine pedicle is bilaterally dissected. Through the relaxing incisions, under direct vision and using a fine elevator, the greater palatine vascular bundle is carefully stretched from the foramen (Fig. 7.80) The greater palatine pedicle must be released from the foramen as much as necessary to allow medial displacement of the mucoperiosteal flaps without tension.

364

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a

b

c

d

Fig. 7.77  The hybrid palatoplasty for severe bilateral cleft palate repair. (a) Surgical markings. Cleft marginal and lateral relaxing incisions. Premaxilla and vomer incisions. (b) Unilateral uvuloplasty and nasal mucosa and premaxila flaps elevation. Muscular release. (c) Nasal mucosa closure using premaxilla and vomer flaps. Monopedicled flap elevation at the left side and non-radical intravelar veloplasty. (d) Oral mucosa closure

7.4 The Lima Cleft Palate Surgical Protocol

365

a

b

c

d

Fig. 7.78  The hybrid palatoplasty for severe bilateral cleft palate. Oral mucosa incision and premaxillary flap elevation. (a) Severe bilateral cleft palate. (b) Left uvular excision and right preserved uvula based on unilateral uvuloplasty technique. Cleft and non-cleft side margin incisions. (c) Premaxillary mucoperiosteal flap for anterior nasal mucosa closure. (d) Closer view of the premaxillary flap

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366

a

b

c

d

Fig. 7.79  Use of premaxillary flap for nasal mucosa repair without vomer flaps during hybrid palatoplasty for severe bilateral cleft palate. (a) Severe bilateral cleft palate. (b, c) Nasal mucosa repair using premaxillary flap and nasal mucosa flaps. (d) Final oral mucosa closure using the hybrid palatoplasty. 1. Premaxillary flaps. 2. Nasal mucosa flaps. 3. Velar muscles. 4. Mucoperiosteal flaps

7.4 The Lima Cleft Palate Surgical Protocol

367

a

b

c

d

e

f

Fig. 7.80  The hybrid palatoplasty for severe bilateral cleft palate. (a, b) Nasal mucosa closure using vomer flaps and premaxillary flap. (c) Right monopedicled mucoperiosteal flap elevation. (d) Left bipedicled mucoperiosteal flap elevation. (e) Severe bilateral cleft palate (preoperative view). (f) Severe bilateral cleft palate (postoperative view)

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(c) Nasal mucosa elevation and closure. At the medial border of the cleft, the nasal mucosa is elevated from the nasal surface of the hard palate using a fine curved periosteal elevator. The extension of this dissection depends on the width of the cleft palate. If these flaps are not enough for nasal mucosa closure, vomer flaps can be used (Fig. 7.80). Using cautery, a posteriorly based mucoperiosteal flap is elevated from the premaxilla (Fig. 7.79). The anterior portion of the nasal mucosa is closed doing a posterior reflection of this flap from the premaxilla and sutured to the vomer (if necessary) and nasal mucosa flaps. Finally, the nasal mucosa closure can be completed without tension along the cleft using a vicryl 5/0 after uvular repair using the unilateral uvuloplasty. (d) Intravelar veloplasty (Fig. 7.79). The soft palate muscular repair is performed using a conservative intravelar veloplasty. The palatine aponeurosis is sectioned, and laterally, the tendon of the tensor veli palatini muscle (attached to the hamulus) is preserved. Multiple interrupted 5/0 PDS sutures are used to approximate the muscles from both sides of the cleft. (e) Oral mucosa closure (Figs. 7.79, 7.80, and 7.81). The cleft palate closure is completed repairing the oral mucosa without tension using simple interrupted vycril 5/0 sutures for this purpose. Control of bleeding is done through the lateral raw surfaces using cautery. (f) Uvular repair. The uvular repair is performed using the unilateral uvuloplasty.

7.4 The Lima Cleft Palate Surgical Protocol

Fig. 7.81  The hybrid palatoplasty for severe bilateral cleft palate

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7.5  Use of Buccal Fat Pad in Primary Cleft Palate Repair The use of buccal fat pad in cleft palate repair has been reported previously [25]. It has been used for secondary cleft palate repair (fistula closure) and to cover lateral raw surfaces [26]. Its utilization is recommended for secondary repair of the cleft palate as a very value resource. I think cleft surgeons will find this method useful for challenging cleft palates and palatal fistula repair. Use of buccal fat pad during primary closure of cleft palate is indicated when the nasal mucosa is not well repaired or deficient midline closure, leaving in higher risk of fistula development. This well vascularized tissue is a reinforcement of the nasal mucosa preventing the development of palatal fistulas. Surgical procedure (Figs. 7.82 and 7.83): Once a defect in nasal mucosa closure is detected, a curved fine scissors is placed in the superior buccal sulcus just lateral to the maxillary tuberosity and introduced through the mucosa with smooth and slow movements until the spontaneous extrusion of the buccal fat pad is observed. Then, using a small forceps, the fat flap is extracted preserving its very fine capsule and vessels. Preservation of these structures is essential for buccal fat pad survival. Special attention should be taken during this procedure since important structures are located close to the buccal fat pad as: buccal branch of facial nerve, facial vein, and Stensen duct. Once released the flap can be mobilized to the defect of the nasal mucosa and be used as an added layer preventing the development of fistulas. Finally, the buccal fat pad can be fixed on this new position used a few non-­ absorbable stitches. Exposed areas of buccal fat pad are fully mucosalized within 2 weeks.

