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Treatment/surgical technique 537 A B ATS C Fig. 23.32 (A) Semiopen rhinoplasty with a reversed U incision on the cleft side and a rim incision on the noncleft side. (B) Exposure of the caudal edge of the lower lateral cartilages (right upper). Release of the fibrofatty tissue from both LLCs with sharp dissection to avoid iatrogenic injury to the cartilages. The fibrofatty tissue should be completely released from the cartilages. (C) Careful trimming of the excessive skin after approximation of the LLCs (left). Additional sutures on medial crura and the alar transfixion sutures (ATS) (right). reconstructing the nostril floor, the alar base is advanced LLC. Skin dimpling from the sutures disappears 2 weeks after farther to its proper width compared with the normal side. surgery (Fig. 23.32C, 23.30, right). The alar-facial groove is further accentuated by the approxi- Examples of the results by the technique described are mation of the lip musculature. shown in Figures 23.33–23.35. Adjustments at cheiloplasty Creation of the alar-facial groove Dissection between the skin and LLC releases the fibrous Making the necessary minor adjustments to achieve a satisfac- attachments between the skin and the LLC.88 It also leaves a tory result is the enjoyment and challenge of cleft surgery. dead space under the skin. Mobilization of the alar base on Every cleft is different and always needs minor adjustments. cleft side will accentuate the vestibular webbing inside the Long vertical length of cleft side lip cleft side nostril. Alar transfixion sutures help solve these problems and define the alar-facial groove. Two sutures are A vertically long lateral lip is seldom encountered. It can be usually required. The lower suture is used to close the dead avoided by the septal anchoring suture used to suspend the space and tack the vestibular webbing. The upper suture lateral lip upward, and by trimming the excessive tissue on catches the leading edge of the LLC and helps to support the the nasal floor. 538 SECTION I •23• Repair of unilateral cleft lip AD BD Fig. 23.33 (A,B) A 2-week-old girl with left CD DD complete cleft of primary palate (LPC, 11–15). (C,D) Postoperative views at the age of 6 years. AD BD Fig. 23.34 (A,B) A 2-week-old boy with right complete cleft of primary and secondary palate CD DD (RPC, RSC, 1–9). (C,D) Postoperative views at the age of 5 years. Treatment/surgical technique 539 AD BD Fig. 23.35 (A,B) A 2-week-old boy with right complete cleft of primary and secondary palate CD DD (RPC, RSC, 1–9). (C,D) Postoperative views at the age of 4 years. Short vertical length of cleft side lip corrected as a secondary procedure with use of temporopari- etal fascia graft for lip augmentation.90 This is a common problem in most complete clefts. An ade- It is more often to see a bulging free border in incomplete quate release and approximation of the orbicularis muscle clefts. The most accurate way to correct the excessiveness is will increase the vertical length by 3 to 4 mm. If the lip is still to make incision along the red line, raise an inferiorly based short, point CPHL′ can be moved laterally 1 to 2 mm. Also, a mucosal flap with a thin layer of marginalis muscle, redrape small 1–2 mm triangular skin flap designed on the lateral lip the flap, and trim the excessive tissue (Fig. 23.36). can be inserted into the medial lip just above CPHL′. Last, a perialar incision can be made; however, this is done as a last resort. Rotation advancement cheiloplasty Long horizontal length of cleft side lip for incomplete clefts This is a relatively simple problem. Point CPHL′ can be moved The incomplete cleft lip is sometimes surprisingly difficult to laterally as far as necessary to shorten the horizontal length. reconstruct. Also, the expectations for a good result are higher. Short horizontal length of cleft side lip It is a common mistake to underestimate the pathology and do less of a procedure in reconstruction. It is also a common This problem is almost impossible to solve. After muscle dis- mistake to have the impression that a vertically long lateral section, release, and approximation, the horizontal length of lip exists, and try to shorten the lip during the operation. the cleft-side lip will usually increase several millimeters. A Intraoperative measurements usually show the vertical height horizontally short lip does not look bad compared with is similar between the two sides. The appearance of a verti- a vertically short lip with peaking of the Cupid’s bow. cally long lateral lip results from the downward displacement of the cleft side alar base. It is important to fully mobilize the Long vertical height of noncleft side lip alar base and reposition it cephalically, instead of vertically Any vertical length over 12 mm on the noncleft side lip, e.g., shortening the lateral lip. on a 3-month old baby is excessively long and difficult to manage. To shorten this would entail excising a portion of Markings and incisions a full-thickness segment of the lip, and that is seldom performed. The rotation incision and muscle dissection is made similar to complete clefts in a Mohler’s fashion. The C-flap is raised Free border of the lateral lip similar to complete clefts. The incision on the advancement If the lateral lip is too thin or deficient, the mucosa can be flap is made along the cleft edge. The WSR flap is also designed released, but this seldom corrects the problem. This is better (Fig. 23.37). 