Postoperative deformities of the
upper lip and palate: etiology,
pathogenesis, clinical features,
surgical treatment of deformities.
Voles of the maxillofacial area,
salivary glands, etiology,
symptoms, diagnosis, surgical
treatment.
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
Clinical Aspects of Cleft Lip/Palate Reconstruction
Iowa Classification
Group I
Group II
Clefts of lip only
Clefts of palate only (2o)
Group III
Group IV
Clefts of lip,
alveolus, palate
Clefts of lip and
alveolus (primary
cleft palate and lip)
Group V
Miscellaneous
Clinical Aspects of Cleft Lip/Palate Reconstruction
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)
Clinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate Reconstruction
Cleft Variants
Combined Clefts
Complete lip/palate
Incomplete lip/palate
Clinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate Reconstruction
Surgical Management
Staging and Timing of Surgery
Different institutions = different practice
Cleft Lip
Rule of 10’s
Cleft Palate
IWK - 9-12 months of age
Hgb = 10g
Weight of 10lbs
Age 10wks
IWK - 6-8 weeks
Clinical Aspects of Cleft Lip/Palate Reconstruction
Surgical Management
Unilateral Complete Cleft Lip
Goal: Symmetric shaped nostrils, nasal sill, and alar bases; well defined philtral
dimple and columns; natural appearing Cupid’s 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)
Clinical Aspects of Cleft Lip/Palate Reconstruction
Millard Technique
“Cut as you go” technique
Preserves’ cupid’s 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
Clinical Aspects of Cleft Lip/Palate Reconstruction
In Complex Resident/Staff Terms:
Clinical Aspects of Cleft Lip/Palate Reconstruction
Clinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate Reconstruction
Post-op Management
Inform the parents of:
Scar contracture
Erythema
Firmness
Avoid placing in direct sunlight until the scar fully matures
Clinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate Reconstruction
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: cont’d for 7-10 days
Arm restraints to prevent placing fingers in mouth
Diet restricted to liquids, soft foods (x3wks): bottles avoided
Clinical Aspects of Cleft Lip/Palate Reconstruction
Post-op Management
Complications
 Airway
obstruction
 Intraoperative bleeding
 Palatal fistula
 Midface abnormalities (early
interventions)
Clinical Aspects of Cleft Lip/Palate Reconstruction
NORMAL LIP
MUSCULAR
ANATOMY
CLEFT LIP
ANATOMY
Problems in Cleft Lip and Cleft Palate
•
•
•
•
•
•
•
•
•
Feeding
Frequent upper respiratuary tract infection
Frequent gas regurtation
Otitis media
Nasal regurtation of food
Aspiration pneumenia
Growing retardation
Other anomalies
Psycological problems (family)
Cleft lip and palate treatment team

Surgeon experienced in cleft management
 Pediatrist
 Orthodontist
 Pediatric Otorhinolaryngologist
 Pediatric dentist
 Geneticist



Spech Terapist
Social Worker
Nurse experienced in cleft problems
Feeding Rules

Swallowing is not impaired, oral feeding is
possible
 Bottle feed with additional cross cut in the end
 Elastic plastic bottle
 Bulb syringe with a nipple
 Feeding with a spoon
 The child should be held in a head-up
position at about 45 º during and after feeding
 Lateral position during sleeping
When to Operate
Generally (Rules of 10’s)

Weight > 10 pound (4500 gr)
 Hb > 10 gr
 Age > 10 weeks
Cleft lips between 3-6 months
Cleft palate between 12-18 months (preferred before
speech devolops)
Cleft Lip Treatment

Cleft lip




Mikroform cleft lip
Unilateral cleft lip
Bilateral cleft lip
Associated nasal deformity is classified as
mild, moderate or severe
 Alveolar arc position evaluated. If
necessary “presurgical maksiller
orthodontics” applied
Operation technique in Microform cleft (Straight line
closure)
Surgical technique for unilateral cleft lip
(Millard Rotation-Advancement)
Surgical technique for unilateral cleft lip
(Tennison Triangular Flap)
Surgical technique for unilateral cleft lip and palate
Millard techniques provides primary lip and nasal repair . It is possible
“gingivoperiostoplasy” after “Presurgical maksiller ortopedics”
Pre -Orthodontic treatment
After 3 months of Grayson molding
plate application
A.M.Kul, right unilateral primary and
secondary cleft palate
Pre -Orthodontic therapy
After 3 months of Grayson molding
plate application
Postoperative 6 months
Postoperative 1,5 years
Bilateral Cleft Lip

More complex and difficult to treat







Projectil premaksilla
Broad and flared nasal tip
Prolabium
Short columella or absent columella
Incomplet or complet
It is important to retropositon the
premaksilla with presurgical orthopedic
treatment
Surgical techniques used for unilateral cleft
lip repair are used for bilateral cleft lip
repair in one or two stage operation
(Millard, Tennison...)
Treatment of Premaksilla

Lip repair or “Lip-adeshion”

Elastic traction ( with a Head Bonnett)

Premaksillary retantion (Latham)

Nazoalveoler molding (Grayson)

Surgical premaksilla excision or set-back
(severe maxillary retrusion)
Bilateral Incomplet Cleft lip Operation Technique
Millard (Two stage)
Bilateral Incomplet Cleft lip Operation Technique
Straight Line Closure (One stage)
Cleft Palate
 Palate
and palatal muscles close the
velopharengeal valve
 Velofarengial closure can not be done in
cleft palate patient.
 Patient can not create intraoral pressure
 Feeding and speach are effected
Problems with cleft palate
Feeding
Speech
Hearing
and middle ear problems
Additional anomalies (% 30)
Psychological problems
Goal of Palatal Repair
 Understanble
speech
 No maxillary retrusion
 No hearing problem
 Good occlusion
Palatoplasty Technique
Surgical treatment of isolated cleft palate
Von Langenback
Method
“Double opposing Z Plasty”
Pierre Robin Sequence

Micrognathy

Glossoptosis

Airway obstruction
Cleft palate( % 50 )
Breathing and feeding problem
Treatment of Velopharyngeal
Insufficency

Patient should evaluate by speech terapist
before any treatment
 Nasendoscopic evaluation and Multiview
videofluoroscopy is importany diagnostic
tests
 Goal is to provide normal velopharyngeal
anatomy
Surgical Treatment of
Velopharyngeal Insufficency
 Pharyngeal
Flaps (Superior, inferior pedicled)
 Pharyngoplasty (Hynes, Orticochea)
 Soft
palate lengtening and levator
muscle repair
 Posterior
proplast)
wall augmentation (teflon,
Other Operations

Fistula Repair
 Velopharyngeal Insufficency correction (5 yeras)
 Secondary Onarımlar (preschool age)
 Alveolar bone grafting (before canine theth eruption)
 Orthodontic Surgery (12-14 years)


(Le-Fort I Maksillary osteotomy, Mandibular split ramus osteotomy)
Rhinoplasty (16-18 years)
Thank you for your Attention