7.3 Presurgical Considerations

371

a

b

c

d

Fig. 7.82  Buccal fat pad flap dissection. (a) Lateral incision and greater palatine pedicle dissection. (b) Dissection through superior buccal sulcus to identify the buccal fat pad. (c) Identification of the buccal fat pad. (d) Extrusion of the buccal fat pad using fine forceps with slow and smooth movements

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a

b

c

d

Fig. 7.83  Use of buccal fat pad during primary cleft palate repair. (a) Severe unilateral cleft palate. (b) Greater palatine pedicle dissection at the non-cleft side. (c) Buccal fat pad flap transposition below greater palatine pedicle for nasal mucosa defect repair. (d) Final closure using the hybrid palatoplasty. 1. Mucoperiosteal flap. 2. Greater palatine pedicle. 3. Maxillary tuberosity. 4. Greater palatine foramen. 5. Soft palate. 6. Buccal fat pad flap. 7. Nasal mucosa closure using vomer flap. 8. Cleft side

7.6  Muscular Reconstruction: The Non-radical Intravelar Veloplasty Importance of the muscular repair during primary cleft palate repair has been highlighted by authors like Veau, Braithwhite, and Kriens. Importance of the levator palatini muscle retroposition has been noticed by these authors without detailed description of the extent of muscular displacement or lateral dissection. Extended lateral dissection has been popularized actually as radical intravelar veloplasty by authors as Sommerlad [27]. This author presents his technique for radical muscular repair based on case series methodology; therefore, its effectiveness wasn’t proven. This technique is based on muscular release from hard palate abnormal insertion, palatine aponeurosis and tensor veli palatine transection, and radical muscular

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retroposition for velopharyngeal sphincter reconstruction. Furlow technique, another popular method of muscular repair in patients with cleft palate, is based on a similar concept since this surgical technique uses a radical retroposition with lateral dissection of the ligament attachments [18]. Main function of the tensor veli palatini system is the Eustachian tube opening upon swallowing or yawing and a tensor of the soft palate. Therefore, audition and middle ear dysfunction should be evaluated after transection of the tendon of the tensor veli palatini muscle. An increased rate of otitis media, hearing loss, and need for myringotomy tubes may be expected. Most of the published studies evaluate the radical intravelar veloplasty through speech and hypernasality [1, 18, 27, 28]. Court Cutting from New  York University described a more conservative procedure doing a tensor tendon release and tenopexy to the hamulus in order to prevent the potential non-desirable effect over Eustachian tube function using the radical method [28]. Difference between these methods was not well studied and role of non-radical surgery over hearing function and middle ear ventilation remains unclear. These techniques reported the better speech outcomes (less than 5% of hypernasality). The non-radical intravelar veloplasty is based on muscular release with transection of the palatine aponeurosis and preservation of the tendon of the tensor veli palatini muscle. A more conservative method is used by the author preserving the muscular action associated to middle ear and hearing function. The non-radical intravelar veloplasty is based on: (a) Velar muscles dissection and release from hard palate. (b) Palatal aponeurosis transection. (c) Preservation of the tensor veli palatini tendon attachment to the hamulus. (d) Muscular (levator veli palatini and palatopharyngeus muscle) retroposition. A comparative study between these three techniques, published by Flores et al., concluded that the preservation of tensor tendon attachment decreases the need for myringotomy tubes [29]. Surgical procedure (Figs. 7.84, 7.85, 7.86, 7.87, 7.88, and 7.89) The non-radical intravelar veloplasty muscular repair starts doing the nasal layer closure. Suturing the nasal layer before makes the muscular dissection easier as recommended by Sommerlad. Muscular structures can be identified attached to the nasal mucosa after carefully oral mucosa dissection and elevation. Muscles are separated from the nasal mucosa around 3 mm from the line of nasal layer sutures using fine scissors. This dissection separates the velar muscles from the nasal mucosa (blue in color). The levator veli palatini, palatopharyngeous muscles, and palatal aponeurosis are divided and dissected from the nasal mucosa. The medial extension of the tensor veli palatini tendon is transected to facilitate its repair. This dissection ends laterally at the medial border of the hamulus preserving the insertion of the tendon of the tensor muscle. This modification differences the non-radical from the radical procedure. The integrity of the muscular-tendinous tensor system may prevent middle ear ventilation and hearing function disturbance. Finally, the velar muscles (including the levator, palatopharyngeous, palatoglossus, and uvular muscles) are separated from nasal mucosa through blunt dissection. This maneuver facilitates the muscular retroposition. Using 5/0 non-absorbable sutures, the muscles and divided aponeurosis from each side are sutured together and to the nasal mucosa.

