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Jurnal Unilateral Cleft lip

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Unilateral Cleft Lip: Principles and Practice of
Surgical Management
Raymond Tse, MD
1
1
Division of Plastic Surgery, Department of Surgery, University of
Washington, Seattle, Washington
Semin Plast Surg 2012;26:145–155.
Address for correspondence and reprint requests Raymond Tse, MD,
Division of Craniofacial and Plastic Surgery, Seattle Children’s Hospital,
4800 Sand Point Way NE, M/S OB.9.527, Seattle, WA 98105
(e-mail: [email protected]).
Surgical management of cleft lip involves changing techni-
ques and evolving principles. Although Gillies and Millard’s
principles of surgery can serve as a framework for recon-
struction,
1
overall care has broadened to a multidisciplinary
team approach with a focus on the patient and family. The
American Cleft Palate-Craniofacial Association has estab-
lished standards for treating centers that encompass team
composition, team management, communication, cultural
competence, psychological/social services, and outcome as-
sessment (www.acpa-cpf.org). Although the focus of this
review is on the specifics of surgery, the importance of a
team-based approachand concentrationof care inspecialized
high-volume centers is emphasized.
Presentation
Embryology, Epidemiology, and Associated Conditions
At 4 to 6 weeks of gestation, the medial nasal, lateral nasal,
and maxillary processes fuse to form the nose, upper lip, and
primary palate. Posterior to the incisive foramen, the second-
ary palate develops from the fusion of lateral palatine pro-
cesses at 6 to 12 weeks of gestation. Failure of mesenchymal
penetration results in a wide spectrum of cleft presentations.
Cleft lip with or without cleft palate occurs in 2 of 1000
Asians, 1 of 1000 Caucasians, and 0.5 of 1000 African Amer-
icans witha 6:3:1 ratio of left:right:bilateral involvement. The
condition is more common in boys and is usually sporadic. In
contrast, isolated cleft palate occurs in 0.5 of 1000 newborns
regardless of ethnicity. The condition is more common in girls
and syndromes are more frequent. The most common syn-
dromes are van der Woude (lower lip pits), Stickler (type 2
collagen abnormality with myopia, retinal detachment, and
glaucoma), and 22Q11 deletion (multiple facial character-
istics, developmental delay, and other associations).
Anatomy
The vermilion is the red part of the lip that is exposed and dry.
It is composed of keratinized squamous epithelium and has
an abundance of superficial capillaries. The white roll is the
shiny convex prominence above the vermilion that is charac-
terized by sparse vellus hair. The vermilion border is the
junction between vermillion and white roll.
The mucosa is the pink lining of the oral cavity that is
composed of nonkeratinized squamous epithelium.
2
It is
unlike dry vermilion in that chronic exposure from inade-
quate vermilion reconstruction results in parakeratosis and
chronic chapped lips. The red line is the junction between
vermillion and mucosa.
3
The Cupid’s bow is defined by the horizontal double curve
of the lip and has two peaks. The philtrum is defined by a
central depression flanked by philtral columns. Deep to the
skin, the pars peripheralis of the orbicularis oris muscle (OOM)
Keywords
► cleft lip
► cleft palate
► cleft lip nasal
deformity
► alveolar molding
► surgery
Abstract Management of cleft lip and palate requires a unique understanding of the various
dimensions of care to optimize outcomes of surgery. The breadth of treatment spans
multiple disciplines and the length of treatment spans infancy to adulthood. Although
the focus of reconstruction is on form and function, changes occur with growth and
development. This review focuses on the surgical management of the primary cleft lip
and nasal deformity. In addition to surgical treatment, the anatomy, clinical spectrum,
preoperative care, and postoperative care are discussed. Principles of surgery are
emphasized and controversies are highlighted.
Issue Theme Pediatric Plastic Surgery—
Clefts; Guest Editor, Edward P. Buchanan,
MD
Copyright © 2012 by Thieme Medical
Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA.
