Surgical Management of Cleft Lip and Palate: A Comprehensive Atlas

188 Pages·2018·36.92 MB·English

by  Nasser Nadjmi

Nasser Nadjmi
Surgical Management
of Cleft Lip and Palate
A Comprehensive Atlas
123
Surgical Management of Cleft Lip and Palate
Nasser Nadjmi
Surgical Management of Cleft
Lip and Palate
A Comprehensive Atlas
Nasser Nadjmi
Department of Cranio-Maxillofacial Surgery
University of Antwerp, University Hospital
Antwerp
ZMACK Association, Antwerp
Belgium
Illustrated by Dr. Adélaïde Carlier
ISBN 978-3-319-91685-9 ISBN 978-3-319-91686-6 (eBook)
https://doi.org/10.1007/978-3-319-91686-6
Library of Congress Control Number: 2018945546
© Springer International Publishing AG, part of Springer Nature 2018
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Printed on acid-free paper
This Springer imprint is published by the registered company Springer International Publishing AG part of Springer
Nature.
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To my parents
and
to my children,
Kian and Julie
Acknowledgments
Writing this book proved to be harder than I could have ever imagined. It proved to be a slow,
but enriching process that made me realize that it was impossible without the help of plenty of
people, and I am sincerely grateful to all of them.
They all helped me make this book from merely a concept in my head to a manuscript and
finally to its current shape.
First of all, I would like to thank my parents and my children to whom I dedicate this book.
To my parents for their unconditional and positive love, sacrifices, support, and encouragement
and to my children who are the light of my life in whatever I pursue.
I am eternally grateful to my teachers and mentors in this domain of our specialty: Maurice
Mommaerts, John Helfrick, Ian Jackson, Ralph Millard, and Joseph Schoenaers. They taught
me discipline, thorough understanding of cleft, self-criticism, and provided me extensive per-
sonal and professional guidance. The world is a better place thanks to people who want to
develop and lead others and share the gift of their time to mentor future professionals.
A very special thanks to Kim Verhaegen not only for her organizational talent in taking care
of the practical arrangements for the care of our cleft patients but also for her warm and kind
character to guide and to provide the necessary support to the parents.
Thanks to Claudia Hellemans for keeping and updating our cleft database and planning the
surgical and other appointments.
I am grateful to our research coordinator Elke Van de Casteele who patiently did the editing
and proofreading of this book, and for her consistent effort to be in touch with the publisher
team of Springer.
Thanks to one of my brilliant associates Herman Junior Vercruysse for the first proofreading
of the manuscript.
I am indebted to all of my residents whom I have had the pleasure to work with and who
took care of my patients, specially to Ellen Collier and Benjamin Denoiseux who performed
many of the literature search.
My special thanks to one of my dedicated residents Adélaïde Carlier who took a consider-
able part of her time to make and refine the unique illustrations in this book.
To my dear friend and the orthodontist of our cleft team Sofie Nuttens for her professional-
ism in providing indispensable care for our patients.
To An Boudewyns and Johan Peetermans, the ENT surgeons of our team.
To Marc De Bodt, our speech therapist, and to all the members of our cleft team for their
outstanding and continuous effort to provide the state-of-the-art medical and paramedical
aspects of the care of our cleft patients.
Finally, to all my lovely patients and their parents who gave me trust and therefore power to
provide the specific care these children deserve.
vii
Contents
1 Functional Lip Closure and Passive Palatal Molding ...................... 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Unilateral Complete Cleft of the Lip, Alveolus, and Palate . . . . . . . . . . . . . . . . . . . . 5
The Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Passive Palatal Molding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Bilateral Complete Cleft of the Lip, Alveolus, and Palate . . . . . . . . . . . . . . . . . . . . . 12
The Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Passive Palatal Molding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2 Primary Unilateral Cleft Lip-Nose Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Surgical Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Seven Points to Achieve Optimal Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Markings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
The Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3 Primary Bilateral Cleft Lip/Nose Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Surgical Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Markings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
The Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
4 A Two-Staged Cleft Palate Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
The Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
First Stage: Soft Palate Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Second Stage: Hard Palate Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Clinical Illustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Patient with a Bilateral Cleft Lip and Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Patient with a Unilateral Cleft Lip and Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Patient with a Unilateral Cleft Lip and Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Patient with a Bilateral Cleft Lip and Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Patient with a Bilateral Cleft Lip and Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Patient with a Unilateral Cleft Lip and Alveolus + Complete Soft and 