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Fig. 7.84  Abnormal insertion of the velar muscles in a cleft palate patient. 1. Hard palate. 2. Palatine process of maxilla. 3. Palatal aponeurosis. 4. Greater palatine artery. 5.  Tendon of the tensor veli palatini. 6. Hamulus. 7.  Tensor veli palatini muscle. 8. Levator veli palatini. 9. Palatopharyngeous and palatoglossus muscles. 10. Uvularis muscle

7.6 Muscular Reconstruction: The Non-radical Intravelar Veloplasty

375

Fig. 7.85  Muscular reposition after non-radical intravelar veloplasty. 1. Hard palate. 2. Nasal mucosa closure. 3. Palatal aponeurosis. 4. Greater palatine artery. 5. Tendon of the tensor veli palatini. 6. Hamulus. 7. Tensor veli palatini muscle. 8. Levator veli palatini. 9. Palatopharyngeous and palatoglossus muscles. 10. Uvularis muscle

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7  Cleft Palate Repair

a

b

c

d

e

f

Fig. 7.86  The non-radical intravelar veloplasty technique for muscular cleft palate repair. (a) Nasal mucosal closure during primary unilateral cleft palate repair using the one-flap technique. 1. Nasal mucosa. 2. Velar muscles. 3. Oral mucosa. 4. Mucoperiosteal flap. 5. Unilateral uvuloplasty. (b) Noncleft side muscular dissection. 1. Palatine bone. 2. Greater palatine foramen. 3. Greater palatine artery. 4. Palatine aponeurosis. 5. Velar muscles. 6. Oral mucosa. (c) Non-cleft side velar muscles elevation. 1. Nasal mucosa. 2. Greater palatine foramen. 3. Greater palatine artery. 4. Palatine aponeurosis. 5. Velar muscles. 6. Levator veli palatini. 7. Palatopharyngeous muscle. 8. Nasal mucosa. 9. Oral mucosa. 10. Unilateral uvuloplasty. (d) Non-cleft side muscular dissection. 1. Velar muscles elevation. 2. Oral mucosa. 3. Unilateral uvuloplasty. (e) Non-cleft side muscular elevation. 1. Nasal mucosa. 2. Velar muscles elevation. 3. Oral mucosa. 4. Unilateral uvuloplasty. (f) Final muscular repair using the nonradical intravelar veloplasty. 1. Nasal mucosa. 2. Oral mucosa. 3. Greater palatine artery. 4. Mucoperiosteal flap. 5. Muscular repair

7.6 Muscular Reconstruction: The Non-radical Intravelar Veloplasty

a

377

b

d c

Fig. 7.87  The non-radical intravelar veloplasty technique for muscular cleft palate repair. (a, b) Non-cleft side muscular dissection. 1. Palatine bone. 2. Greater palatine foramen. 3. Greater palatine artery. 4. Palatine aponeurosis. 5. Velar muscles. 6. Oral mucosa. a. Palatopharyngeous muscle. b. Levator veli palatini. c. Tendon of the tensor veli palatini. d. Palatoglossus muscle. e. Uvularis muscle. (c) Non-cleft side velar muscles elevation. 1. Nasal mucosa. 2. Palatine bone. 3. Greater palatine artery. 4. Palatine aponeurosis. 5. Tendon of the tensor veli palatini. 6. Levator veli palatini. 7. Palatopharyngeous muscle. 8. Nasal mucosa. 9. Oral mucosa. 10. Unilateral uvuloplasty. (d) 1. Nasal mucosa. 2. Palatine bone. 3. Greater palatine artery. 4. Hamulus. 5. Tendon of the tensor veli palatini. 6. Levator veli palatini. 7. Palatopharyngeous muscle. 8. Uvularis muscle. 9. Palatine aponeurosis

7  Cleft Palate Repair

378

a

b

c

d

Fig. 7.88  The non-radical intravelar veloplasty for primary unilateral cleft palate repair. (a) Moderate unilateral cleft palate. (b) Mucoperiosteal flap elevation and nasal mucosa closure. 1. Nasal mucosa closure. 2. Cleft side oral mucosa. 3. Mucoperiosteal flap. 4. Non-cleft side oral mucosa. 5. Velar muscles. 6. Unilateral uvuloplasty. 7. Palatine process of the maxilla. 8. Palatial spine. 9. Posterior nasal spine. 10. Palatine bone. 11. Greater palatine foramen. X: Greater palatine artery. (c) Muscular retroposition and repair. 1. Nasal mucosa closure. 2. Cleft side oral mucosa. 3. Mucoperiosteal flap. 4. Non-cleft side oral mucosa. 5. Velar muscles. 6. Unilateral uvuloplasty. 7. Palatine process of the maxilla. 8. Palatial spine. 9. Posterior nasal spine. 10. Palatine bone. 11. Greater palatine foramen. X: Greater palatine artery. (d) Final closure using the one flap palatoplasty

7.6 Muscular Reconstruction: The Non-radical Intravelar Veloplasty

a

b

c

d

379

Fig. 7.89  The non-radical intravelar veloplasty for primary bilateral cleft palate repair. (a) Severe bilateral cleft palate. (b) 1. Nasal mucosa closure. 2. Oral mucosa. 3. Soft palate. 4. Velar muscles. 5. Unilateral uvuloplasty. (c) Muscular retroposition using the non-radical intravelar veloplasty. 1. Nasal mucosa closure. 2. Oral mucosa. 3. Soft palate. 4. Repaired velar muscles. 5. Unilateral uvuloplasty. (d) Final closure using the hybrid palatoplasty

