Seminar on cleft lip

Presented by
Dr.Cathrine Diana PG III
content
 Introduction
 History
 Embryology
 Etiology
 Epidemiology
 Classification
 Parent counselling
 Feeding
 Surgical procedures – lip repair
 Post op care
 Further procedures
 Recent advances
Introduction

 A cleft lip is a type of birth defect that affects the upper lip.

 Cleft lip (cheiloschisis) and cleft palate (palatoschisis) most

common congenital malformation since prehistoric times.

 Occurs in a Well-defined places, along definite axis.

 History
 The 1st documented CL surgery was from china in 390 BC.in a 18 years old
soldier wey young chi

 Jehan Yperman - 1st to describe the unilateral and bilateral CL repair

 Ambrose Pare – 1st diagrammatic representation of CL repair in 14th century

 Le monnier – 1st successful CP repair in paris (1776)

 Asensio – novel technique of CL repair in 1950

 Germanicus Mirault – originator of traiangular flap – modified by tennison and

Randall

 Ralph Millard – classic- rotational advancement technique in mid 1950s

 Cleft-lip – the historic perespetive S.Bhattacharya, V.Khanna,R. Kohli international journal of olastic surgery oct 2009
Emryology:
 Facial embryogenesis:
 Its not the birth marriage or death but the gastrulation ..
Which is truly the most important time in your life - lewis
Wolpert
 Etiology

 The exact cause of clefting is unknown

 Multifactorial

 chemical exposures, radiation, maternal hypoxia, teratogenic drugs,

nutritional deficiencies, physical obstruction, and genetic influences.
Genetic (non- syndromal)
 Genetic basis is significant, but not predictable

 Lack of potential for mesodermal proliferation across the fusion lines after the
component parts are in contact.

 Error in the transitional shift of the embryonic blood supply.

 Chromosomal abnormalities causing multiple congential malformations

including cleft

 Obstructing tongue ,asynchronous development or foetal position

The syndromal etiologic factors were classified by Pashayan in 1983 into:

1. Major mutant genes usually with a known Mendelian inheritance pattern

such as the Treacher-Collins, Stickler or van der Woude syndrome.

2. Chromosomal abnormalities such as the trisomy D,E and G

3. Teratogenic syndromes secondary to drug and alcohol ingestion

• > 300 craniofacial syndromes involve cleft lip and/or palate

 Family relation
 Affected relatives predicted recurrence CL/P

 1 sibling 4.4%
 1 parent 3.2%
 1 sibling , 1 parent 15.8%

 Environmental :
Intensity, duration and the time of action – more important than etiological
factor
1. Infections (rubella, toxoplasmosis)
2. Growth hormone deficiency
3. Drugs: Steroids, Diazepam, Aminopterin, Anticonvulsants (incidence10X),
Aspirin,
4. Alcohol: fetal alcohol syndrome
5. Smokers (2X incidence)
6. Vitamin B and Folate deficiency
7. Radiation energy
8. Hypoxia and amniotic fluid alteration
 Epidemiology
 Cleft lip and palate occurs in about 1 to 2 per 1000 births in the developed
world. Rates for cleft lip with or without cleft palate and cleft palate alone
varies within different ethnic groups.
 The highest prevalence rates for (CL ± P) are reported for Native
Americans and Asians . Africans have the lowest prevalence rates.
 Native Americans: 3.74/1000
 Japanese 0.82/1000 to 3.36/1000
 Chinese 1.45/1000 to 4.04/1000
 Caucasians 1.43/1000 to 1.86/1000
 Latin Americans : 1.04/1000
 Africans: 0.18/1000 to 1.67/1000

 Watkins, SE; Meyer, RE; Strauss, RP; Aylsworth, AS (April 2014). "Classification, epidemiology, and genetics of
orofacial clefts.". Clinics in plastic surgery. 41 (2): 149–63
 It caused about 4,000 deaths globally in 2010 down from 8,400 in
1990.

 CLP – Native americans> Orientals >Caucasians > Blacks.

 No preponderance to any race in isolated cleft palate cases.

 CLP: M:F = 2:1

 Isolated palates: F:M = 2:1

 Site of clefting : Left: Right: Bilateral 6:3:1

CLASSIFICATIONS OF CLP
David and Ritchie (1922): according to position of the clefts in relation to
the alveolar process.

