BY
DR MAHESH KUMAR
FCPS
HOD AND CHAIRMAN
PLASTIC & RECONSTRUCTIVE
SURGERY DEPARTMENT
L.U.M.H.S.
JAMSHORO
OBJECTIVES :
The development of CLP
 The etiology of Cleft CLP
 The normal anatomy of CLP
 The anatomy of Cleft LP
 The classification of Cleft LP
 The key features of the Perioperative care of
the child with Cleft lip & Palate
 The associated complications of Cleft lip &
their management

DEVELOPMENT OF FACE :

After 8 weeks Embryo is called ‘Fetus’ due to
the fusion of prominences.

Development of face
 Appearance of ‘5’ prominences
 Growth of these prominences
 Fusion of the prominences
EMBRYOLOGY OF LIP:
EMBROLOGY
Palatal development  7th 
to 10th weeks
Palatal shelves
are initially 
oriented vertically
Head grows & the neck 
straightens , tongue falls away
allowing the palatal shelves to
rotate upward into normal
horizontal position.
Growth factors & hyalronic acid 
Frontonasal
Forehead, bridge of nose,
medial & lateral nasal
prominences, nasal
septum
Maxillary
Cheeks, lateral portion of
upper lip
Medial nasal Philtrum of upper lip, crest
& tip of nose
Lateral nasal Alae of nose
Mandibular
Lower lip
THE INCIDENCDE:








The isolated cleft palate is 0.5:1000
Cleft lip with or without palate is 1:1000
CL/P predominates in males
Isolated CP predominates in females
Majority of bilateral CL(86%) & unilateral
CL(68%) are associated with a CP
Unilateral CL : Left side affected in 60%
Unilateral CL are 9 times common than
Bilateral
Typical distribution of cleft type is:
 Cleft lip alone: 21%
 Cleft lip & palate: 46%
 Isolated cleft palate: 33%
ETIOLOGY




Idiopathic
Genetic defect
Environmental Teratogens
 Phenytoin , Other Anticonvulsants, steroids
 Maternal Smoking , old age marraiges
 Alcohol & Retinoic Acid
Familial 1 Affected Child Or Parent, Risk Of Child Of The Next
Pregnancy Having CLP Is 4%
 If 2 Previous Children Have CLP Risk Increase To 9%
 If 1 Parent & 1 Child Were Previously Affected, Risk Is
17
 Not associated with solar or moon eclipse
, White Skin Roll &
Vermillion.
 , Symmetrical Alar
Arches & Equal Alar
Base.

LIP ANATOMY

MusclLip – Consists
Of Symmetrical
Cupids Bow & Philtral
Colum – Orbicularis
Oris.
 Nose –
Straight
Columella &
Septum
CLASSIFICATION

CLEFT LIP
 UNILATERAL
 BILATERAL
 MEDDIAN
○ COMPLETE/ SEVERE
○ INCOMPLETE/
MODERATE
○ MICROFORM/ MILD
CLEFT ALVEOLUS
1. NARROW- NON
COLLAPSE
2. NARROW- COLLAPSE
3. WIDE- NON COLLAPSE
4. WIDE- COLLAPSE
NASAL DEFORMITY
Mild
 Lateral Displacement Of The Alar Base,
called flaring of ala of nose
 Normal Alar Contour & Dome Projection

Moderate
 – flaring of Alar Base,
 Columella Deficiency
 A Depressed Dome.

Severe Flaring of ala nose
 deprressed Alar Dome
 Complete Collapse Of Lower Lateral
Cartilage
 Severe Deficiency Of Columella Height.
 Hypoplasia of alar cartilage
MICROFORM CLEFT LIP

Furrow Or Scar .

A Vermilion
Notch.
Imperfection In
White Roll.
Varying Degree Of
Vertical Lip
Shortness.
Nasal Deformity –
May Be Present



UNILATERAL INCOMPLETE CLEFT
LIP


Varying Degree Of
Vertical Seperation
Of Lip
An Intact Nasal Sill/
Simonart Band
UNILATERAL COMPLETE CLEFT LIP


Disruption Of The
Lip, Nostril Sill &
Alveolus(complete
Primary Palate)
No Simonart Band
INCOMPLETE BILATERAL CLEFT LIP
INCOMPLETE WITH
A NEAR NORMAL
NOSE.
 NORMALLY
POSITIONED
PREMAXILLA.
 SIMONART BANDS
& CLEFT
INVOLVING ONLY
LIP.