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7  Cleft Palate Repair

7.7  Uvular Repair: The Unilateral Uvuloplasty Surgical repair of the uvular component of the cleft palate was not well studied. Conventional repair of the uvula using a straight line closure between the two hemi uvulas is the most common type of uvuloplasty around the world. My personal experience doing cleft palate repair during the last 25  years let me observe non-­ desirable outcomes using this method. Bifid uvulas, retractions, and absence of this segment have been observed after using the conventional method during my first 10 years. The unilateral uvuloplasty is an innovative technique but not invented by me. The technique is based on preservation of the larger hemi-uvula and excised the other one. Carlos Navarro in Perú described a similar method before for uvular repair during primary cleft palate repair [14]. After different studies and personal modification, I have concluded that this is a good technique which let me obtain better cosmetic and functional uvular repairs. A randomized clinical trial performed by us observed better aesthetic outcomes using the unilateral uvuloplasty versus conventional method [15]. Additionally, the mobilization of the preserved uvula reduces the velopharyngeal space improving its function [16]. Velar function is improved in this technique because of three mechanisms: (a) Intravelar veloplasty muscle reposition (b) Velopharyngeal space reduction (c) Lengthening of the soft palate using a unilimb Z plasty Markings: The design of the surgical incisions is done following the cleft margins to the anterior border of the hard palate as in Fig. 7.90. One of the hemi uvulas is selected to be removed (usually the smaller one). The area of uvular tissue should be extended laterally until the medial junction of the anterior and posterior tonsillar pillars in order to prevent the lateralization of the repaired uvula (a common mistake observed using the original technique). The line of incision at the preserved uvula is a transverse line at the base of the uvula (1 cm of length). This line is extended turning 90 degrees with the cleft margin incision. Surgical procedure (Figs. 7.91, 7.92, and 7.93: The preserved uvula is selected and a mucosal incision is made along the cleft margin and extended up to the base of this hemi-uvula. Then, the incision is turned 90 degrees for 1 cm and includes only oral mucosa preserving the uvularis muscle. The uvular tissue excision is performed at the base of the smaller uvula and should be extended laterally to the junction between the soft palate and the top of tonsillar pillars. Nasal and oral mucosa are carefully repaired with non-absorbable 5–0 sutures and a unilimb Z plasty is performed in which a triangle of mucosa from the excised side is placed over the preserved uvula providing additional length and preventing scar retraction of the repaired soft palate.

7.7 Uvular Repair: The Unilateral Uvuloplasty

a

381

b

c

Fig. 7.90  The unilateral uvuloplasty. (a) Surgical design. (b) Mucosal flaps elevation and line of excision (dotted line). (c) Oral mucosa line of closure (unilimb Z plasty)

7  Cleft Palate Repair

382

a

b

c

d

e

f

Fig. 7.91  The unilateral uvuloplasty for uvular cleft palate repair. (a) Preoperative view. (b) Uvular excision. (c) Incision at the base of the preserved uvula. (d) Nasal mucosa excision (Fig. 7.88b). (e) Nasal mucosa closure. (f) Oral mucosa closure using unilimb Z plasty

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Fig. 7.92  Preoperatory view of complete bilateral cleft palate (left) Postoperatory view of the repaired uvula using the unilateral uvuloplasty. (right)

Fig. 7.93  Preoperatory view of complete unilateral cleft palate (left) Postoperatory view of the repaired uvula using the unilateral uvuloplasty. (right)

7.8  Postoperative Care Postoperative care is provided according to the short- and long-term moments. (a) Immediate postoperative care (first 24  hours). Monitoring. Post-anesthetic observations are an important requirement for patient assessment after primary cleft palate repair. Continuous cardio-respiratory and pulse oximetry monitoring at PACU (Post Anesthesia Care Unit) is mandatory. When the baby’s vital signs are stable, then he will be moved to regular patient room if hospitalization is indicated. In my hospital, hospitalization of patients is indicated for all cleft palate repair during 1 day. Some bleeding is frequent after cleft palate repair in special if the patient is crying. There may be bloody fluid draining from the nose and mouth decreasing during the first day. Tongue stitch (commonly used to facilitate reintubation if necessary) is not used in our practice. Surgical hemostasis is required depending on amount and persistence of the bleeding and