• Group I – Pre-alveolar clefts – unilateral (right or left), bilateral or median

• Group II – Post-alveolar clefts –

– involving soft palate only

– involving soft and hard palates

– submucous cleft

• Group III – Alveolar clefts – unilateral (right or left), bilateral or median.

Veau (1931) : divides cleft palates into
four groups.

• Group I – Cleft of soft palate only.

• Group II – Cleft of hard and soft palate

• Group III – Complete unilateral cleft

• Group IV – Complete bilateral cleft,

 Kernahan (1971) striped ‘Y’ classification

Millards modification
American Association of Cleft Palate Rehabilitation
Classification (AACPR):
based on the same principles used by Kernahan and Stark:

I . Cleft of primary palate

A) Cleft lip – unilateral, bilateral, median, prolabium, congenital scar

B) Alveolar cleft – unilateral, bilateral, median

II. Cleft of palate proper

A) Involving soft palate

B) Involving hard palate

III. Mandibular process cleft

A) Mandibular cleft lip

B) Mandibular cleft

C) Lower lip pits

IV. Naso-ocular cleft – extending from narial region to the medial

canthal region

V. Oro-ocular cleft – extending from the angle of the mouth towards

the palpebral fissure

VI. Oro-aural cleft – extending from the angle of the mouth towards
the ear
Tessier (1973) : Orbitocentric
classification of facial clefts.
• Facial clefts are numbered 0 – 7

• Cranial clefts from 8-14.

• Orbit - reference landmark

• Cleft lip is part of clefts 2 and 3.

Indian classification Balakrishnan 1975 :
 Cleft type abbreviation

 Cleft lip GP 1

 Cleft palate GP 2

 Ceft lip. Palate alveolus GP 3

 Right R

 Left L

 Median M

 Alveolus A

 Partial P

 Submucosal S

 Simonart’s band Sb

 Microform micro
 US classification 1995:
 type 1, cleft lip alone
 type 2, unilateral cleft lip and palate
 type 3, bilateral cleft lip and palate
 type 4, midline cleft lip and palate
 type 5, facial defects associated with amniotic bands or limb-
body-wall complex
 Prenatal diagnosis
 2D ultrasound between 18-24
weeks (18 –complete clefts, 24 –
incomplete clefts)

 All except isolated cleft palate

seen in 67-93% cases.
 The ultrasonographic surface
rendered oro-palatal (SROP)
allows the simultaneous
visualization on a single scan of the
superior lip, alveolar ridge and
secondary palate.

 Parent counselling begins from

here itself.

Fetal cleft lip and palate detection by three-dimensional ultrasonography W. Lee MD, J. S. Kirk, International
Society of Ultrasound in Obstetrics and Gynecology Volume 16, Issue 4 1 September 2000 Pages 314–320
Sequence in management
1. Immediately after birth

A) pediatric consultation and complete head and neck examination

B) parent councelling - special concerns, expected development,

treatment and expected outcomes should be explained to the parents.
C) genetic evaluation - first step taken, before initiation of any
treatment, to diagnose any associated syndromes. E.g. If a b/l clp is
associated with trisomy 13, lip repair should not be done as child is not
expected to live beyond early infancy

D) feeding

E) pre-surgical orthopedics

F. Surgical repair
 Pediatric consultation and complete head and neck
examination
 head – symmetry
• Auricle and external canal - for development and location.
• Facial analysis - symmetry and harmony, hemifacial hypertrophy or atrophy, and
facial clefting
• Otologic examination - pneumatic otoscopy and tuning forks.
• Anterior and posterior rhinoscopy - clefting, septal abnormalities, intranasal
masses, and choanal atresia.
• Oral cavity- cleft, dental arch abnormalities and tongue anomalies such as bifid
tongue, macroglossia, glossoptosis, or lingual thyroid, malocclusion.
• Upper airway tract - adequacy of phonation, cough, and deglutition, and by
auscultating and palpating the neck.
Feeding

• Unilateral cleft lip alone - seldom present with feeding problems.

• Cleft lip and palate or isolated cleft palate – major feeding

problems

• Easier to breast feed a child with CP than CL.

Feeding precautions
Minimise nasal regurgitation and aspiration -
hold the child at an angle of 45-60° to the
horizontal during feeding.

2. Do not flood the pharynx - provoke

aspiration.

3. Infant with a major cleft tends to swallow air

while feeding – feed more frequently than a
normal child.