Tel: +1(212) 584-4662.
DOI http://dx.doi.org/
10.1055/s-0033-1333884.
ISSN 1535-2188.
145
forms a compact decussation at the midline with fibers
inserting into skin on either side of the philtral ridges.
4
The
deep component originates from the modiolus and acts as a
sphincter, whereas the superficial component originates from
the muscles of facial expression and acts as a retractor.
5
At the
lower end of the OOM the pars marginalis turns more
superficial forming a distinct J shape on sagittal section
that contributes to the pout of the lip on profile.
The unilateral cleft lip deformity is characterized by
progressive tissue deficiency and tethering of structures to
either side of the cleft. On the medial side, the lip is short, the
philtral column is flattened, and the vermilion is narrow.
Similarly, on the lateral side, the vermilion border and red
line start parallel to one another, but converge as they
approach the cleft. Noordhoff’s point is found along the
lateral lip where the vermillion height is at its greatest
3
;
here, the white roll is well formed, but becomes less distinct
toward the cleft. Similar to the overlying tissues, there is a
progressive deficiency of OOM. Disruption of muscle is
associated with misdirection of OOM fibers into the alar
base and columella.
6
The nasal floor, alveolus, and palate can
also be involved. Disruption of the alveolar arch results in a
splayed skeletal base and untethered growth on one side of
the premaxilla. The anterior nasal spine and caudal septum
deviate toward the noncleft side, while the alar base remains
tethered to a retropositioned lesser segment. Separation of
the nasal base elements results in collapse of the arch forms
that normally define the nose.
7,8
Classification/Clinical Spectrum
Kernahan proposed a system to classify cleft lip and palate
with the incisive foramen as the central landmark and a
Y-shaped diagram where components could be stippled
(complete) or striped (incomplete) to indicate the extent of
clefting (►Fig. 1a).
9
Kriens proposed another system that
used letters to represent components, with capitals for com-
plete clefts and small letters for incomplete clefts.
10
Letters
run from the patient’s right to left so that a complete bilateral
cleft of lip, alveolus, hard palate, and soft palate would be
represented as “LAHSHAL” (►Fig. 1b).
Unilateral cleft lip has been further described as
“complete,” with Simonart band, incomplete, or microform.
ASimonart band is a soft tissue bridge that is devoid of muscle,
spans the lip elements, and can be differentiated from an
incomplete cleft by the presence of a complete alveolar cleft.
11
It is found in 30% of patients.
12
A microform cleft lip is a very
mild formof incomplete cleft lip, whose features can variably
include indented mucosa, notched vermillion, disrupted
white roll, furrowed philtral skin, flattened nasal sill, and
displaced nasal ala.
13,14
Even more subtle forms of isolated
OOM disruption have been identified, but these may be more
relevant for genetic study.
15,16
Onizuka differentiates micro-
formclefts fromincomplete clefts by a deformity that extends
to less than one fourth of the height of the lip.
13
Yuzuriha
defines a microformcleft as one where the medial vermilion-
cutaneous point of the cleft is < 3 mm above the normal
Cupid’s bow peak.
14
Presurgical Molding
Early in life, malleable tissues and rapid facial growth provide
an opportunity to correct the position and shape of the
skeleton in preparation for definitive reconstruction. Passive
molding can take the formof lip taping, alveolar molding, and
nasoalveolar molding; active molding involves the Latham
device. Lip taping produces an indirect restraining force on
Fig. 1 (a) Kernahan’s “Y”; (b) LASHAL classification; (c) anthropometric analysis adapted (Fig. 1c reproduced with permission from Fisher
DM, Tse R, Marcus JR. Objective measurements for grading the primary unilateral cleft lip nasal deformity. Plast Reconstr Surg 2008;
122:874–880).
Seminars in Plastic Surgery Vol. 26 No. 4/2012
Unilateral Cleft Lip: Principles and Practice of Surgical Management Tse 146
the alveolar segments that is simple, inexpensive, and can
reduce an alveolar gap by 53%.