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associated changes in vital signs. Reintubation and surgical revision of hemostasis is urgently necessary in this situation. Nasal packing using a Foley balloon is a safe and effective method for postoperative bleeding control after palatoplasty in patients with cleft palate [30]. This could be used to avoid surgical revision under general anesthesia. Hyperthermia during the first day of surgery is frequently observed, and it is associated to physiological mechanisms and not to surgical infection. Its presence is not an indication for hospital admission. Medical discharge criteria: Stable vital signs, oral feeding restored and surgical wound without active bleeding. Feeding. Feeding is initiated with saline solution IV administration and oral feeding is initiated 2 or 3 hours after the surgery using a small spoon. Breast-feeding or bottle may be initiated the day after the surgery. Pain management. Multi modal pain management is actually recommended for pain management. Acetaminophen is usually sufficient for pain control during few days. Agitation control. Sedation may be necessary in selected patients. Use of benzodiazepines is indicated when the pain is not successfully controlled and the baby is still crying. Special attention must be considered if there is some bleeding because of the risk of aspiration of a sedated patient. Wound care. Palate wound doesn’t require to be manipulated for cleaning. Parents would rinse the child’s mouth with cooled boiled water after feeding. Absorbable sutures don’t require to be removed. They will start to dissolve in 7–10 days. Arm splints are not necessary. Medical indications: Oral feeding including diet according to patient’s age. Prophylactic antibiotics and analgesics conditional to pain. (b) Short term (first week to first month). Feeding. Oral feeding should be supervised by a pediatrician to guarantee its restoration. Wound care. Wound cleaning is not necessary and drink of water is enough to maintain the palate wound in proper condition. Dental evaluation. Pediatric dentist evaluation would be recommended to evaluate dental status and provide information about prophylaxis. Antibiotics and analgesics. Prophylactic antibiotic is used orally during 5 days. Analgesics are conditioned to pain. Persistent manifestation of crying or discomfort should be evaluated by a pediatrician as a probability of associated disease. (c) Middle term (6 months to 5 years). Speech therapy. This time is essential for speech stimulation provided by a speech therapist. Physical exam and nasoendoscopy is indicated around 5 years of age to determine the development of velopharyngeal insufficiency. Velopharyngeal insufficiency treatment. Treatment modality for velopharyngeal insufficiency is establish according to the physical exam and nasoendoscopy findings. Surgical and non-surgical methods are effective to correct hypernasality in combination with speech therapy at this age. Maxilofacial development. Protraction mask may be used if early maxillary hypoplasia is detected during the mixed dentition period. (d) Long term (5 years to skeletal maturity time). Dental occlusion evaluation. Physical exam, cephalometric study, and occlusal models are required to determine if any occlusal disorder is developed in the patient. Combination of orthodontics and orthognatic surgery may be necessary to correct occlusal problems.

7.7 Uvular Repair: The Unilateral Uvuloplasty

7.9  Case Studies Case 1 Case 2

Fig. 7.94  Diagnostic: mild incomplete cleft palate (repaired using Furlow technique)

Fig. 7.95  Diagnostic: moderate incomplete cleft palate (repaired using hybrid technique)

385

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7  Cleft Palate Repair

Case 3 Case 4

Fig. 7.96  Diagnostic: severe incomplete cleft palate (repaired using Von Langenbeck)

Fig. 7.97  Diagnostic: mild bilateral cleft palate. Repaired using a hybrid technique

7.7 Uvular Repair: The Unilateral Uvuloplasty

387

Case 5

Fig. 7.98  Diagnostic: moderate bilateral cleft palate. Repaired using the Von Langenbeck technique

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7  Cleft Palate Repair

Case 6

Fig. 7.99  Diagnostic: severe bilateral cleft palate. Repaired using a hybrid technique

7.7 Uvular Repair: The Unilateral Uvuloplasty

389

Case 7

Fig. 7.100  Diagnostic: left mild unilateral cleft palate. Repaired using a hybrid technique. Dental occlusion at 3 years of age

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7  Cleft Palate Repair

Case 8

Fig. 7.101  Diagnostic: right moderate unilateral cleft palate. Repaired using the one-flap palatoplasty. Dental occlusion at 3 years of age

7.7 Uvular Repair: The Unilateral Uvuloplasty

391

Case 9

Fig. 7.102  Diagnostic: left severe unilateral cleft palate. Repaired using a hybrid palatoplasty. Dental occlusion at 3 years of age

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Case 10

Fig. 7.103  Diagnostic: left severe unilateral cleft palate. Dental occlusion observed during mixed dentition period

References

393

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23. Yuan N, Dorafshar A, Follmar K, Pendleton C, et al. Effects of cleft width and Veau type on incidence of palatal fistula and velopharyngeal insufficiency after cleft palate repair. Ann Plast Surg. 2016;76(4):406–10. 24. Lam D, Chiu L, Sie K, Perkins J. Impact of cleft width in clefts of secondary palate on the risk of velopharyngeal insufficiency. Arch Facial Plast Surg. 2012;14(5):360–4. 25. Adeyemo W, Ibikunle A, Jame O, Taiwo O. Buccal fat pad: a useful adjunct flap in cleft palate repair. J Maxillofac Oral Surg. 2019;18(1):40–5. 26. Ladani P, Sailer H.  Application of buccal fat pad for lining of lateral defect in cleft palate repair. J Cleft Lip Palate Craniofac Anomal. 2016;3(2):63–6. 27. Sommerlad B. A technique for cleft palate repair. Plast Reconstr Surg. 2003;112:1542–8. 28. Cutting C, Rosenbaum J, Rovati L. The technique of muscle repair in the cleft soft palate. Oper Tech Plast Reconstr Surg. 1995;2(4):215–22. 29. Flores R, Jones B, Bernstein J, Karnell M, et al. Tensor veli palatini preservation, transection and transection with tensor tenopexy during cleft palate repair and its effects on Eustachian tube function. Plast Reconstr Surg J. 2010;125(1):282–9. 30. Rossell-Perry P, Schneider WJ, Gavino-Gutierrez AM. A comparative study to evaluate a simple method for the management of postoperative bleeding following palatoplasty. Arch Plast Surg. 2013;40(3):263–6.