4. Breast feeding is only sufficient for two

weeks. After this, expressing milk and
supplement is necessary.
Feeders:
 Soft bottles, modified teats -
slightly enlarged hole/cruciform
design.

 • Spoon-feeding is an
alternative to bottle feeding.
Squeeze Haberman feeder.
Pigeon feeder
Check weigh gain: + 8 ounces (225 gms) a week (pre & post
surgery)

• Fever, diarrhea, vomiting, excessive sweating or other reason

to lose fluid (drains, bleeding, etc) greatly increase this
requirement
PRE-SURGICAL ORTHOPEDICS
 Reduces the size of cleft; Aids in Surgery

 Partial obturation aids in feeding

 CONTROL OF PREMAXILLA
Lip correction over a conspicuously protruding premaxilla - excessive tension,
dehiscence of the wound or spreading of the scar.

• Traction by external elastic with headcap

• Lip adhesion

• Intra-oral elastic devices

• Surgical setback of the premaxilla

Orthodontic (lip) taping :
 Pre-surgical Orthopedic (PSO) appliances - custom-made acrylic
base plate that provides improved anchorage in the molding of
lip, nasal and alveolar structures during presurgical phase.
Duration – 2-3 months
 The use of infant orthopaedic plate before CL repair may favour
correct arch form establishment in infants with unilateral
complete cleft lip and palate
 Latham appliance: screw retained device -
significant growth restriction of midface

• Grayson’s naso-alveolar molding

appliance: non pin retained

Quinn – Georgiade appliance designed by

Orthodontist,).
•"The nasal ala projection length demonstrated an average ratio of 93.0 percent in
the surgery-alone group and 96.5 percent in the nasoalveolar molding group"

Barillas I, Dec W, Warren SM, Cutting CB, Grayson BH (March 2009)."Nasoalveolar molding improves long-term nasal
symmetry in complete unilateral cleft lip-cleft palate patients". Plast. Reconstr. Surg. 123 (3): 1002–6.
Gingivoperiosteoplasty:
 Using limited flaps to close alveolar cleft during primary lip/palate
repair, in an attempt to have bone formation at the alveolus.

.
 In Isolated cleft lip the incidence of hearing loss is equal to norm al
population.
 • Cleft palate - eustachian tube dysfunction –require frequent
evaluation
 10-12 WEEKS: PRIMARY CHEILORHINOPLASTY:
• PRIMARY LIP REAPIR:

Aim:

• 3 layered closure of skin, muscle and mucosa, approximate normal

tissues, excise hypoplastic tissues at cleft margins

• reconstruct orbicularis oris into a continuous sphincter.

Primary nasal surgery:
– Minimal surgical dissection . Scarring affect the growth
–. Goals include closure of the nasal floor and sill, symmetry of the alar base, and
symmetry of the lower lateral cartilages with appropriate projection of the dome.
Recent literature supports that rhinoplasty performed at the time of the primary cleft lip
closure may reduce the frequency and magnitude of required intermediate and
definitive rhinoplasty operations.
– Alternative - correction of the displaced alar cartilages before school age
(approximately 5 years). Primary nasal reconstruction performed with cleft lip repair
makes the nasal tip more symmetric and requires less complex intervention at the time
of definitive secondary rhinoplasty

 Curr Opin Otolaryngol Head Neck Surg. 2014 Aug;22(4):260-6. Update on primary cleft lip rhinoplasty.
Gudis DA1, Patel KG
 Plast Reconstr Surg. 2012 Mar;129(3):740-8. doi: 10.1097/PRS.0b013e3182402e8e.
 Long-term effect of primary cleft rhinoplasty on secondary cleft rhinoplasty in patients with unilateral cleft lip-
cleft palate.
 Haddock NT1, McRae MH, Cutting CB
Normal anatomy - upper lip
• Vermillion: The lower margin of the upper lip, characterized

by its rosy colour.

• Vermillion border: The line or ridge between the skin of the

upper lip and the vermilion

• White roll: thin raised white line just above vermillion

border

• Cupid’s bow: the concave or dipped portion of the

vermilion border in the centre of the upper lip.

Philtral dimple: Above the center of the upper lip

• Philtral columns/lines: the raised ridges on either side of this dimple

• Prolabium: In unilateral clefts, the philtrum remain attached to the larger

portion of the lip. In bilateral clefts, the philtrum is isolated from the lateral lip
segments.

