48 Revision Cleft Lip and Palate Surgery Cleft lip and palate surgery represents an intervention on complex, three-dimensional interrelated abnormalities that undergo continued growth and development postoperatively. Residual imperfections and imbalances of the lip are very common; in fact, they may be considered the rule rather than the exception. Likewise, cleft palate surgery has a significant incidence of oronasal fistula formation and velopharyngeal insufficiency. The key to successful management of secondary deformities of the cleft lip and palate lies in an accurate diagnosis of the abnormality present. The surgeon must have an assortment of treatment choices in his or her armamentarium and choose the appropriate one thoughtfully. This chapter will begin with an outline of the essential treatment options for the primary repairs. This is followed by a listing of the common secondary deformities that may persist (or manifest as growth and development continue), with the treatment options available for each. A more thorough discussion of the secondary deformities and the treatment options available then follows. An attempt is made to provide the most useful techniques for the most common problems, keeping in mind that a vast array of techniques have been described for each historically. The cleft lip nasal deformity will only be briefly touched upon. I. Primary unilateral cleft lip repair A. Straight line closure B. Millard rotation advancement repair C. Tension-Randall triangular flap repair II. Primary bilateral cleft lip repair A. Veau straight line repair B. Millard straight line muscle repair with worked flaps III. Primary cleft palate repair A. V to Y pushback/two-flap palatoplasty B. Furlow double-reverse Z-plasty IV. Secondary deformities of unilateral and bilateral cleft lip A. Red lip deformities 1. Vermilion deficiency (“whistler’s deformity”) 2. Vermilion excess 3. Vermilion border deformities B. White lip deformities 1. Irregularities of the philtrum 2. Short upper lip 3. Tight upper lip 4. Long white lip 5. Columellar abnormalities C. Orbicularis D. Buccal sulcus abnormalities V. Secondary deformities of cleft palate A. Palatal fistula B. Velopharyngeal insufficiency (VPI) VI. Correction of secondary cleft lip deformities A. Red lip deformities 1. Z-plasty 2. V to Y mucosal advancement 3. Revision of lip repair 4. Excision of scar 5. Diamond excision 6. Horizontal versus vertical vermilion excision 7. Sublabial buccal mucosal advancements 8. Transposition flaps B. White lip deformities 1. Scar excision 2. Dermal grafts, subcutaneous rotation flaps 3. Redo lip repair with rotation-advancement flaps 4. Z-plasty 5. V to Y advancement flaps 6. Abbe flap 7. Subalar skin excisions 8. Supravermilion excisions 9. Vermilion advancement C. Orbicularis deformities 1. Take down repair, reapproximate muscle D. Buccal sulcus abnormalities 1. Local rotation or advancement flaps 2. Grafts: oral mucosa, split thickness, palatine mucoperiosteal VII. Correction of secondary cleft palate deformities A. Oronasal fistula 1. Observation 2. Turnover flaps 3. Rotation flaps 4. Redo two-flap palatoplasty 5. Furlow double-reverse Z-plasty 6. Local flaps: nasolabial, buccinator, tongue 7. Radial forearm free flap B. Velopharyngeal insufficiency 1. Speech therapy 2. Prosthesis 3. Sphincteroplasty 4. Posterior pharyngeal wall augmentation 5. Pharyngeal flap The primary treatment of unilateral cleft lip differs considerably from the treatment of bilateral clefts. In general, the bilateral cleft lip patient represents a significantly greater challenge to the facial plastic surgeon. However, the secondary deformities that present later with unilateral and bilateral cleft lips are often similar. Therefore, these two distinct entities will be considered together for the purposes of discussing the correction of secondary deformities. The cleft lip nasal deformity will not be included in this text. The key to successful outcomes with revision surgery lies in the accurate diagnosis of the deformity. One must be both thorough and precise. The patient must be observed carefully in both animation and repose. The scar is only one aspect of the lip evaluation. The entire lip must be analyzed critically. This includes the white lip, the orbicularis muscle function, the vermilion border, Cupid’s bow, the philtral columns, the white roll, the columella, and the sulcus. The lip is inspected in all three dimensions. This careful evaluation of the entire lip is then performed in animation, as the patient smiles and puckers. Next, the lip is palpated. The integrity of the orbicularis oris is determined at rest and in motion. The distensibility of the lip is checked. Measurements are made of the landmarks. It may be helpful to consider the lip as if it had not been operated on before, to evaluate the entire lip and not simply focus on what seems initially to be the deformity. Photodocumentation is performed. Multiple factors influence the timing of the secondary procedure. Initially, it is best to be conservative and allow time for the initial procedure to fully heal. The patient may be mature enough at this point that he or she is aware of an abnormality that exists and wishes it corrected. This must be taken into consideration, as significant psychological stress may be associated with the deformity. Because the treatment of the cleft lip and plate is a multistage process, it may be possible to perform the revision surgery at the time of another procedure. Deficiencies of the red lip, which include the classic “whistler’s deformity” (a central notching defect) of the bilateral cleft lip, are relatively common after cleft lip repair.1 In the case of the unilateral cleft, this often takes the form of a Cupid’s bow deficiency. The vermilion deficiency may be the result of the overaggressive resection of the mucosa or secondary to poor alignment of the orbicularis oris. Another manifestation includes asymmetry of the vermilion. The patient with evidence of vermilion deficiency must be carefully examined to determine if the problem is secondary to inadequate orbicularis approximation versus excessive resection of mucosa. This is commonly seen after the rotation-advancement technique when excessive scar contracture occurs. Failure to recognize the former will lead to inadequate correction. The vermilion deficiency of either unilateral or bilateral cleft lip may be treated with a V to Y mucosal advancement flaps, Z-plasties, transposition flaps, free grafts, or cross lip flaps (Abbe flaps). Initially, inspection will reveal if the defect is secondary to a tethering band in the sulcus. If so, this can be released and elongated with a Z-plasty. The V to Y advancement flap is often useful. In this case, the V incision is made with the apex toward the sulcus, extending superiorly to the vermilion border. Including the orbicularis muscle in the flap adds fullness to the reconstruction. The mucosa is advanced superiorly and closed as a Y to fill in the deficient area.
Secondary Deformities of Unilateral and Bilateral Cleft Lip
Evaluation
Timing
Red Lip Deformities
Vermilion Deficiency
Treatment Options
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