17
Alveolar molding (AM) in-
volves a custom appliance that is adjusted regularly to guide
palatal growth. Although AM affords greater control of the
arch form, the molding plate can cause irritation and ulcers,
results rely on a skilled orthodontist, and the frequent visits
can be a burden to the family. Long-term studies have also
found no difference in the ultimate alveolar form.
18,19
Nasoal-
veolar molding (NAM) is an extension of AM that includes a
nasal stent to support the nasal dome once the alveolar
segments are aligned (< 6 mm gap or normal arch
form).
20–22
Many studies have demonstrated improved pre-
operative nose form; however, long-term improvements are
still unclear.
23–28
In addition to the risks and burdens of NAM,
overly aggressive NAM can produce a “mega-nostril” by
overstretching the ala while it is still tethered to the alveo-
lus.
29
Active molding was introduced by Latham and involved
manipulation of the alveolar segments using a pin-retained,
screw-actuated appliance. Although active molding provides
more control, it has not been widely adopted due to concerns
of growth disturbance and the need for anesthesia for
installation.
30,31
Lip adhesion is a partial repair of the cleft lip that
produces a restraining force on the alveolar segments
and can reduce the gap by 60%.
32,33
Various techniques
have been described,
34,35
but the common approach
involves repair of tissues along the cleft margin that would
normally be discarded. Proponents argue that conversion of a
cleft to a less severe form facilitates definitive repair,
34,36,37
while skeptics argue that the additional surgery is unneces-
sary and the scar compromises the ultimate outcome.
38–40
The use of presurgical molding or lip adhesion is based
upon the cleft, family, available expertise, and surgeon
preference.
Primary Repair of the Unilateral Cleft Lip
and Nose
Analysis
“Diagnose before you treat” – Sir H. Gillies
1
Analysis of the specific cleft deformity is important for
surgical design. Formal anthropometric measurement is use-
ful to objectively document the deformity and the severity
(►Fig. 1c).
41,42
At minimum, analysis considers the lateral lip
height, medial lip height, horizontal lip length, and nostril
dimensions.
Planning and Design
“Make a plan and a pattern for this plan” – Sir H. Gillies
1
An ideal technique should facilitate the creation of a balanced
lip, allow for adjustments, and produce a favorable pattern of
scar. Although each method has its own merits, the surgeon
should select one that compliments his or her style. In Cleft
Craft, Millard details much of the history of cleft lip repair.
35
Recognizing the need to lengthen the lip, Rose
43
and Thomp-
son
44
designed concave excisions of the cleft margins that
provided length when closing in a straight line. This is now
known as the Rose-Thompson effect. LeMesurier lengthened
the lip with a Z-plasty, placing the peak of the lateral lip into
the center of Cupid’s bow (►Fig. 2A). Although the lip form
producedwas favorable,
45
the orientation and position of scar
was not ideal. Modern techniques of cleft lip repair incorpo-
rate some form of Rose-Thompson effect, Z-plasty, or both.
The Tennison-Randall Approach
Tennisonwas inspired by LeMesurier, but moved the Z-plasty
to the cleft side Cupid’s bow peak.
46
Randall built on the
Fig. 2 Designs for cleft lip repair and expected lines of closure: (A) LeMesurier; (B) Tennison-Randall; (C) Millard II; (D) Mohler; (E) Fisher.
Seminars in Plastic Surgery Vol. 26 No. 4/2012
Unilateral Cleft Lip: Principles and Practice of Surgical Management Tse 147
design using anatomic landmarks and a geometric pattern
(►Fig. 2B).