• Length of the lip: length of the skin from the base of the nose to the lower
margin of the vermilion
Timing of surgery
Millard "rule of ten’s”:10 weeks old, 10 grams Hb,10 pounds weight, WBC
count of 10,000/mm3

• Randall - repair in first ten days of life, as soon as health permitted - maximal
healing potential exists, prevents a separate hospitalization and parents leave
the hospital with a relatively normal appearing child

• Delay of closure - time to complete pediatric evaluation, understanding of the

congenital defects Landmarks more visible as age increases.

• B/L CL – weight = 12-14 pounds - to have more tissue to work.

Recent protocol 2001

Atlas of oral and maxillofacial Clinics of NA: 2009

 Basic surgical preparation
 GA using oral RAE (Ring – Adair- Elwyn) tube taped
to midline of lower lip - not to produce any lateral
distortion
 • The infant is placed in folded towels with the neck
slightly extended.
 • Points – 30 gauge needle - Bonney’s blue (Brilliant
green 1/2 g, Crystal violet 1/2 g, Alcohol 96% 46ml,
Water for injection 53ml) or methylene blue.
 • After markings - 0.5% lignocaine with 1:2,00,000
epinephrine is injected into the lip tissue. It also helps
to grip lip firmly between thumb and index finger to
avoid bleeding while incising. Wait for 5 minutes after
infiltration. GA using oral RAE (Ring – Adair- Elwyn)
tube taped to midline of lower lip - not to produce any
lateral distortion
 Goal of surgery is to achieve a normal looking lip and a
normal looking nose, which will not be distorted by the effects
of ageing and growth
 Steffenson (1953) - five criteria for a satisfactory lip repair:

 1. Accurate skin, muscle and mucous membrane union with adequate lip

lengthening,

 2. Symmetrical nostril floor,

 3. Symmetrical vermilion border,

 4. Slight eversion of the lip and

 5. A minimal of scar, which by contraction will not interfere with the

accomplishments of the other, stated requirements.

 • Two additional criteria were added later by Musgrave
(1971)
 1. Preservation of the cupid’s bow,
 2. Production of symmetrical nostrils.
 TECHNIQUES OF REPAIR

U/L CLEFT LIP B/L CLEFT LIP

• Millard’s rotational advancement • Straight line closure

• Modifications of millard’s • Columella lengthening

technique: • Millard repair

– Millard II • Tennison-Randall triangular flap

– Skoog’s Technique • Other techniques:

– Bauer Method
– Mohler’s Technique
– Manchester method
• Tennison-Randall Triangular flap
– Skoog method
• Delaire’s Functional lip closure
– Wynn method
Afroze technique
– Barsky technique – Modified Veau II
– Primary Abbe’s flap
Ambroise Paré1564
Mirault ( Blair and Brown)
 Mirault (1844) described a lateral inferior triangular flap

 approximated to a medial pairing, that increased the length of lip.

 Blair (1930) and Brown (1945) modified to reduce the size of

triangular flap – straight line scar without a cupid’s bow and an
asymmetric vermillion tubercle.
Hagedorn (Le Mesurier)

 In 1949, Le Mesurier demonstrated a modification of the Hagedorn

technique (1892), in which a quadrilateral flap is introduced into the

releasing incision to create and artificial cupid’s bow.

Tennison – Z plasty

 Tennison (1952) –frustrated by straight-line scar contraction in blacks -

Z-plasty technique which preserves the cupid’s bow and places it in
normal position - He inserted a wedge from the lateral lip into the
lower portion of the medial lip, and achieved good results – and called
it ‘stencil method’ - came to be known as the Tennison triangular flap
technique.
 Randall’s modification

 Randall (1959) modified - by reducing the size of the inferior

triangular flap, and defined the precise mathematics of the method.
 Disadvantages:
 Violation of philtrum on the cleft
side

 Difficult in modifying the repair

during Secondary revision

 mathematical precision in
measurement is necessary in the
pre-operative assessment and
during the surgery
Millard’s rotation-advancement
repair "cut as you go"
 Advantages:
Disadvantages:
 • The flaps can be modified after
initial cutting to bring down the cleft • The scar is almost always a
side to the level of the non cleft little short and even when the
side. This technique scarifies little static length of the new
tissue from the margin of the cleft. philtral column is satisfactory,
 • Dissection of muscle as a dynamic motion will not be
separate layer is relative natural. In a wide cleft the
straightforward and a three layer closure can be difficult to
closure can be achieved. achieve and it an be a very
 • This scar is excellent for later radical procedure where cleft
revision. It stimulates a normal is minimal.
philtral column and this technique
produces a best possible nasal
philtrum.