Index

A Alveolar bone deficiency, 61 Alveolar cleft closure bilateral cleft lip, 267–269 unilateral cleft lip, 150–153 Alveolar bone graft bilateral cleft lip, 269, 270 unilateral cleft lip, 152–154 Anatomy soft palate, 18 arterial supply, 21–25 muscles, 20, 21 upper lip and nose, 1 arterial supply, 9, 15–17 muscles, 12–14 B Bilateral cleft lip asymmetrical cleft lip, 178 classification, 179 microform cleft side closure of mucosa, 222, 224 columellar base flap, 217–219 labial nasal advancement flap, 217 mucosa dissection, 221 mucosa resection, 220–222 muscular dissection, 221, 223 skin closure, 222, 226, 227 skin flap elevation, 220, 221 skin resection, 220–222 surgical incision, 219, 220 upper lip muscles, 222, 225 vermillion resection, 220–222 mild cleft lip, 272, 273 columellar base flaps, 184, 185

complete deformity, 181, 183 incomplete deformity, 181, 182 labial sulcus repair, 192 labionasal advancement flaps, 184 mild bilateral cleft lip, 183 minimal cleft lip asymmetry, 182 mucosal flaps, 191 muscular dissection, 191–193 muscular repair, 195 oral mucosa repair, 194 oral mucosa view, 193 prolabial skin resection, 188, 189 prolabium flaps, 183, 184 skin closure, 194, 196–198 skin flap elevation, 189–191 subnasal skin excision, 186 surgical incision, 182, 184–189 vermillion flap, 184, 185 moderate cleft lip, 273, 274 columellar base flaps, 205 complete deformity, 194, 195, 199, 201 incomplete deformity, 194, 195, 199, 200 labionasal advancement flaps, 204 lateral segment skin resection, 206, 207 mucosal flaps, 207, 208, 210–212 muscular dissection and repair, 208–210, 213 prolabium flaps, 198, 206, 207 skin closure, 209, 214–216 skin flap elevation, 207–209 subnasal skin excision, 205 surgical incision, 195, 202–206 vermillion flap, 204 presurgical orthopedics, 163, 164 primary cleft lip, 189, 190

© Springer Nature Switzerland AG 2020 P. Rossell-Perry, Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair, https://doi.org/10.1007/978-3-030-44681-9

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396 Bilateral cleft lip (cont.) primary repair, 165, 166 reconstruction of, 181 severe alveolar component, 168–170 severe cleft lip, 275 closure of mucosa, 242–245 columellar base flaps, 228 complete cleft side, 233–235, 238 deformity, 222, 228, 229, 233, 239 labionasal advancement flaps, 225, 227 microform cleft side, 238, 240, 241 mucosa dissection, 242 mucosal flaps elevation and repair, 231, 232, 234 mucosa resection, 239, 240, 242 muscular dissection, 232, 235, 242 muscular repair, 232, 235 preoperatory view, 271, 272 prolabial skin, 230 prolabium flaps, 223–225 skin closure, 232, 236, 237, 243, 247, 248 skin flap elevation, 230–233, 241, 242 skin resection, 230, 239, 240, 242 surgical incision, 223, 228–231, 239 upper lip muscles, 243, 246 vermillion flap, 227 vermillion resection, 239, 240, 242 surgical lip adhesion alar flaps, 171–173 anatomical landmarks, 169, 170 columellar base flap, 171, 173 lateral flaps, 171–173 lip adhesion closure, 173–177 lip landmarks, 172 muscular dissection, 173, 174 oral mucosa, 172, 173 prolabium flaps, 170, 171, 173 surgical incision, 173 surgical premaxillary setback, 174, 175, 178–180 surgical technique degree of deformity, 166 degree of severity, 166 Noordhoff´s modifications, 166 presurgical, 166–168 types, 180 Bilateral cleft nose components, 248, 249 mild forms alar cartilage reposition and repair, 252, 253 bilateral nasal packing, 252 limen nassi, 251 nasal columella, 251 tissue deficiency, 249, 250

Index transcutaneous interdomal suture, 252 moderate form with complete clefts, 253, 254 V-Y-Z technique, 254–257 nasal stitches, 262–265 severe form bilateral V-Y-Z plus skin excision, 258–262 with complete clefts, 258 skeletal reconstruction alveolar bone graft, 269, 270 alveolar cleft closure, 267–269 maxillary arch alignment, 266, 267 panoramic radiograph, 265, 266 primary autologous bone graft, 265 Buccal fat pad muscular reconstruction, 372–379 reinforcement, 370 surgical procedure, 370–372 uvular repair, 380–383 C Cleft lip and palate classification cleft code, 44 clock diagram, 43 nose deformity bilateral cleft lips, 31, 33, 34 unilateral cleft lips, 31–33 primary palate bilateral cleft lips, 34, 35, 38, 39 unilateral cleft lips, 34–37 secondary palate bilateral cleft lips, 35, 42 incomplete cleft palate, 38–40 unilateral cleft lips, 35, 36, 40, 41 severity, 27 upper lip bilateral cleft lips, 29, 30 unilateral cleft lips, 27, 28, 30 Cleft nose alar cartilage reposition, 126 components, 124, 129 mild unilateral cleft lip incomplete cleft lip nose repair, 137 minimal tissue deficiency, 128, 130 rotational composite flap elevation, 132–134 rotational composite flap incisions, 129–131 transcutaneous sutures, 132, 133, 135 moderate and severe forms, 134, 137, 138 alar cartilage position, 139 complete nose repair, 144 composite V–Y–Z technique, 135, 139–143

