Clinical aspects of cleft lip & palate reconstruction

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Clinical aspects of cleft lip & palate reconstruction

  1. 1. Clinical Aspects of Cleft Lip/PalateClinical Aspects of Cleft Lip/Palate ReconstructionReconstruction ANJAN K DEBANJAN K DEB Dept of Plastic surgery BIRDEMDept of Plastic surgery BIRDEM
  2. 2. OverviewOverview • Relevant Anatomy & PhysiologyRelevant Anatomy & Physiology • Embryology of Facial CleftingEmbryology of Facial Clefting • Classification/Epidemiology/Related SyndromesClassification/Epidemiology/Related Syndromes • Principles of ManagementPrinciples of Management • Preoperatve Assessment/ OrthodonticsPreoperatve Assessment/ Orthodontics – Indications/ContraindicationsIndications/Contraindications • Time table of Procedures/EventsTime table of Procedures/Events • Surgical TechniquesSurgical Techniques – Millard / Tennison-RandallMillard / Tennison-Randall – Wardill-Kilner/ Z-plastyWardill-Kilner/ Z-plasty – Speech assessment/PharyngioplastySpeech assessment/Pharyngioplasty – Alveolar bone graftAlveolar bone graft • Post-op managementPost-op management – Complications – Follow up Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  3. 3. Applied AnatomyApplied Anatomy Normal LipNormal Lip CENTRAL PHILTRUM Lateral margins Philtral columns Inferior border Cupids bow and tubercle VERMILLION-CUTANEOUS BORDER White roll COMMISURE Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  4. 4. Applied AnatomyApplied Anatomy • PHILTRAL ZONE – Column/Dimple • VERMILION – Cupid’s Bow/Apex • SUB VEMILION • PERISTOMAL – Wet & Dry Line • COMMISURE • LATERAL • CENTRAL
  5. 5. Applied AnatomyApplied Anatomy • Glabella • Root Or Nasion • Dorsum Or Rhinon • Ala (3) • Columella (2) • Tip (8)/ Infratip (1) • Soft Triangle/Facet (4) • Nasal Sill (5) • Columella-philtral Angle (6) • Alar –Facial Groove (7)
  6. 6. Applied AnatomyApplied Anatomy MUSCLES Orbicularis oris (superficial and deep) Levator labii superioris Levator superioris alaeque Levator anguli oris Zygomaticus major et minor Buccinator Depressor labii inferioris Depressor anguli oris Mentalis Disruption of the normal termination of the muscle fibers that cross the embryologicDisruption of the normal termination of the muscle fibers that cross the embryologic fault line of the maxillary and nasal processes, resulting in abnormal insertion &fault line of the maxillary and nasal processes, resulting in abnormal insertion & abnormal muscular forces between the normal equilibrium that exists with theabnormal muscular forces between the normal equilibrium that exists with the nasolabial and oral groups of musclesnasolabial and oral groups of muscles
  7. 7. Applied AnatomyApplied Anatomy MUSCLES OF LIP INNER VIEWMUSCLES OF LIP INNER VIEW
  8. 8. Applied AnatomyApplied Anatomy BLOOD SUPPLY LIPSBLOOD SUPPLY LIPSDORSAL NASALDORSAL NASAL FACIALFACIAL INF ALVEOLAR terminal brINF ALVEOLAR terminal br INFERIOR LABIALINFERIOR LABIAL SUPERIOR LABIALSUPERIOR LABIAL INFRA ORBITALINFRA ORBITAL MAXILLARYMAXILLARY POST SUP ALVEOLARPOST SUP ALVEOLAR BUCCALBUCCAL
  9. 9. Applied AnatomyApplied Anatomy BLOOD SUPPLY PALATEBLOOD SUPPLY PALATE NASAL SEPTUMNASAL SEPTUM TURBINATESTURBINATESSPHENOPALATINESPHENOPALATINE GREATER PALATINEGREATER PALATINE ANASTOMOSIS POSTERIOR SEPTAL & GR PALATINEANASTOMOSIS POSTERIOR SEPTAL & GR PALATINE LESSER PALATINELESSER PALATINE
  10. 10. Applied AnatomyApplied Anatomy Normal PalateNormal Palate Primary palatePrimary palate Secondary palateSecondary palate Soft palateSoft palate Hard palateHard palate
  11. 11. Applied AnatomyApplied Anatomy
  12. 12. Applied AnatomyApplied Anatomy • SUPERIOR CONSTRICTOR » primary sphincter • TENSOR VELI PALATINI » tenses palate • LEVATOR VELI PALATINI » elevates palate » dilates Eust Tube • Salpingopharyngeus, palatopharyngeous, palatoglossus: minor contribution Postero-superior view PHARYNGEAL VIEWPHARYNGEAL VIEW