 Millard II operation
 Adequate rotation has been a problem for a number of surgeons.
Millard himself suggested acute back-cut at approximately 90° at the
end of the rotation incision, running parallel but medial to the philtrum,
and the C flap insertion into the upper half of the back-cut. During the
final suturing, the tip of the advancement flap is sutured to the depth
of the rotation back-cut. This increases the rotation and ensures
adequate lengthening and horizontalisation of the cupid’s bow.
 Mohler modification

He extended the rotation into the base of the columella, made a back-cut, and
sutured it to the lateral flap. Muller in 1989 - concept of differential
reconstruction of the orbicularis oris muscle in unilateral cleft lip repair’
The Mohler technique yielded a more symmetric result
Skooge’s Modification
Delaire’s functional lip closure
• Does not make use of flaps - accurate reconstruction of the 3 rings
of muscles of the Lip and nose

• Creates a highly symmetric nose and a functional lip: separates

cosmetics from function
Delaire – 3 rings of muscles

• NASO-LABIAL/UPPER RING: Transverses nasi,

levator labii superioris alequi nasi, levator labii
superioris, zygomaticus minor and the levator
anguli oris.
• BILABIAL/MIDDLE RING: Represents oral
sphincter, consisting of the upper and lower lip
orbicularis oris muscle.
• LABIO-MENTAL/LOWER RING:Lower ring has
an incomplete circumference and consists of
orbicularis inferior, triangularis labii and quadrates
labii inferioris.
•Concept: The integrity of the first ring is fundamental for sustaining and
allowing normal functioning of the other two. The cartilaginous nasal
septum stimulates the periosteum of anterior part of maxilla and
ensures harmonius growth of the latter.
Labial motility in addition to modeling directly the underlying dento
alveolar structure by means of median septum acts in positively
influencing the growth of premaxilla.
The lower ring acts by remodeling the dento alveolar complex and chin
portion of the mandible vertically and transversely.
Drawback:
Straight-line scar and inability to achieve adequate lengthening of the
lip, resulting in a notching. But its proponents claim that this lack of lip
symmetry will gradually reduce by the effect of normal labial muscle
function.
 Afroze technique:

The Afroze incision is a combination 2 incision, that is, the Millard incision on the
noncleft side and Pfeiffer incision on the cleft side

Afroze Incision for Functional Cheiloseptoplasty. Gosla srinivas reddy, rajgopal R reddy, Stefaan Berg The Journal of craniofacial
surgery 20 Suppl 2(8):1733-6 · September 2009
 The advantage of this technique is that there is no tension on the
postoperative scar because the incision is essentially horizontal in
nature, and the contracture of the scar occurs horizontally rather
than vertically
 incision can be used in all types of complete unilateral cleft lip
regardless of the width of the cleft, shortening the cleft lip segment.
Afroze Incision for Functional
Cheiloseptoplasty
 B/L cleft lip repair
A lip that is completely cleft on both sides - usually associated with a
cleft of primary or whole palate.

• Prolabium- total absence of orbicularis oris muscle and is attached to

the tip of the nose by an almost non-existent columella.

PRE-TREATMENT EVALUATION:

1. Whether the cleft is complete or incomplete

2. The size and position of the premaxilla and the prolabium

3. The length of the columella

4. Whether the inter-alveolar space is sufficient to accommodate the

premaxilla

5. The presence or absence of associated anomalies, like lip pits.

1. Straight Line Closure (Veau III operation)
• Simplest technique with satisfactory results
• Some resulting scar contracture – symmetrical an
accentuates cupid’s bow
 2. Tennison’s adaptation
 The procedure for unilateral clefts is done on both sides. This repair
results in zigzag scars. The central part of the vermilion margin
protrudes in a more normal manner than is achieved with the straight-
line repair. Usually, a two-stage procedure is necessary, one
side repaired at a time
Bauer, Trusler, Tondra (1959, 1971)
Opposed any surgery on a protruding pre-maxilla and preferred
controlling it by operating one side at a time, with incisions similar to
Tennison.
 4. Millard repair (1960)