47
The Tennison-Randall technique involves a
back-cut that extends fromthe cleft Cupid’s bowpeak toward
the center of the philtrum that is filled by a laterally based
triangular flap whose width is the measured deficiency in lip
height. Two points of closure along the nostril floor are
designed so that when they are brought together the nasal
deformity is corrected. Fromthese two points, corresponding
lines are dropped to the cleft Cupid’s bow peak medially and
to the base of the triangular flap laterally (►Fig. 3A). Calipers
can be used to facilitate the final design by making intersect-
ing arcs swung from the lateral lip (the selected Cupid’s bow
peak) and lateral nostril point of closure. Cronin suggests
placing the triangular flap 1 mm above the vermillion to
optimize definition of the repaired white roll.
48
Brauer
suggests making the repaired side 1 mm shorter than the
noncleft side to avoid making the lip too long.
49
In the case of
incomplete cleft lips, the lateral lip element may be too long
and can be shortened by full-thickness excision below the
ala.
50
The Tennison-Randall repair relies upon rigid geomet-
ric design rather than surgeon experience and is particularly
useful for wide clefts with severe vertical deficiency. Howev-
er, the technique has been criticized for producing lips that
are too long and the closure does not follow borders of
anatomic subunits.
The Millard Approach
With the goal of preserving the philtral dimple, Millard
described the rotation-advancement repair (►Fig. 2C) that
emphasized minimal tissue discard, a “cut as you go” ap-
proach, and placement of scars that better respect anatomic
borders.
51
On the medial side, a curvilinear incision extends
upward from Cupid’s bow peak toward the noncleft philtral
column. Downward rotation of the philtrum corrects the
deformity and leaves a gap. Advancement of the lateral lip
fills the defect, corrects the alar flare, and narrows the nostril
floor. Finally, a superiorly-based C-flap is elevated and trans-
posed for nasal floor closure. The overall tissue rearrange-
ment is much like a Z-plasty.
Although the Cupid’s bow peak on the medial side of the
cleft is fixed, selection of the corresponding point on the
lateral lip considers the available lateral lip height (►Fig. 3B).
Measurement and transposition of the horizontal lip length
from the normal side tends to produce a point that is
very medial and incorporates deficient cleft tissues.
3,52
Noordhoff’s point is further lateral and ensures adequate
tissue quality, but not necessarily the required lip height.
53
If
further height is required, the upper end of the advancement
flap is limited by nasal sill and the design is moved lateral on
the lip until sufficient height to match the medial lip incision
is attained (►Fig. 3B). Although sacrifice of horizontal length
can give the vermilion a thinned appearance, leaving a
deficiency in vertical height is a much more obvious
asymmetry.
54,55
Numerous modifications of Millard’s original technique
have been described. A back-cut at the end of the rotation
incision allows greater rotation.
35,56
Another small back-cut,
inor above the white roll, canbefilledwitha lateral triangular
flap to drop the Cupid’s bow further.
41,56,57
In the case of a
vertically oriented philtrum, the rotation incision can be kept
on the cleft side to avoid crossing anatomic borders.
57
Millard
described extending the advancement incision around the
Fig. 3 Design details. Incisions are in black, measurements are in white and corresponding points are indicated: (A) Tennison-Randall; (B) Mohler;
(C) Fisher—before final lateral lip design; (D) Fisher—lateral lip components and variations in design.
Seminars in Plastic Surgery Vol. 26 No. 4/2012
Unilateral Cleft Lip: Principles and Practice of Surgical Management Tse 148
alar base; however, this should be abandoned as it is unnec-
essary and produces a conspicuous scar.
35,56
Millard also
described using the C-flap to lengthen the columella, espe-
cially if a back-cut is added to the rotation incision. Stal has
compiled a comprehensive description of the many subtle
variations used by notable surgeons.
58
An important modifi-
cation is that described by Mohler.
The Mohler Modification
Dissatisfied with a scar that traverses the upper third of the
philtrum, Mohler modified Millard’s repair and used the
columella to lengthen the lip (►Fig. 2D). The rotation incision
is designed to mirror the normal philtral column and extends
onto the columella (►Fig. 3B).