  13. 13. Muscle of velum 3D view
  14. 14. Embryology of CleftingEmbryology of Clefting FACIAL DEVELOPMENT - 4FACIAL DEVELOPMENT - 4THTH - 10- 10THTH WEEKWEEK Formed by the fusion ofFormed by the fusion of 55 prominences/processesprominences/processes FRONTONASAL x1FRONTONASAL x1 Lateral/medial nasal processesLateral/medial nasal processes MAXILLARY x2 MANDIBULAR x2 Nose/Philtrum of upper lipNose/Philtrum of upper lip Cheeks/Upper lip (Cheeks/Upper lip (-philtrum-philtrum)) Lower face (lower lip/chin)
  15. 15. Embryology of CleftingEmbryology of Clefting FACIAL DEVELOPMENTFACIAL DEVELOPMENT Medial nasal processesMedial nasal processes migrate toward each other and fuse 55thth -7-7thth weekweek Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  16. 16. Embryology of CleftingEmbryology of Clefting • 7th -8th week – Inferior tips of medial nasal processes expand laterally form the intermaxillary process – Tips of maxillary swellings grow & meet the intermaxillary process and fuse Failure of maxillary swellings to fuse with intermaxillary process = cleft lipFailure of maxillary swellings to fuse with intermaxillary process = cleft lip
  17. 17. FORMATION OF THEFORMATION OF THE PALATEPALATE 66thth -7-7thth weekweek As nasal pits of lateral nasalAs nasal pits of lateral nasal process invaginate and fuse,process invaginate and fuse, intermaxillary process extendsintermaxillary process extends to form primary palateto form primary palate Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction Embryology of CleftingEmbryology of Clefting
  18. 18. 88thth - 9- 9thth weekweek Medial wallsMedial walls ofof MAXILLARY PROCESSESMAXILLARY PROCESSES produceproduce PALATINE SHELVESPALATINE SHELVES Shelves grow downwards,Shelves grow downwards, parallel to lateral sufaceparallel to lateral suface of tongueof tongue End ofEnd of week 9week 9,, rotaterotate upwardupward into ainto a horizontal position andhorizontal position and fuse with eachfuse with each otherother andand primary palateprimary palate toto FORMFORM SECONDARY PALATESECONDARY PALATE Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction Embryology of CleftingEmbryology of Clefting
  19. 19. Embryology of CleftingEmbryology of Clefting • MESODERM H&N derived from – PARAXIAL MESODERMPARAXIAL MESODERM • Floor Of Brain CaseFloor Of Brain Case • Occipital & Parietal BonesOccipital & Parietal Bones • All Voluntary Muscle of H&NAll Voluntary Muscle of H&N • Dermis & CT of Dorsal HeadDermis & CT of Dorsal Head – LATERAL PLATE MESODERMLATERAL PLATE MESODERM • Laryngeal Cartilages & CTLaryngeal Cartilages & CT – NEURAL CREST CELLSNEURAL CREST CELLS (deficient in superoxide dismutase & catalase)(deficient in superoxide dismutase & catalase) • Mid-facial & Pharyngeal Arch skeletonMid-facial & Pharyngeal Arch skeleton • Overlying Dermis & Soft TissuesOverlying Dermis & Soft Tissues • DentinDentin – ECTODERMAL PLACODES • Neuron of Sensory Ganglia, V,VII,I X, X
  20. 20. CRANIO-FACIAL CLEFT • Tessier,s Classification – Spoke wheel – Radiating from orbit – Magic No- 14 – Incidence: 1:150000
  21. 21. Cleft Lip & Palate VariantsCleft Lip & Palate Variants Great anatomic variationGreat anatomic variation in types of clefts!in types of clefts! ANATOMIC CLASSIFICATIONANATOMIC CLASSIFICATION basedbased on:on: 1) LOCATION1) LOCATION 2) COMPLETENESS2) COMPLETENESS (Incomplete/Complete)(Incomplete/Complete) 3) EXTENT3) EXTENT Since lip, alveolus, and hard palate differ in embryologicSince lip, alveolus, and hard palate differ in embryologic origin,origin, 4) ANY COMBINATION CAN OCCUR4) ANY COMBINATION CAN OCCUR Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  22. 22. Cleft Lip & Palate VariantsCleft Lip & Palate Variants CLEFLIP & PRIMARY PALATECLEFLIP & PRIMARY PALATE CLEFT OF PRIMARY & SECONDARY PALATECLEFT OF PRIMARY & SECONDARY PALATE CLEFT OF SECONDARY PALATECLEFT OF SECONDARY PALATE