540 SECTION I •23• Repair of unilateral cleft lip (cid:39)(cid:36) (cid:39)(cid:37) (cid:39)(cid:38) Fig. 23.36 The most accurate way to correct the excessiveness is to make incision along the extension of the red line from medial lip (A), raising an inferiorly based mucosal flap with a thin layer of marginalis muscle (B), re-draping the flap and trimming the excessive tissue (C). abnormal muscle insertions to the alar base, which will cause the lateral and downward displacement of the alar base in secondary deformities. The OM flap is raised as in complete clefts. Nasal floor reconstruction The local tissue on the nasal septum and piriform area is turned over and sutured to each other, matching the height of the nasal floor on noncleft side nostril (Fig. 23.39). The alar base is turned in, and the leading edge of the vestibular incision is sutured to the mucosa on the nasal floor as in complete clefts. Theoretically, placing Surgicel under the periosteum of the cleft side nasal floor could stimulate new bone formation, thus correcting the bony deficiency in this area. However, in a study performed by the authors, there was no benefit achieved in the overall aesthetic outcome.91 Muscle reconstruction Muscle reconstruction is performed as in complete clefts, using an anchoring suture to the septum for centralizing Cupid’s bow. Overlapping mattress muscle sutures are used Fig. 23.37 Markings for incision lines in incomplete clefts with incision made along the free edge of the skin. to reconstruct the philtral column. Nasal correction Nasal floor incision Nasal correction is performed as in complete clefts with a A transverse incision is made inside the nasal floor at the rim incision on noncleft side nostril and reversed U incision junction of the skin and mucosa, leaving ample tissue on piri- on cleft side. The cartilage dissection, cartilage repositioning, form area and premaxilla. A subperiosteal dissection is made alar transfixion sutures are the same. The cleft side nostril from septum along the nasal floor to the piriform rim to raise needs to be over-corrected (a taller and narrower nostril) the local tissue. The local flap will be used for correction of as in complete clefts. An example of the result is shown in the nasal floor deficiency (Fig. 23.38). Figure 23.40. Dissection and release of muscle and elevation Excessive free border of OM flap Although the “long lateral lip” is usually a false impression The technique and extent of muscle dissection is similar to in incomplete clefts, it is not unusual to have some bulging complete clefts. Less muscle dissection tends to leave the on the free border of the cleft side lateral lip after leveling Fig. 23.38 The incision lines for C-flap and nasal floor: a transverse incision is made inside the nasal floor at the junction of skin and AD (cid:37) mucosa leaving ample tissue on piriform area and premaxilla. (cid:39)(cid:36) (cid:39)(cid:37) (cid:39)(cid:38) Fig. 23.39 The local tissue on nasal septum and piriform area (A) is turned over (B) and sutured with each other to match the height of the nasal floor on noncleft side nostril (C). AD BD Fig. 23.40 (A,B) A 2-week-old boy with left incomplete cleft of primary and complete CD DD cleft of secondary palate (LPI, LSC, 12–19). (C,D) Postoperative views at the age of 7 years. 542 SECTION I •23• Repair of unilateral cleft lip Postoperative care Immediate postoperative care and monitoring is performed in the recovery room. The caregiver is allowed to enter the recovery room to hold the baby and is given instructions about maintaining the airway. A nurse specialist gives further instructions about the airway and subsequent care of the infant after return to ward. Instructions are given for clearing any mucus in the mouth or upper airway. A soft nipple with good flow is used with bottle-feeding. Feeding is started as soon as the baby desires. No arm restraints are used. The wound is cleaned of any blood or mucus by a normal saline-soaked swab every 2–6 h. Antibiotic ointment is placed on the suture line after it is cleaned, keeping it from drying out or crusting. Normal saline sponges placed on the wound also seem to reduce pain and swelling. The infant and mother are discharged home the day after surgery and seen in the outpatient department in 5 days. At that time, skin sutures are Fig. 23.41 A typical feature of a left occult cleft lip showing its characteristic removed under oral chloral