59
A back-cut is designed to
end at the lip-columellar junction and the C-flap is used to
both fill the columellar defect and abut the rotated lip
segment. Lip closure follows anatomic subunits and the
concept of using the columella to lengthen the lip has gained
popularity.
54,58,60
The Fisher Approach
Fisher recently described another approach to cleft lip repair
that avoids scars on or under the columella and is not limited
by deficiencies of lateral lip height or width. The design is
measured and geometric, but uses anatomic landmarks to
place closure along borders of anatomic subunits. Lip length is
attained by the Rose-Thompson effect and a small triangle
placed within the concavity immediately above the white roll
(►Fig. 2E). Compared with other techniques, it is a “measure
twice, cut once” style of repair. The design relies upon 25
landmarks and can be time consuming.
The sequence of landmarks begins with central and non-
cleft side points sothat the corresponding cleft side points can
be measured and identified. Three points are placed along the
crease between the lip and columella: the center and the two
peaks of the philtral columns. While manually correcting the
nasal deformity, two points are placed at each alar base: the
subalare (lowest part of the ala) and the alar insertion point
(junction of ala and sill). An arbitrary point is identified
within the noncleft nostril that is collinear with the two
noncleft alar base and the two noncleft columellar landmarks.
The arbitrary point can then be transposed to the cleft side to
produce two points along a line of closure (►Fig. 3C). By
manually bringing the points of closure together, the nasal
deformity should be corrected.
On the medial side of the lip, the center and two peaks of
the Cupid’s bow are identified along the vermilion border,
above the white roll, and along the red line. The medial
incision runs along the base of the medial footplate, down
the philtral column, and perpendicular to the white roll and
red line. A back-cut is designed above the white roll to
augment lip height and along the red line to augment
vermilion (►Fig. 3C). On the lateral side, Noordhoff’s point
and the corresponding points above the white roll and along
the red line are identified. An incision is designed perpendic-
ular to the white roll and down the vermilion to match the
medial lip vermilion height. The remaining vermilion is
incorporated into a flap for augmentation. The point above
the white roll defines one fixed point; the previously identi-
fied lateral point of closure within the nostril floor defines the
other fixed point (►Fig. 3C). Between these two points, three
components need to be designed to fit the medial lip mark-
ings: the limb along the medial footplate, the length of the
cleft-side philtral column, and a small triangular flap (whose
width is defined by the relative deficiency in philtral height
minus 1 mmbecause of the Rose-Thompson effect). The angle
between each limb can be varied much like the limbs of an
articulating ruler so that the components span the two fixed
points (►Fig. 3D). Although the planning for a Fisher repair is
extensive, there is less reliance on surgeon experience, and
the anatomic basis allows it to be reliably applied to a wide
spectrum of clefts.
Comparison of Techniques and Changes with Growth
It is difficult to compare different designs of lip repair due to
variations in cleft severity and surgeon expertise. Although
outcomes of traditional triangular and rotation-advancement
repairs have been found to be similar,
61–63
rotation-advance-
ment tends to produce short lips whenusedfor wide clefts.
62,63
For this reason Meyer uses a Tennison-Randall repair for wide
clefts and a Millard repair for narrow clefts.
64
The suggestion
that imbalances occur from differential growth has been
challenged by studies that have found relative lip dimensions
to be stable with both triangular
62,65
and rotation-advance-
ment
54,55,66–68
repairs. The immediate result is likely the best
predictor of eventual outcome, and the results of surgery rely
on more factors than just the surgical markings.
Wide Surgical Release
“Treat the primary defect first” – Sir H. Gillies
1
Although Gillies’ notion of wide surgical release is based upon
traumatic deformities, the principle is well applied to clefts.
The lip and nose are tethered to the distorted underlying
anatomy; much like a burn contracture, there is a point of
maximal tension that can be clearly visualized when traction
is applied to the lip and nose. Adequate release allows three-
dimensional (3D) correction. Wide mobilization over the
maxilla permits medial and superior movement, whereas
release along the piriform rim allows anterior movements.