  23. 23. Veau Classification CLCPVeau Classification CLCP • Veau Classification - 1931 – Veau Class I: isolated soft palate cleft – Veau Class II: isolated hard and soft palate – Veau Class III: unilateral CLAP – Veau Class IV: bilateral CLAP • Iowa Classification - a variation of Veau Classification
  24. 24. Iowa Classification CLCPIowa Classification CLCP Group IGroup I Clefts of lip onlyClefts of lip only Group IIGroup II Clefts of palate only (Clefts of palate only (22oo )) Group IIIGroup III Clefts of lip,Clefts of lip, alveolus, palatealveolus, palate Group IVGroup IV Clefts of lip andClefts of lip and alveolusalveolus (primary(primary cleft palate andcleft palate and lip)lip) Group VGroup V MiscellaneousMiscellaneous
  25. 25. Striped Y Modified Kernahan’sStriped Y Modified Kernahan’s 1 & 51 & 5 -- FLOOR OF NOSEFLOOR OF NOSE on right &on right & left sidesleft sides 2 & 62 & 6 -- LIPLIP 3 & 73 & 7 -- ALVEOLAR RIDGESALVEOLAR RIDGES 4 & 84 & 8 -- PREMAXILLAPREMAXILLA to incisiveto incisive foramenforamen 9 & 109 & 10 - Each half of the- Each half of the HARDHARD PALATEPALATE 1111 -- SOFT PALATESOFT PALATE 1212 - Congenital- Congenital VELOPHARYNGEALVELOPHARYNGEAL INCOMPETENCEINCOMPETENCE without obviouswithout obvious cleftsclefts 1313 -- PROTRUSIONPROTRUSION of premaxillaof premaxilla KERNAHANSKERNAHANS
  26. 26. Cleft Lip & Palate VariantsCleft Lip & Palate Variants Isolated INCOMPLETEIsolated INCOMPLETE Intact skin/muscle between the lip and noseIntact skin/muscle between the lip and nose Less distortion brought on by abnormal muscle pullLess distortion brought on by abnormal muscle pull Bilateral/UnilateralBilateral/Unilateral CLEFT LIPCLEFT LIP Expressed in structuresExpressed in structures anterior to incisive foramenanterior to incisive foramen - prepalatal alveolus, maxilla, lip, nasal structures- prepalatal alveolus, maxilla, lip, nasal structures GAPING CLEFT of alveolus/lip structures toGAPING CLEFT of alveolus/lip structures to MERE ‘SCAR’ (MERE ‘SCAR’ (forme frusteforme fruste)) DEFICIENCY INDEFICIENCY IN SKINSKIN,, MUSCLES, MUCOUSMUSCLES, MUCOUS MEMBRANESMEMBRANES, MAXILLARY/NASAL, MAXILLARY/NASAL BONESBONES, NASAL, NASAL CARTILAGESCARTILAGES
  27. 27. ISOLATED COMPLETEISOLATED COMPLETE Bilateral/UnilateralBilateral/Unilateral Cleft runs entire length of lip to floor of noseCleft runs entire length of lip to floor of nose Abnormal muscle pull distorts nose extensivelyAbnormal muscle pull distorts nose extensively and creates wide clefts between the lipand creates wide clefts between the lip segmentssegments Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction Ipsilateral Lower Lat CartIpsilateral Lower Lat Cart flattenedflattened rotated downwardrotated downward Bifid tipBifid tip Short columellaShort columella Flattened alaFlattened ala Cleft of alveolusCleft of alveolus Cleft Lip & Palate VariantsCleft Lip & Palate Variants
  28. 28. Cleft Lip & Palate VariantsCleft Lip & Palate Variants ISOLATED CLEFT PALATEISOLATED CLEFT PALATE COMPLETE/INCOMPLETE/SUBMUCOUSCOMPLETE/INCOMPLETE/SUBMUCOUS Soft PalateSoft Palate cleft can extend into the hard palate tocleft can extend into the hard palate to any extentany extent Hard PalateHard Palate Primary PalatePrimary Palate Secondary PalateSecondary Palate Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  29. 29. Cleft Lip & Palate VariantsCleft Lip & Palate Variants COMBINED CLEFTSCOMBINED CLEFTS Complete lip &/palate UnilateralComplete lip &/palate Unilateral
  30. 30. Cleft Lip & Palate VariantsCleft Lip & Palate Variants Complete lip &/palate BilateralComplete lip &/palate Bilateral PROTRUDED PEMAXILLAPROTRUDED PEMAXILLA
  31. 31. EpidemiologyEpidemiology • Isolated CLEFT PALATE genetically distinct from isolated CLEFT LIP OR CLAP – same among all ethnic groups (1:2000, M:F 1:2) – More assoc with Syndrome • Isolated CL or CLAP – different among ethnic groups • American Indians: 3.6:1000 (M:F 2:1) • Asians 3:1000 (M:F 2:1) • African American 0.3:1000 (M:F 2:1) • 20% CL (18% unilateral, 2% bilateral)20% CL (18% unilateral, 2% bilateral) • 50% CL and CP (38% unilateral, 12% bilateral)50% CL and CP (38% unilateral, 12% bilateral) • 30 % CP alone30 % CP alone
