Clinical Aspects of Cleft LipPalate Reconstruction

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Clinical Aspects of Cleft Lip/Palate
Reconstruction
Brian Clarke MED II Dalhousie University Halifax,
Nova Scotia
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Overview

• Relevant Anatomy
• Embryology of Facial Clefting
• Classification/Epidemiology
• Principles of Management
• Assessment
• Indications/Contraindications
• Surgical Techniques
• Millard
• Wardill-Kilner
• Post-op management
• Complications
• Follow up

Clinical Aspects of Cleft Lip/Palate
Reconstruction
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Anatomic Principles
Normal Lip
1) Central Philtrum
Lateral margins - philtral columns Inferior
border - Cupids bow and tubercle
2) Vermillion-cutaneous border
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Reconstruction
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Anatomic Principles
3) Muscles
Orbicularis oris (superficial and deep)
Levator labii superioris
Levator superioris alaeque
Transverse nasalis
End result of cleft lip Disruption of the
normal termination of the muscle fibers that
cross the embryologic fault line of the maxillary
and nasal processes, resulting in abnormal
muscular forces between the normal equilibrium
that exists with the nasolabial and oral groups
of muscles
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Anatomic Principles
Normal Palate
Primary palate
Secondary palate
Soft palate
Hard palate
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Embryology of Clefting
Facial Development - 4th - 10th week of
development
Formed by the fusion of five prominences
Unpaired frontonasal process - lateral/medial
nasal processes
Nose/Philtrum of upper lip
Paired maxillary swellings
Cheeks/Upper lip (-philtrum)
Paired mandibular swelling
Lower face (lower lip/chin)
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Embryology of Clefting
Facial Development
6th week
Medial nasal processes (green) migrate toward
each other and fuse
7th week
Inferior tips of medial nasal processes expand
laterally to form the intermaxillary process
Tips of maxillary swellings (yellow) grow to meet
the intermaxillary process and fuse
Failure of maxillary swellings to fuse with
intermaxillary process cleft lip
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Formation of the Palate
6th week
1) As nasal pits of lateral nasal process
invaginate and fuse, intermaxillary process
extends to form primary palate
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8th - 9th week
2) Medial walls of maxillary processes produce
palatine shelves
3) Shelves grow downwards, parallel to lateral
suface of tongue
4) End of week 9, rotate upward into a horizontal
position and fuse with each other and primary
palate to form secondary palate
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Reconstruction
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Cleft Variants
Great anatomic variation in types of clefts!
Anatomic Classification based on
1) Location
2) Completeness (Incomplete/Complete)
3) Extent
Since lip, alveolus, and hard palate differ in
embryologic origin, any combination can occur
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Iowa Classification
Group I Clefts of lip only
Group II Clefts of palate only (2o)
Group III Clefts of lip, alveolus, palate
Group IV Clefts of lip and alveolus (primary
cleft palate and lip)
Group V Miscellaneous
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Striped Y
1 5 - Floor of nose on right left sides 2
6 - Lip 3 7 - Alveolar ridges 4 8 -
Premaxilla to incisive foramen 9 10 - Each half
of the hard palate 11 - Soft palate 12 -
Congenital velopharyngeal incompetence without
obvious clefts 13 - Protrusion of premaxilla
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Reconstruction
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Cleft Variants
Cleft Lip
Expressed in structures anterior to incisive
foramen
- prepalatal alveolus, maxilla, lip, nasal
structures
Deficiency in skin, muscles, mucous membranes,
maxillary/nasal bones, nasal cartilages
1) Isolated Incomplete
Bilateral/Unilateral
Intact skin/muscle between the lip and nose
Less distortion brought on by abnormal muscle pull
Gaping cleft of alveolus/lip structures to mere
scar (forme fruste)
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2) Isolated Complete
Bilateral/Unilateral
Cleft runs entire length of lip to floor of nose
Abnormal muscle pull distorts nose extensively
and creates wide clefts between the lip segments
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Reconstruction
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Cleft Variants
Isolated Cleft Palate
Primary Palate (CL)
Secondary Palate
Soft Palate
Hard Palate
Complete/Incomplete
-cleft can extend into the hard palate to any
extent
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Reconstruction
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Cleft Variants
Combined Clefts
Complete lip/palate
Incomplete lip/palate
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Epidemiology
Cleft lip/palate are second most common
congenital abnormalities
Overall incidence of CP w CL and isolated CL
1 in 1000 live births Isolated CP 1 in
2000 live births
Incidence of CL/P varies with race and gender
AsiangtCaucasiangtAfrican American
MalegtFemale (exception isolated cleft palate)
Among total number of clefts
20 CL (18 unilateral, 2 bilateral)
50 CL and CP (38 unilateral, 12 bilateral)
30 CP alone
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Epidemiology