Correction of the nasal deformity requires that the alar base,
lower lateral cartilage, and accessory cartilages are free from
the maxilla. Wide muscle release permits functional OOM
reconstruction, but dissection should be discriminating. Care
must be taken to preserve the philtral depression and the J
shape of the orbicularis along the lower lip margin.
Component Reconstruction
“Losses must be replaced in kind” – Sir H. Gillies
1
Nasal Floor
Repositioning of the alar base is crucial in correcting the nasal
deformity. In the case of a bony defect, nasal floor closure
provides a stable platform for accurate 3D repositioning and
Seminars in Plastic Surgery Vol. 26 No. 4/2012
Unilateral Cleft Lip: Principles and Practice of Surgical Management Tse 149
rotation of the ala. Lateral vestibular skin can be apposed to
skin along the medial footplate; more posteriorly, lateral
vestibular mucosa can be apposed to septal mucosa. Closure
even further posterior requires an extended incision along
the palatal shelf for elevation of the nasal mucoperiosteum.
Single- and double-layer closures of the nasal floor extending
into the palate have also been described.
69,70
An alternate
method that preserves the palatal mucoperiosteum uses an
anteriorly based turbinate flap transposed 90 degrees
(►Fig. 4A). In addition to stabilizing the nose, nasal floor
closure facilitates subsequent palatoplasty and alveolar bone
grafting by sealing the nasal mucosa along the alveolus when
the exposure is wide and easy.
Nasal Sidewall
With great anterior movement of the lateral nose, release of
the mucoperiosteum leaves a potential space along the piri-
form rim. This defect can be addressed in several ways
depending upon surgeon preference or the clinical scenario
(►Fig. 4). (1) The turbinate flap is anteriorly based and rotates
90 degrees to fill the defect after release of the lateral nose.
Harvest requires an open cleft palate for posterior access. It
replaces like with like tissue and preserves all of the nasal
mucoperiosteum that may be used for palatoplasty. (2) The
L-flap is the marginal lateral lip vermilion and mucosa that
would otherwise be discarded with cleft lip repair. Blood
supply can be robust if it is based upon periosteum of the
lateral nasal wall. The flap is transposed into the defect along
the nasal vestibule while more posterior mucoperiosteum is
mobilized to close the nasal floor. Although nasal mucosa is
replaced by lip vermilion and mucosa, the L-flap is
versatile and can be used in any scenario. (3) Lateral nasal
wall advancement involves movement of mucoperiosteum in
continuity with the rest of the nose as a broad flap.
Incision along the palatal shelf allows elevation of mucoper-
iosteum and a back-cut posterior to the piriform aperture
leaves the defect along the bony nasal wall. Although the
flap is robust, the release is posterior to the site of greatest
tension and a low-lying turbinate can limit the extent of the
back-cut.
Following wide release of the lateral nose and component
reconstruction, absorbable quilting sutures along the vesti-
bule and alar crease can be used to obliterate the vestibular
web, support the lower lateral cartilage, and create better
definition for the nose.
Nasal Septum
Disruption of the palatal arch results in untethered growth of
palatal segments and rotation of the anterior nasal spine
away fromthe cleft. Displacement of the caudal septumhas a
ripple effect on the rest of the septum and nasal cartilages.
71
Smahel described correcting the position of the caudal
septum at the time of cleft lip repair to improve nasal
form.
72
No alteration in maxillary growth was reported
73
and other surgeons report similar favorable results.
39,74–76
The caudal septum is approached via the medial lip incision
and is found behind an often bifid anterior nasal spine. Firm
attachments on the noncleft side need to be released to
unfurl the cartilage and reposition it to the midline of the
face.