COMPLETE BILATERAL CLEFT LIP
Protuded Premaxilla
Poorly Formed Or Absents
Anterior Nasal Spine
Severe Nasal Deformity,
Flat Nasal Tip
The Portion Of LIP between
Philtral Columns Form Wide,
Short Disk Called Prolabium.
classification of Cleft Palate
EMRYOGENIC 
Cleft of primary palate
Cleft of secondary palate
ANATOMIC 
Ceftt of uvula 
Cleft of soft palate 
Cleft of hard palate 
Cleft of alveolus 
SIMPLE
Classification
Kernehans striped YClassification
Veau Classification - 
1931
Veau Class I: isolated
soft palate cleft
Veau Class II: isolated
hard and soft palate
Veau Class III:
unilateral CLAP
Veau Class IV:
bilateral CLAP




Symptoms
Separation of the lip
Separation of the
palate (roof of the
mouth)
Nasal distortion
Misaligned teeth
Recurring ear
infections






Symptoms (cont.)
Failure to gain
weight
Nasal regurgitation
when bottle feeding
Poor speech

Growth retardation



PROBLEMS
(PATHOPHYSIOLOGY)
LIP
 Inability to have a tight seal
 Malocclusion,
 alveolar defect & teeth deformities
 PALATE
 Inability to separate nasal from oral
 Feeding difficulty
 Regurgitation
 Middle ear disease
 Speech problem

PROBLEMS
Upper airway 
Speech 
Feeding difficulty 
Ear infection 
Airway Problems
Cleft Palate patients
e.g. Pierre-Robin Sequence
Micrognathia 
, Cleft Palate, 
Glossoptosis 
CYANOSIS 
develop airway distress from tongue fall
and touch pharanyx
lodged in palatal defect


FEEDING PROBLEM
FEEDING IN HEAD ELEVATED POSITION 
FEEDING WITH SPCIAL CP BOTTLES OR 
D/SYRINGE OR DROPPER
AFTER FEED LAY BABY ON SHOULDER 
AND SLAB ON BACK TILL RETCHING
Hearing problem
ETD- Due to abnormal insertion of 
levator veli palatini and salpingo
pharyngeus muscle into hard palate
milk enter into eustachian tube and lead 
to serous otitis media and infective
otitis media and finally ankylosis of
oscicles
30% develop permanent deafness 
Speech Disorders
Errors in Articulation: Fricatives, 
Affricates
Velopharyngeal Competence- 
competence after initial palate surgery
Incompetence- nasal emission or snort 
Evaluation- Direct exam , Fiberoptic 
Exam
TIMING OF SURGERY

RULE OF TENS
FOR CL:
 1O POUNDS
 10 gm OF Hb
 10 WEEKS OF AGE
 10,000 TLC
FOR PALATE
10 KG
10 GM Hb
10 MONTH
10000 Tlc





Treatment
Treatment involves
many things which
include plastic
surgery,
orthodontics, and
speech therapy

PRIMARY MANAGEMENT




Antenatal Diagnosis
 Diagnosed By US 3D
After 18 Weeks’ Gestation
 Parents Need Counseling
Reassure The Parents
Explain Functional Problems
Advise On
 Feeding
 Timing Of Surgery
○ Ideally, The Newborn Infant
With A Cleft Is Evaluated By
Cleft Team In 1st Weeks Of
Life
PRESURGICAL MANAGEMENT
1:Presurgical infant orthopedics:
 Appliances
latham appliance for collapsed alveolar arch
2:Presurgical nasoalveolar molding :
objective of NAM :
 To align & approximate the alveolar segment
 To correct the malposition of the nasal cartilage & alar base on
affected side
 To idealize the position of philtrum & columella
Naso alveolar mold
Surgical techniques:
 For
unilateral cleft lip:
Modern accepted technique is the
modified Millards rotation &
advancement repair
 For microform cleft lip:
Straight line repair
Modified Millard rotation –
advancement repair
 For
bilateral cleft lip:
1,Manchester repair
MANCHESTER REPAIR
Surgical Repair- Cleft Palate
Several Techniques- 
less scarring and less tension on palate 
Scarring of palate may cause impaired
mid-facial growth(alveolar arch collapse,
midface retrusion, malocclusion)
Facial growth may be less affected if
surgery is delayed until 18 months, but
feeding, speech, socialization may suffer.
Surgical techniques
Von langenback operation 
Veau, Wardill, Kilner push back palatoplasty

Intravelar veloplasty 
Furlow z – plasty 
Bordeck palatoplasty 
Complications of lip repair
Unilateral cleft lip:
 Deficient tubercle
 Vermilion deficiency & irregularity
 Short upper lip or Long upper lip
 Tight upper lip
 Unfavorable scar
Bilateral cleft lip:
 Whistle deformity
 Nostril stenosis
complications
Immediate 
Bleeding 
Delayed 
Fistula formation 
Failure of repair 
Speech problem 
Bilateral incomplete cleft lip
bilateral millard procedure
bilateral millard repair
Bilateral complete cleft lip
unilateral Complete cleft lip
Incomplete cleft lip
POSTOPERATIVE CARE

Soft arm restrain for 2 weeks

Analgesics

Feeding

Suture line care

Stitch removal
Avoid oral suction

POSTOPERATIVE CARE
Fluids for one week 
Water after every feed 
Semi solids for next two weeks and 
water after every diet
Solids are allowed after three weeks 
No need to remove stiches (vicryl) 
Cleft palate
Lower lip cleft (cleft 30)
CONFIDENCE LIKE
ART NEVER
COMES FROM
HAVING ALL THE
ANWERS, BUT IT
COMES FROM
BEING OPEN TO
ALL QUESTIONS !