hydrate sedation. The incision is pathologies. treated with micropore tape and silicone sheeting (Fig. 23.43). The patient is usually seen in another week and then periodi- cally, to assure the parents are following the instructions. Massage of the lip scar is usually encouraged to hasten scar Cupid’s bow. If it is too prominent, the excessive free maturity.37 border can be trimmed using the technique shown in Figure 23.36. Postoperative maintenance of nasal shape Microform cleft lip Postsurgical molding was first used in 1969 by Osada95 and Skoog.96 Friede97 using an acrylic conformer, noted improve- Pathology ment in nasal contour. Matsuo98,99 first reported presurgical molding in the unilateral incomplete cleft with a silicone con- The pathology presented in a microform cleft lip includes: former, and this was continued full time for 3 months post- nasal asymmetry, a philtral groove or striae parallel to the operatively, and then at night for up to 12 months of age. The noncleft side philtral ridge, notching on free border of the lip, belief is that the deformed nasal cartilage is more easily and disrupted white skin roll with high peaking of the Cupid’s molded while it is still plastic enough to be manipulated. bow.92 The orbicularis muscle ring is often disrupted or mala- Subsequently, silicone nasal conformers have been used in ligned (Fig. 23.41). Bony deficiency is often present as shown many centers to support the LLC during the healing phase, in Figure 23.2. and to prevent contracture and nasal stenosis.35,37,100,101 Silicone nasal conformers have been used in the Chang Gung Center Discussion of different techniques since the late 1980s.102 The parents are instructed to use the conformers full-time for 6 months to 1 year if possible. The Surgical correction of microform cleft lip has received less conformers need periodic adjustment to increase the height of attention in the literature because of its minor deformity. the cleft side nostril, and maintain the nostril in an over- Efforts have been made to eliminate the external scar as corrected position. The adjustments are made by adding sili- with traditional rotation-advancement or straight-line clo- cone sheets (one millimeter in thickness) on top of the dome sures. Cho93 advocated orbicularis muscle interdigitation of the cleft side every 2–4 weeks (Fig. 23.44). Success in nasal through an intraoral incision. Mulliken92,94 suggested double conformer use depends more upon the cooperation of the uni-limb Z-plasties, muscle approximation and philtral ridge parents rather than the compliance of the patients. augmentation with a retro-auricular graft. The authors’ pref- erence is still a modified rotation advancement cheiloplasty similar to the technique used in incomplete cleft lips. It is felt that a rotation advancement cheiloplasty can better release Outcomes, prognosis and the malaligned muscle, mobilize the displaced alar base, complications reconstruct the philtral column in both height and direction, and over-correct the cleft side nostril. It also allows for the excision of the groove or striae which is not parallel to the Long-term results of lip morphology noncleft side philtral column. The repair almost always needs a triangular skin flap above the noncleft side Cupid’s bow to A symmetrical balanced lip is the goal of cleft lip repair. A correct the high peaking of the Cupid’s bow. Although scaring study was recently performed at the Chang Gung Craniofacial is the major concern, scars are usually good if surgery is Center evaluating the long-term lip morphology in a group of performed early (i.e., at 3 months) and parents follow instruc- 19 complete unilateral cleft lip patients operated on in 2002 tions for postoperative scar care (Fig. 23.42). with at least 4 years follow-up.103 The surgical technique was Outcomes, prognosis and complications 543 AD (cid:37) Fig. 23.42 (A,B) A 3-month-old girl with left CD (cid:39) occult cleft lip. (C,D) Postoperative views at the age of 7 years. similar to the technique herein described, except for the septal anchoring muscle suture. There were statistically significant differences among the measurements in lip vertical height (VR, VL) and horizontal length (HR, HL), and in the measurements from the central columellar base to the points CPHR and CPHL, between initial intraoperative measurements and those at 3 months. However, the data at 4 years follow-up revealed that VR was significantly longer than VL; that HR was significantly longer than HL; and that the columella- CPHR was slightly shorter than columella-CPHL (however not significant). This demonstrated that Cupid’s bow was deviated to the cleft side. Therefore, the authors now utilize a septal anchoring suture (Fig. 23.45), to pull the cleft side lateral lip medially, thus helping to centralize the Cupid’s bow. Long-term result of nasal morphology Fig. 23.43 Postoperative care with micropore tapes across the lip and silicone nasal conformer. The nasal