Fig. 4 Options for lateral nasal wall reconstruction and nasal floor closure: (A) Turbinate flap; (B) L-flap; (C) Lateral nasal wall advancement
(Base photograph courtesy of Joseph Gruss).
Seminars in Plastic Surgery Vol. 26 No. 4/2012
Unilateral Cleft Lip: Principles and Practice of Surgical Management Tse 150
Nasal Tip Cartilages
The nasal tip cartilages sit on top of a deformed nasal base.
Dissection of the nasal tip was once criticized for potential
growth disturbance, but short-term anthropometrics
76
and long-term subjective analyses
77,78
have demonstrated
no alteration in growth. McComb describes suspension of the
cleft alar dome via long sutures tied over bolsters at the
glabella,
77
whereas Tajima describes suspension to the upper
lateral cartilage and the contralateral lower lateral cartilage.
79
Many surgeons have incorporated nasal tip dissection and
have used limited vestibular incisions,
40,41,60
an extensive
intranasal approach,
35,56,80
or an open external approach
81,82
for exposure. Although the greater dissection affords the
ability to manipulate and modify anatomy, it also risks
iatrogenic insult.
83
Warnings of scarring, vestibular stenosis,
micronostril, and other iatrogenic deformities have accom-
panied
40
reports of favorable outcomes. Proponents of pri-
mary nasal tip rhinoplasty admit that nasal correction can be
limited and that there is a “perverse tendency for the genu to
slump with time.”
60,84
Objective long-term audit demon-
strates deterioration of alar symmetry over time, especially
with wide clefts.
55,80,85
Nasal revision is performed in 20 to
74% of patients and at some centers most patients go on to
definitive septorhinoplasty.
40,60,86
As such, the balance of
surgical manipulation against surgical insult with nasal tip
correction at lip repair must be considered.
Controversies in Correction of the Cleft Lip Nasal
Deformity
“Never do today what can honourably be put off till tomor-
row” – Sir H. Gillies
1
The composite tissues and complex shape make the nose a
difficult structure to correct. With presurgical molding, vari-
ous forms of primary rhinoplasty, and variations in postoper-
ative stenting, the relative impact of each intervention on the
ultimate result is unclear. For example, NAM has been asso-
ciated with improved outcomes without any nasal dissec-
tion,
23,28,87,88
with primary rhinoplasty,
25,89
and with
varying durations of postoperative nasal stenting.
23,25,28,88,89
Likewise, septal repositioning has been associated with im-
proved nasal formwith
39,60,74,76
and without
72,75,90
nasal tip
dissection. Analysis needs to consider early results, late
results, deterioration over time, and treatment outcome at
completion. The lack of any universally accepted objective
assessment makes comparison of the various components of
treatment difficult. While the relative merits of molding and
various forms of primary rhinoplasty remain unclear, sur-
geons need to constantly reassess their outcomes as they
relate to their treatment protocols.
Alveolus
Gingivoperiosteoplasty (GPP) is a mucoperiosteal flap closure
of the cleft alveolus that is typically performedfollowing NAM
if the alveolar segments are in close proximity. Adequate bone
can form within the constructed cavity in up to 73% of
patients.
91,92
Although GPP is used with good bone produc-
tion and no apparent alteration in facial growth by some
centers,
73,93
GPP has not gained widespread use due to
reported concerns of facial growth disturbance
30,31,94,95
and variable quality of alveolar bone.
91,95,96
Lip Mucosa
Adequate upper buccal sulcus incision and release allows
the lateral lip mucosa to advance to meet the medial lip
mucosa. If the cleft side buccal sulcus hangs low on the
alveolus, the mucosa can be secured to periosteum higher
up. Final inset of mucosa requires accurate alignment of the
red line.
