Cleft Lip and Palate Repair

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Cleft Lip and Palate Repair

Anil Gungor


♦ Cleft Lip Repair



  • The surgical/aesthetic success of cleft lip repair is dependent on:

    • Extent of deficiencies of bone, cartilage, and soft tissue
    • Surgical skill and technique
    • Attention to details, such as racial characteristics, biology of scar formation, parent education, and cooperation in postoperative care

  • Simultaneous repair of the cleft lip and cleft nasal deformity grant the best results. Future nasal reconstruction may not be necessary with simultaneous repair.

Preoperative Considerations



  • Preoperative evaluation includes determination of:

    • Width of cleft and deficient lip elements
    • Extent of nasal deformity
    • Columellar dimensions
    • Premaxillary protrusion

  • Lip repair should be undertaken at 10 weeks of age, in a child of at least 10 lbs, with a minimum hemoglobin level of 10 g/dL. Airway obstruction, comorbid conditions, and genetic evaluation should be resolved prior to surgery.
  • The use of presurgical orthopaedics (PSO) (combined nasoalveolar molding with maxillary and premaxillary manipulation) in clefts with severe asymmetry and/or severe protrusion of the premaxilla and short columella will improve cosmetic outcome and reduce risk of postoperative wound dehiscence.

Surgical Technique



  • Millard’s1 original description (1976) of the rotation–advancement technique provides consistently pleasant results for unilateral clefts. The goals of surgery are to:

    • Match the scar of repair with the philtral column on the noncleft side
    • Create three-dimensional symmetry of the Cupid’s bow on the cleft side
    • Match the white roll on the vermilion-cutaneous border and the red line (wet vermilion to dry vermilion) on the mucosal lip (Fig. 41–1A).

  • All landmarks are carefully marked after measurements with surgical calipers using operating loupes. Marking starts with the identification of (1) the low point (midline) and the peak (2) of the noncleft side (NCS) Cupid’s bow. The distance between these two points is used to determine the position of the peak of the Cupid’s bow on the cleft side (CS) (3). The alar base on the NCS (4), the columellar base (5), and the commissures (6) and (7) are marked freehand. The lateral peak of the Cupid’s bow (8) is marked by taking the distance from the CS commissure and the width of the vermilion into account. The combined vertical height of the wet and dry vermilion at (8) should match that of the vertical height of the vermilion at (3) (r and r‘). Therefore, (8) can be placed within 1 to 2 mm of the measured distance (matching the distance between (2) and (6)) from the commissure, to match the vermilion in height. A close match of the required vermilion height is necessary. The alignment of the red line and additional vermilion height is obtained by drawing a laterally based triangular vermilion flap (VF) on the CS (Fig. 41–1B).
  • The tip of the advancement flap (9) is marked so that the distance between (8) and (9) matches the distance between (2) and (5) (Fig. 41–1A). Avoid discolored, thin skin with increased vascular patterns when designing the flap. The slightest difference in color here will be highly visible against the contrast provided by the NCS lip and columellar skin.
  • The nasal tip (projection) and columella are the slowest growing elements. These features can be constructed of normal size or of slightly larger than normal size.
  • The rotation incision is followed by a very small (<1 mm) releasing cut made high in the lip in a near-perpendicular angle to the rotation incision (Fig. 41–1B). This should allow the NCS to drop down without tension, creating a symmetrical prolabium and minimal transgression of the upper philtral column. Do not extend the back cut to the columella or across the philtrum.
  • The orbicularis oris is dissected from the skin along the rotation and advancement flaps. The extent of the dissection should not exceed 1 to –2 mm on the advancement flap and should not extend over the philtral dimple (midline) on the rotation flap (Fig. 41–1C

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Jun 14, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Cleft Lip and Palate Repair

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