Index lateral Z plasty incisions, 135, 139, 141 right cleft lip, 159, 160 surgical nasal molding concept, 144 transcutaneous stitches, 138, 140 transdomal sutures, 142, 143 nasal floor reconstruction, 126 nasal septum correction, 126, 127 postoperative care, 155, 156 presurgical orthopedics, 125 skeletal reconstruction, 148 alveolar bone graft, 152–154 alveolar cleft closure, 150–153 bone reconstruction, 148–150 maxillary arch alignment, 148, 149 V–Y–Z technique nasal floor reconstruction, 146, 147 nasal stitches, 141, 143, 145 Cleft palate index, 35 Cleft palate repair delayed hard palate closure, 278, 279 delayed soft palate closure, 278 Lima protocol (see Lima cleft palate surgical protocol) postoperative care, 383, 384 primary cleft palate repair, 277 surgical technique, 279–282 Columellar base flaps, 184, 185 D Delayed hard palate closure, 278, 279 Delayed soft palate closure, 278 F Furlow’s technique, 53, 60, 286 mucosal flaps, 283–286 muscular repair, 287–290 myomucosal flaps, 284, 285, 287 surgical incisions and tissue excision, 286 G Gingivoperiosteoplasty (GPP), 52, 148 Gothenburg’s protocol, 278, 279 H Hybrid palsatoplasty mild bilateral cleft palate, 339 mild unilateral cleft palate, 313, 314 moderate incomplete cleft palate, 299–302 severe bilateral cleft palate, 357, 358 severe unilateral cleft palate (see Severe unilateral cleft palate)

397 I Incomplete bilateral cleft lip, 184 advancement flap, 184 columellar base flap, 185 muscular dissection, 193 skin closure, 194 skin, vermillion, and mucosal resection, 188, 189 surgical procedure, 187 Incomplete cleft palate, 289 mild incomplete cleft palate, 290 moderate incomplete cleft palate, 299 severe incomplete cleft palate, 305 Incomplete unilateral cleft lip, 86 advancement flap, 87 closure of mucosa, 92–94 columellar base flap, 88 mucosa dissection, 92 muscular dissection, 91–93 nose deformity, 85–87 skin closure, 95, 97, 98 skin flap elevation, 90, 91 skin, vermillion, and mucosal resection, 89–91 surgical incisions, 85, 89 upper lip muscles, 93–97 L Labionasal advancement flaps, 184 Lima cleft palate surgical protocol, 59 Lip adhesion, 169–171 M Microform unilateral cleft lip, 77, 79 closure of mucosa, 81 markings and measurements, 78 minimal tissue deficiency, 75, 77 muscular dissection, 80, 81 skin closure, 83–85 skin flap elevation, 79, 80 skin, vermillion, and mucosal resection, 79, 80 surgical incision, 79 upper lip muscles, 82, 83 Mild bilateral cleft palate diagnosis, 386 intravelar veloplasty, 344, 345 lateral relaxing incision, 339 medial surgical incisions and hemi-uvular excision, 339 nasal mucosa elevation and closure, 344 oral mucosa closure, 345, 346 oral mucosal elevation, 339, 343 unilateral uvuloplasty method, 339 uvular repair, 345

Index

398 Mild incomplete cleft palate closure, 296 mucosa flaps, 291–296 muscular repair, 295, 296 myomucosal flaps, 292, 295, 296 surgical incisions and hemi-uvular excision, 293 surgical procedure, 296, 298, 299 uvular repair, 294, 296 Mild unilateral cleft palate cleft palate index, 313 diagnosis, 389 intravelar veloplasty, 318 lateral relaxing incision, 316 medial surgical incisions and hemi-uvular excision, 314, 315 nasal mucosa elevation and closure, 317 oral mucosa closure, 317, 319, 320 oral mucosal elevation, 316, 317 palatoplasty, 313, 314 uvular repair, 319 Moderate bilateral cleft palate bipedicled flaps, 346 diagnosis, 387 intravelar veloplasty, 354 lateral relaxing incisions, 347, 349 medial surgical incisions and hemi-uvular excision, 347, 352 nasal mucosa elevation and closure, 353, 354 oral mucosa closure, 354–356 oral mucosal elevation, 347, 353 transverse incision, 347, 351 uvular repair, 354 Moderate incomplete cleft palate closure, 305, 306 diagnosis, 385 lateral relaxing incision, 300 mucosa flap, 300, 302, 303, 305 muscular repair, 304, 305 myomucosal flap, 300, 303, 305 surgical incisions and hemi-uvular excision, 300–303 uvular repair, 305 Moderate unilateral cleft palate diagnosis, 390 intravelar veloplasty, 326 monopedicled mucoperiosteal flap, 321 nasal mucosa elevation and closure, 325, 326