Forked flaps are raised initially and stored for future use while the lip is
closed in one stage. A prime requisite of this technique is a fairly large
prolabium (if the prolabium is too narrow, a straight-line repair or the
Wynn method is more preferable).
 The lateral vermilion mucosal flaps with the white roll are
brought to the midline while the prolabial vermilion is turned
downward. As a second stage, a V-Y advancement of the
banked flaps on the floor of the nose is employed to lengthen
the columella.
Primary b/l chilorhinoplasty
modified Millard technique

MARKINGS TO ASSESS THE DISTANCE –

TO OPTIMISE EQUALITY FROM
INTRA-OPERATIVE CLINICAL COMMISURES TO PROPOSED PEAKS OF
MARKINGS CUPID’S BOW
RESIDUAL VERMILLION – FULL THICKNESS INCISION TO
TRIMMED AND USED TO AID RELEASE EACH RESPECTIVE LATERAL
CLOSURE OF PRE-MAXILLARY LIP ELEMENT.
MUCOSA
AFTER SHARP DISSECTION OF 3
LAYERS, INCISION OF
NASOALVEOLAR WEBBING IS DONE
FOR FINAL LATERAL
LIP RELEASE

SUTURING OF LATERAL LIP

MUCOSA
TO PRE-MAXILLARY
MUCOSA ON
EACH SIDE
INSET OF NEWLY CONSTRUCTED PHILTRUM AND
CLOSURE.

STERILE STRIPSAND ADHESIVE TAPES

APPLIED
TILL SUTURE REMOVAL
 Muliken technique
Stage 1

Stage 2
 6- Manchester method
2 stage repair of B/L lip and palate

• 1st – 5 months PSO – straight line closure preserving

prolabium, anterior palate repair

• 2nd – push back palate repair at 9 months of age

• Drawback – whistle deformity

Columella lengthening
A shortened columella is almost always associated with a complete
bilateral cleft lip. Columellar lengthening is usually not attempted at
the time of initial lip repair. It has been found that early repair
results in downward slippage of the columella and lip over the
premaxilla. Lengthening of columella may be done any time after
the patient is 2-3 years of age.
Cronin (1958) described a method of advancing skin from the floor of the nose and
base of the ala into the columella.
Converse (1957) also used skin from the floor of the nose. Millard (1958, 1971) and
associates used a forked flap from the prolabium.
Brauer and Fara (1966) employed the V-Y principle in the region of wide tip.
 Post op care:

 Dressing to be in place for 24 hrs

 Logan’s bow may be used
 Feed with bulb syring – 10-14 days
 All skin sutures were removed on 4th post op day
 Steri-strips for 10 days
I.V. Rehydration with maintenance fluids –

• 4 cc/hr/kg for each of the first 10 kg

• 2 cc/hr/kg for each kg between 10 and 20 kg

• 1 cc/hr/kg for each kg above 20 kg

 Complications of lip repair
1. Wound infection

2. Wound disruption / spreading of scar - only supporting tapes should be used

in the initial phase. No definitive repair should be attempted until all the
induration has subsided.

3. Lip scars – unavoidable – revision – Z plasty, W plasty, waveline excision.

Remove sutures within 4 days and use adhesive tapes

4. Long lip (vertical excess) – Tennison-Randall and LeMesurier techniques, or

excessive rotation in Millard flap. Correction – full thickness horizontal excision
below nostrill
5. Short lip (vertical defeciency) – notching – vertical scar along suture
line, inadequate rotation of medial flap.

6. Tight Lip (Horizontal defeciency): sacrifice of excessive tissue during

primary repair

– indrawn upper lip stretched across teeth. Correction is done using

Abbe’s flap – 180 degree transposition of lower lip flap inserted into
upper lip. Or maxillary advancement by orthognathic surgery

7. Orbicularis oris abnormalities: defeciency, discontinuity, diastasis.

8. Whistle deformity- thin central vermillion – after Manchester type
repair - may be prevented by augmenting the thickness of the
prolabium. B/L V-Y advancement or vermillion island flaps used for
correction.