Hard Palate with Anterior 1/3 of Hard Palate Being Submucosal Cleft . . . . . . . . . 80
Reduction of the Cleft Palate Width After Soft Palate Reconstruction . . . . . . . . . . 81
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
ix
x Contents
5 Robotic-Assisted Transoral Cleft Palate Surgery (TORCS) . . . . . . . . . . . . . . . . . 85
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Surgical Illustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
6 Early Secondary Alveolar Bone Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Timing of Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Presurgical Orthodontic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Harvesting Iliac Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Unilateral Alveolar Cleft Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Bilateral Alveolar Cleft Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
7 Case Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Case 1: A Severe UCLP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Case 2: A Severe UCLP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Case 3: Severe UCLP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Case 4: Severe UCLP with Partial Bilateral Cleft Palate . . . . . . . . . . . . . . . . . . . . . . 151
Case 5: Bilateral Cleft Lip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Case 6: Bilateral Cleft Lip and Unilateral Cleft Alveolus and Palate . . . . . . . . . . . . . 162
Case 7: Bilateral Cleft Lip and Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Case 8: A Bilateral Cleft Lip and Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
References to Materials and Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Introduction
Cleft lip, with or without cleft palate, is the most common congenital facial malformation. The
prevalence ranges from 1 in 500 to 1 in 2500 live births, depending on geographic origin and
ethnic background. For the treatment of the cleft, however, there is no consensus about the
timing or technique to be used. A multidisciplinary approach is on the other hand accepted as
the standard of care.
The surgeon who deals with the reconstruction of cleft lip, alveolus, and palate must have a
thorough understanding of the complex anatomic deformity and psychosocial development
and have sufficient knowledge of the delicate balance between surgical repair and optimization
of growth and speech development.
My intention of writing this atlas is to introduce an anatomical approach to the reconstruc-
tion of cleft defects: recognizing the anatomical border of these defects, releasing them deli-
cately from their abnormal position, and putting the created puzzle into the right anatomical
place. I introduce a multistep approach. Each step must be as minimally invasive as possible
and pave the way for a next reconstructive step. The cleft surgeon must be able to recognize
any possible and unforeseen negative effect of a surgical step and provide a solution to it. This
solution might not be a surgical one, but he/she must coordinate the measure(s) need to be
taken. Therefore, a team approach is of paramount importance.
The organization of the cleft team must be based on a “patient-centered” approach and can
vary depending on the organization of health care in any particular country.
The American Cleft Palate-Craniofacial Association (ACPA) has set forth guidelines on the
standard cleft and craniofacial team composition. These guidelines might serve as a base for
the composition of any cleft-craniofacial team. A cleft team is required to include a designated
patient care coordinator, speech-language pathologist, and orthodontic specialist as well as a
surgeon who has most commonly an oral and maxillofacial or plastic surgery background. A
pediatric neurosurgeon could join the team for the joint treatment of cranial tumors and cranio-
synostosis. Furthermore, the team should provide access to adjunct professionals in the disci-
plines of pediatric dentistry, otolaryngology, pediatrics/primary care, genetics, audiology,
social work, and psychology.
The author believes that the surgical procedures explained in this book are interdependent
and must be done with extreme care and knowledge of the surgical anatomy, preferably by one
surgeon. The ultimate aim is to make sure that when a cleft child is entering primary school,
the following goals have been achieved:
• An acceptable aesthetic lip, nose, and facial profile
• Normal function of soft palate without fistula formation in the palate
• Reconstructed alveolar cleft
• Appropriate jaw relationship with healthy dentition and periodontium
• Appropriate speech and language development
• A normal psychosocial interaction
The purpose of this atlas is to provide the cleft surgeon the rationale of our multistep
approach to cleft surgery. In each chapter, step-by-step perioperative pictures and drawings
xi
xii Introduction
guide the reader through the delicate road of reconstruction of these deformities. I do believe
that by adopting this surgical protocol, one can provide reconstructive answers to the hetero-
geneity that exists even within a single cleft type.
The treatment protocol presented in this atlas is as follows:
1. Lip-nose adhesion at 3 months (Chap. 1).
2. Primary cleft lip-nose repair at 6 months (Chaps. 2 and 3).
3. A two-staged cleft palate repair: soft palate at 9 months and hard palate at 18 months
(Chaps. 4 and 5).
4. Early secondary alveolar bone grafting between the age of 5 and 6 years (Chap. 6).
Although the protocol of treatment is based on chronological age, the age at which a certain
reconstruction is performed may vary considering whether the tissues are adequate in quantity
and quality and whether the geometric relationship of cleft parts is favorable or unfavorable for
reconstruction.