conformer is held in nostril with tapes. It is also important to know the outcomes of long-term nasal morphology following the integrated approach with 544 SECTION I •23• Repair of unilateral cleft lip (cid:36) (cid:37) (cid:38) Fig. 23.44 The modification of the nasal conformer. Silicone sheets are added to the cleft side to increase the nostril height for maintenance of the nostril in over-corrected position. DA (cid:39)(cid:37) Fig. 23.45 Serial photographs of a boy with right complete cleft of primary and secondary palate. (A) 2 weeks old; (B) immediate after operation; (C) 1 year old before palate repair DC (cid:39) and (D) at the age of 5 years. The Cupid’s bow, though leveled, is deviated to the cleft side. presurgical nasoalveolar molding, surgical refinement, and shorter than the noncleft side, and the cleft side nostril was postsurgical maintenance. Two studies were conducted at the significantly wider (Fig. 23.46). The recent study included a Chang Gung Craniofacial Center evaluating the long-term group of patients who received the modified Grayson tech- nasal morphology outcomes. The initial study evaluated nasal nique of nasoalveolar molding. The surgical technique morphology in 25 patients operated on between 1997 and included repositioning of the LLCs through bilateral rim inci- 1999. All patients underwent Liou’s technique for nasoalveo- sions. This study demonstrated better results when compared lar molding.42 The surgical technique is similar to that with the previous study; nonetheless, there was a similar described herein, except no cartilage dissection or reposition- trend in terms of relapse. Based on these observations, it is the ing was performed. Although the nasal shape was quite sym- authors’ current practice to perform a reversed U incision on metrical immediately following surgery, at 3 years follow-up, the cleft side, and to over-correct the cleft side nostril in its there were significant differences among measurements of columellar height, nostril height and nostril width. As well, nostril height, columellar length and nostril width. The cleft the cleft nostril needs to be maintained in the over-corrected side nostril height and columellar height were significantly position with postoperative modified silicone conformer use. Secondary procedures 545 DA (cid:37) DC (cid:39)(cid:39) Fig. 23.46 Serial photographs of a girl with left complete cleft of primary and secondary palate. (A) 2 weeks old; (B) during nasoalveolar molding with Liou’s method; (C) immediate after operation (without cartilage dissection and repositioning); (D) 1 year old before palate DE (cid:39)(cid:41) repair; (E) at the age of 1 year and half and (F) at the age of 3 years. Satisfaction of patients Secondary procedures Patient and parental satisfaction is largely dependent upon psychosocial adaptation. A study performed in early 2000 at Notching on Cupid’s bow the Chang Gung Center evaluated the results in 77 patients receiving cleft lip repair in 1996. A total of 24% of patients It is not uncommon to have notching at the height of Cupid’s required no revision of the nose or lip; 36% required a nasal bow on the cleft side. The similar appearance can have two correction; 10% a lip correction, and 28% required both a nasal different pathologies. The first scenario results from elevation and lip revision.37 Approximately 60% of the patients requested of the point CPHL with correct position of the point CPHL′ lip or nose revision before school age. In recent years, with (Fig. 23.47, left). Lowering CPHL can correct the deformity our integrated approach and improvement in outcomes, few with a unilimb Z-plasty above the point CPHL. The white skin patients now request revision before school age. roll above CPHL should not be violated because of its unique nature.104 The second scenario results from the downward Complications displacement of CPHL′ with CPHL in a correct position (Fig. 23.47, right). A unilimb Z-plasty will result in an over-rotated A total of 112 patients underwent unilateral cheiloplasty at the Cupid’s bow and should not be used. The technique to correct Chang Gung Craniofacial Center from January 2008 to this deformity is described below. November 2009. They were evaluated for postoperative complications. No instances of wound dehiscence were encoun- Vertical discrepancy of the lateral lip tered. There was one minor separation of the nasal floor and two minor separations of the nasolabial junction that healed The vertically long lateral lip with CPHL′ lower than CPHL without problems. There were no wound infections except for is extremely difficult to correct and should be avoided in the five stitch abscesses (4.5%). Hypertrophic scarring was noted primary cheiloplasty. It is corrected by complete opening of in 3% of the patients. There were no instances of postoperative the lip, mobilizing the lateral lip, suspension of the lateral lip bleeding. muscle to the nasal septum, and horizontal full thickness