9. Vermillion border defeciency: most common – corrected by Z plasty,

V-Y plasty, transposition flaps, free grafts, cross lip flaps

10. Buccal sulcus defeciency: corrected by V-Y or V-Z advancements.

11. Collapse of maxillary segments behind the premaxilla

Recent advances

 Neonatal chieloplasty: involving neonatal cleft lip repair and one-stage

palatal repair performed up to the first year of UCLP patient's life, has
shown good speech outcomes .
 Non- surgical correction of nasal deformity in CLP cases using special
retainer during neonatal period
 In utero correction of CLP - Successful open repair of a cleft lip in utero
has the advantage of scarless wound healing in the fetus. – in animal
study
 Repair of Cleft Lip in Utero by Reactivation of Craniofacial
Developmental Programs

 Journal of Pediatric Otorhinolaryngology, Volume 90, November 2016, Pages 71-76

References:
1 .Fonseca volume 6: Cleft and craniofacial deformities
2. Mc Carthy: PLASTIC SURGERY. Vol.4. Cleft lip & palate and Craniofacial
Anomalies
3. Peterson’s principles of oral and maxillofacial surgery volume 2
4. Atlas of oral and maxillofacial Clinics of NA: 2009
5. Cleft-lip – the historic perespetive S.Bhattacharya, V.Khanna,R. Kohli
international journal of olastic surgery oct 2009
6. Barillas I, Dec W, Warren SM, Cutting CB, Grayson BH (March
2009)."Nasoalveolar molding improves long-term nasal symmetry in complete
unilateral cleft lip-cleft palate patients". Plast. Reconstr. Surg. 123 (3): 1002–6.
7. Fukuyama E, Omura S, Fujita K, Soma K, Torikai K (November 2006). "Excessive
rapid palatal expansion with Latham appliance for distal repositioning of protruded
premaxilla in bilateral cleft lip and alveolus". Cleft Palate Craniofac. J. 43 (6): 673–7
8. Watkins, SE; Meyer, RE; Strauss, RP; Aylsworth, AS (April 2014). "Classification,
epidemiology, and genetics of orofacial clefts.". Clinics in plastic surgery. 41 (2):
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9. Repair of Cleft Lip with Nonsurgical Correction of Nasal Deformity in the Early
Neonatal Period. Matsuo, Kiyoshi M.D.; Hirose, Takeshi M.D.; Otagiri, Tetsutaro
M.D.; Norose, Noboru M.D. 1989American Society of Plastic Surgeons
10 Repair of Cleft Lip in Utero by Reactivation of Craniofacial Developmental
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11.Palatal growth in complete unilateral cleft lip and palate patients following neonatal
cheiloplasty: Classic and geometric morphometric assessment International Journal of
Pediatric Otorhinolaryngology, Volume 90, November 2016, Pages 71-76 Eva Hoffmannova,
Šárka Bejdová, Jiri Borský, Ján Dupej, Veronika Cagáňová, Jana Velemínsk

12. Variation trends of the postoperative outcomes for unilateral cleft lip patients by modified
Mohler and Tennison-Randall cheiloplasties Journal of Cranio-Maxillofacial Surgery, In Press,
Accepted Manuscript, Available online 9 September 2016 Liqi Li, Lishu Liao, Yuxiang Zhong,
Yuangui Li, Li Xiang, Wanshan L

13. Comparison of two treatment protocols in children with unilateral complete cleft lip and
palate: Tridimensional evaluation of the maxillary dental arch Journal of Cranio-Maxillofacial
Surgery, Volume 44, Issue 9, September 2016, Pages 1117-1122 Paula Karine Jorge, Wanda
Gnoinski, Karine Vaz Laskos, Cleide Felício Carvalho Carrara, Daniela Gamba Garib, Terumi
Okada Ozawa, Maria Aparecida Andrade Moreira Machado, Fabrício Pinelli Valarelli, Thais
Marchini Oliveira

14. Treatment outcome after neonatal cleft lip repair in 5-year-old children with
unilateral cleft lip and palate International Journal of Pediatric Otorhinolaryngology, Volume
87, August 2016, Pages 71-77 Olga Košková, Jitka Vokurková, Jan Vokurka, Alena Bryšova,
Pavel Šenovský, Julie Čefelínová, Darina Lukášová, Petra Dorociaková, Juraj Abelovský
15. Prenatal diagnosis of cleft lip/palate: The surface rendered oro-palatal (SROP) view of the
fetal lips and palate, a tool to improve information-sharing within the orofacial team and with the
parents Jean-Marc Levaillant a , Romain Nicot a , Laurence Benouaiche b , Gerard Couly c ,
Daniel Rotten
Thank you