oral mucosa closure, 327–329 oral mucosal elevation, 324, 325 surgical incisions and hemi-uvular excision, 322, 323 uvular repair, 327 Millard principle, 165 Mucosal flaps, 283–286, 291–296, 300, 302 Myomucosal flaps, 284, 285, 287, 292, 295, 296, 300, 303 N Nasal vestibule, 7, 11, 12 Nasoalveolar molding (NAM), 126 Non-radical intravelar veloplasty technique, 372–379 Noordhoff’s technique, 52 O Orthognatic surgery, 61 Oslo’s protocol, 278 P Pool’s concepts, 85 Preoperative evaluation analysis, 63 anesthesia evaluation, 64 chest X-ray, 63 cleft lip instrumental set, 64, 65 cleft palate instrumental set, 64, 66 forced air warming system, 66, 67 illumination, 67, 68 magnification, 68, 69 pediatric head positioning device, 67 surgical loupes, 64 Primary cheilorhinoplasty, 48, 49 bilateral cleft lip, 50–52 GPP, 52 unilateral cleft lip, 48, 49, 51, 52 Primary palatoplasty bilateral cleft palate, 56–59 incomplete cleft palate, 53, 54, 59 Lima protocol, 59 unilateral cleft palate, 55, 56, 59 Prolabium flaps, 183, 184 R Randall’s modification, 53

Index S Secondary rhinoplasty, 61 Severe bilateral cleft palate congenital hypoplasia, 357 delayed hard palate closure, 357–362 diagnosis, 388 intravelar veloplasty, 368 medial surgical incisions and hemi-uvular excision, 363, 365 nasal mucosa elevation and closure, 368 nasoalveolar molding, 357 oral mucosa closure, 368, 369 oral mucosal elevation, 363, 366, 367 surgical incisions, 363 uvular repair, 368 Severe incomplete cleft palate diagnosis, 386 hemi-uvular excision, 307 intravelar veloplasty, 310, 311 medial and lateral surgical incisions, 307 nasal mucosa elevation and closure, 310 oral mucosa closure, 310, 312 oral mucosal elevation, 308–310 uvular repair, 310 Von Langenbeck method, 305, 308, 309 Severe unilateral cleft palate diagnosis, 391, 392 intravelar veloplasty, 335, 336 monopedicled mucoperiosteal flap, 330 nasal mucosa elevation and closure, 334, 335 oral mucosa closure, 335, 337, 338 oral mucosal elevation, 330, 334 surgical incisions and hemi-uvular excision, 330, 333 uvular repair, 335 Submucous cleft palate bifid uvula, translucent zone, 282 closure, 288 Furlow technique, 286 mucosal flaps, 283–286 muscular repair, 287–290 myomucosal flaps, 284, 285, 287 surgical incisions and tissue excision, 286 uvular repair, 289 Surgical orthopedics, 168–178 Surgical protocol, 60 non-syndromic patients, 47 premaxillary setback, 174 prenatal diagnosis, 47 presurgical management, 47 syndromic patients, 47

399 T Tennison-Randall and Pool’s concepts, 85 U Unilateral cleft lip mild cleft lip incomplete unilateral cleft lip (see Incomplete unilateral cleft lip) microform (see Microform unilateral cleft lip) moderate cleft lip, 99 advancement flap, 99, 100 closure of mucosa, 106–108 columellar base flap, 100, 101 mucosa dissection, 104, 105 mucosal flaps elevation, 104, 105 muscular dissection, 105–107 non-cleft and cleft segments, 96, 99 skin closure, 109, 112, 113 skin flap elevation, 103 skin, vermillion and mucosa resection, 102–104 surgical incisions, 99–102 upper lip muscles, 108–112 nose deformity (see Cleft nose) postoperative care, 270 severe cleft lip, 111, 114 columellar base flap, 114 mucosal flaps elevation and closure, 118–121 muscular dissection and repair, 119, 121–126 non-cleft and cleft segments, 110, 114 skin closure, 124, 127, 128 skin flap elevation, 117, 120 skin, vermillion, and mucosal resection, 116, 118, 119 surgical incisions, 110, 115–117 surgical techniques classification, 73 curved closure technique, 72–74 presurgical, 74–76 straight closure technique., 71, 73, 74 triangular closure technique, 72–74 Unilateral uvuloplasty method, 339, 363, 380–383

Index

400 Upper lip and nose anatomy arterial supply, 21–25 bilateral cleft lip nose, 7, 10 cartilaginous anatomy, 11 clinical presentation, 1 complete unilateral cleft lip, 5, 8 deformities, 1–3 incomplete unilateral cleft lip, 3–5 levator labii superioris alaeque nasi, 8, 9, 12–14 microform unilateral cleft lip, 2, 4 nasal vestibule, 7, 11, 12 orbicularis oris muscle, 8, 12–14 soft palate muscles, 20, 21 surface anatomy bilateral cleft palate, 18, 20

incomplete cleft palate, 18–20 submucous cleft palate, 18–20 unilateral cleft palate, 18, 20 unilateral cleft lip nose, 7, 9 vascularization in bilateral cleft lip, 9, 10, 17 in normal person, 9, 10, 15 in unilateral cleft lip, 9, 10, 16 V Veau’s classification, 289, 290 Velopharyngeal insufficiency, 60 Vermillion flaps, 184, 185 Von Langenbeck technique, 54, 57, 305, 308, 309