Lip Musculature
Anatomic studies have emphasized the importance of accu-
rate muscle repair. On the medial side, release of muscle from
the columella lengthens the lip and opens a space. On the
lateral side, downward rotation of muscle from the alar base
creates an “empty triangle.” When the lateral muscle is
inserted into the base of the columella, a muscular sling for
the nasal sill is created. At the same time, the empty triangle
docks against the ala at the nose–cheek junction and the
height of the medial lip muscle is augmented. Further muscle
repair establishes the oral sphincter, aligns the overlying
structures, and reduces tension on skin repair. Particular
care should focus on aligning the J shape of the caudal
OOM as it contributes to the lip’s natural pout. If a traction
stitchis used at the lower end of the muscle, the surgeon must
ensure that muscle form is not distorted and the pout is not
obliterated.
Lip Skin and Vermillion
Final adjustments are well worth the investment in time as
the formachieved at the completionof the procedure predicts
the ultimate outcome. The white roll and vermilion should
be perfectly aligned and the lip and nose should have
balanced form. Adjustments will vary according to the tech-
nique used.
Variations for the Microform Cleft Lip
Microform cleft lips can be the least severe, but most chal-
lenging to treat. Compared with more severe clefts, results of
surgery are less dramatic, risks of surgery are the same, and
family expectations can be high. In appropriately selected
microform cleft lips,
13,14
the disruption of white roll, vermil-
ion, and mucosa can be addressed by a limited excision and
triangular flap augmentation of deficient skin and vermilion,
when necessary.
14
Disruption of muscle should be repaired
and the alar base can be repositioned by lenticular excision or
V-Yadvancement. If skin/vermilion excision is minimal or not
needed, an intraoral approach can be used to access muscle
for repair.
14,97
Aftercare
“The after-care is as important as the planning” – Sir H.
Gillies
1
Seminars in Plastic Surgery Vol. 26 No. 4/2012
Unilateral Cleft Lip: Principles and Practice of Surgical Management Tse 151
Prolonged use of nasal stents for 6 months after surgery has
been shown to improve long-term nasal form.
98
Although
other Asian centers report favorable outcomes with use for 3
to 6 months,
24,28
maintenance requires tremendous efforts
and compliance. Adoption of postoperative stents by Canadi-
an and American centers has been variable
99
and the benefits
of short-term use are unclear.
Audit and Outcome Analysis
“Never let routine methods become your master” – Sir H.
Gillies
1
Meaningful audit requires standard timing and methods of
image capture. Although 2D images are limited by parallax
and magnification, 3D imaging is limited in speed and
resolution. Use of a protocol that incorporates the modalities
available permits eventual outcome analysis and comparison
of results. ►Figure 5 illustrates a favorable result in a child
with a complete cleft lip and palate who presented with a
moderate to severe cleft lip nasal deformity. The patient
underwent NAM, Fisher lip repair, careful OOM reconstruc-
tion, nasal floor closure, L-flap for nasal sidewall, septal
repositioning, alar quilting, and postoperative nasal conform-
ers for 1 week. No nasal tip dissection was performed. The
outcome of this case challenges the notion that nasal tip
dissection needs to be performed at primary lip repair.
Though expert opinions will continue to be debated, the
ultimate answer will rely upon objective audit and careful
outcome analysis.
Summary and Conclusions
Management of the child with cleft lip and palate involves a
breadth that spans multiple disciplines and a course that lasts
from infancy to adulthood. Surgical treatment of cleft lip
seeks to produce lasting form and function while considering
growth and development. Planning, wide surgical release,
and reconstruction of each component remain guiding prin-
ciples of surgery. Thoughtful analysis of eachdeformityallows
selection of appropriate interventions to address skin, ver-
milion, muscle, mucosa, nasal floor, nasal sidewall, nasal
septum, and nasal tip. Although controversies persist, sur-
geons need to have a standardized approach with a mecha-
nism for clinical audit to ensure ongoing optimal care.
Acknowledgments
Special thanks to Drs. David Fisher, Richard Hopper, Joseph
Gruss, Craig Birgfeld, and Damir Matic, for their insights,
feedback, and perspectives in cleft care.
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