Genetic Basis
Clustering noted in particular families
Associated with over 150 syndromes!
Overall incidence of associated anomalies (eg
cardiac) 30
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Risk increases with parental age (gt30yrs
particular paternal age)
Environmental Factors
Viral infections (rubella)
Teratogens (steroids, anticonvulsants, alcohol,
retinoic acid derivatives)
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Reconstruction
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Principles of Management
Assessment
Indications restoring normal morphologic form
and function
Important for normal dentition, mastication,
speech, hearing, and breathing
Contraindications malnutrition, anemia or other
conditions that render infant unable to tolerate
general anesthesia - airway obstruction, otitis
media with CP
Work-up
(1) Thorough PE to uncover any associated
anomalies
Additional work-up determined by physical
findings that suggest involvement of other organ
systems
(2) Weight, oral intake, growth/development are
of primary concern and must be followed closely
(3) Routine lab studies generally not required
Hgb level before surgery
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Surgical Management
Cleft Lip and Palate
Multidisciplinary approach
Beyond lip repair are other issues
Hearing (otolaryngologists)
Speech (speech pathologists)
Dental (oromaxillofacial surgeons)
Nutrition
Psychosocial
Integration with team-based approach
Each case is assessed independently by those
involved and a global treatment plan is
instituted based on present need in his/her
development
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Surgical Management
Staging and Timing of Surgery
Different institutions different practice
Cleft Lip
Cleft Palate
Rule of 10s
IWK - 9-12 months of age
Hgb 10g Weight of 10lbs Age 10wks
IWK - 6-8 weeks
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Surgical Management
Unilateral Complete Cleft Lip
Goal Symmetric shaped nostrils, nasal sill, and
alar bases well defined philtral dimple and
columns natural appearing Cupids bow
functional muscle repair
Surgical Principle Lengthen medial side of cleft
so that it equals the vertical dimensions of
non-cleft side
Flap designs
1) Triangular (Tennison-Randall)
2) Quadrangular
3) Rotation-advancement (Millard, Mohler)
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Millard Technique
Cut as you go technique
Preserves cupids bow and philtral dimple
Scar placed in more anatomically correct position
along philtral column
Tension of closure under the alar base reduces
flair and promotes better molding of the
underlying alveolar processes
In simple medical student terms
1) Medial flap rotates downward to achieve
necessary lengthening
2) Lateral flap advances into the defect produced
by downward displacement of medial flap
3) Small pennant-shaped medial flap can be used
to restore nostril sill or lengthen the columella
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In Complex Resident/Staff Terms
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Post-op Management
Cleft Lip
1) Feedings administered with catheter tip
syringe fitted with small red rubber catheter for
the first 10 days post-op
2) Nipples are avoided to minimize strain on the
muscle/skin sutures
3) Velcro arm restraints to protect repair from
flailing hands/fingers
4) Suture line care PRN cleansing with half
strength peroxide followed with polymixin
B-bacitracin ointment
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Post-op Management
Inform the parents of
Scar contracture
Erythema
Firmness
Avoid placing in direct sunlight until the scar
fully matures
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Post-op Management
Complications

• Aesthetic
• vermilion-cutaneous mismatch
• vermilion notching
• tight appearing lateral lip segement
• lateral muscle buldge
• laterally displaced ala
• constricted appearing nostril

• Other
• dehiscence
• excessive scar formation

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Surgical Management
Cleft Palate
Goal Production of a competent velopharyngeal
sphincter
Two most common repairs
1) V-Y (Veau-Wardill-Kilner)
2) von Langenbeck
Main difference V-Y repair involves elongation
of the palate, while von Langenbeck does not
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Wardill-Kilner
1) Incisions made along free margins of cleft and
extend anteriorly to apex
2) Dissection continued posteriorly along oral
side of alveolar ridge to retromolar trigone
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Wardill-Kilner
3) Mucoperiosteal flaps are elevated from
nasal/oral surfaces of bony palate
4) Dissection of the greater palatine vessels
from the foramen lengthens the pedicle
5) Tensor veli palatini muscle is elevated off
the hamulus to aid in relaxing the midline closure
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Wardill-Kilner
6) Nasal mucosa freed from bony palate and closed
to either side, or if necessary closed by using
vomer flaps
7) Muscle and oral mucosa closed in a second
single layer in a horizontal fashion
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Wardill-Kilner
8) Anteriorly, the oral mucoperiosteal flaps are
attached to the third flap (mucosa overlying the
primary palate
9) Posteriorly, the palate is closed in 3
layers Nasal mucosa Levator muscle Oral mucosa
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Post-op Management
Cleft Palate
Immediate concerns 1) Airway management
Change in nasal/oral airway dynamics
2) Analgesia
Risk of oversedation and subsequent airway
comprimise
Acetominophen, Codeine sufficient contd for
7-10 days
Arm restraints to prevent placing fingers in mouth
Diet restricted to liquids, soft foods (x3wks)
bottles avoided
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Post-op Management
Complications

• Airway obstruction
• Intraoperative bleeding
• Palatal fistula
• Midface abnormalities (early interventions)

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Cleft Palate Clinics
Through a protocol of sequential, regular
evaluations by a team composed of plastic
surgeon, speech pathologist, orthodontist, and
audiologist, great strides have been made in
improving all aspects of care of the child with
cleft palate
Clinical Aspects of Cleft Lip/Palate
Reconstruction