  32. 32. EpidemiologyEpidemiology • GENETICS (Clustering in families) FAMILY MAKEUP RISK OF CLEFT LIP / PALATE RISK OF CLEFT PALATE ONE AFFECTED SIBLING OR PARENT 1 IN 25 (4%) 2.5% TWO AFFECTED SIBLING 1 IN 11 (9%) 1% ONE SIBLING AND ONE PARENT 1 IN 6 (16%) 15%
  33. 33. EpidemiologyEpidemiology • SYNDROMIC CLAP – associated with more than 300 malformations • CHROMOSOMAL – Trisomy 13, 18, 21 & Deletion 22q11 (Velocardiofacial Syndrome) • NON MENDELIAN – PIERRE ROBIN, Goldenhar • MENDELIAN – Corlin’s, Dysplasia-Clefting, Treacher-Collins, Van der Woude (AD) – Smith-Lemli-Opitz (AR) – Oto-Palato-digital, Oto-Palato-Facial (XL) • UNKNOWN – DeLarge , Kabuki • TERATOGENIC – Fetal Alcohol, Phenytoin, Valproate • NONSYNDROMIC CLAP • diagnosis of exclusion • OVERALL INCIDENCE OF ASSOCIATED ANOMALIES (e.g.OVERALL INCIDENCE OF ASSOCIATED ANOMALIES (e.g. CARDIACCARDIAC) = 30%) = 30%
  34. 34. EpidemiologyEpidemiology • RISK FACTORS – PARENTAL AGE: >30yrs – VIRAL INFECTIONS: Rubella – TERATOGENS: Alcohol, Steroids, Anticonvulsants, Retinoic acid derivatives
  35. 35. Principles of ManagementPrinciples of Management • Multidisciplinary Approach • These are not merely surgical problems – Requires team approach throughout life • neonatal period • toddler • grade school • adolescence • young adulthood
  36. 36. Principles of ManagementPrinciples of Management MULTIDISCIPLINARY APPROACHMULTIDISCIPLINARY APPROACH Beyond lip repair are other issues:Beyond lip repair are other issues: Hearing (Otolaryngologists)Hearing (Otolaryngologists) Speech (Speech Pathologists / Therapist)Speech (Speech Pathologists / Therapist) Dental (Periodontologist/Orthodontist / Prosthodontist/)Dental (Periodontologist/Orthodontist / Prosthodontist/) Maxillofacial Surgeons/Maxillofacial Surgeons/ Psychosocial (Psychologist/ Psychiatrist/ Social Worker)Psychosocial (Psychologist/ Psychiatrist/ Social Worker) GeneticistGeneticist Integration with team-based approachIntegration with team-based approach Each case is assessed independently by those involved and a global treatment planEach case is assessed independently by those involved and a global treatment plan is instituted based on present need in his/her developmentis instituted based on present need in his/her development Cleft Lip and PalateCleft Lip and Palate Nutrition (Nutritionist )Nutrition (Nutritionist )
  37. 37. Principles of ManagementPrinciples of Management ASSESSMENTASSESSMENT AIMAIM: RESTORING NORMAL MORPHOLOGIC FORM AND FUNCTION: RESTORING NORMAL MORPHOLOGIC FORM AND FUNCTION Important forImportant for normal dentition, mastication, speech, hearing,normal dentition, mastication, speech, hearing, andand breathingbreathing CONTRAINDICATIONSCONTRAINDICATIONS: MALNUTRITION, ANEMIA RESPIRATORY: MALNUTRITION, ANEMIA RESPIRATORY INFECTION or other conditions that render infantINFECTION or other conditions that render infant UNABLE TO TOLERATEUNABLE TO TOLERATE GENERAL ANESTHESIA Airway obstruction, Acute otitis mediaGENERAL ANESTHESIA Airway obstruction, Acute otitis media Work-upWork-up (1) Thorough(1) Thorough PEPE to uncover anyto uncover any ASSOCIATED ANOMALIESASSOCIATED ANOMALIES Additional work-up determined by physical findings that suggest involvementAdditional work-up determined by physical findings that suggest involvement ofof other organother organ systemssystems (2)(2) WEIGHT, ORAL INTAKE, GROWTH/DEVELOPMENTWEIGHT, ORAL INTAKE, GROWTH/DEVELOPMENT are of primary concern and must be followed closelyare of primary concern and must be followed closely (3) Routine lab studies generally not required; Hgb level before surgery(3) Routine lab studies generally not required; Hgb level before surgery
  38. 38. The Neonatal Period • Pediatrician: – directs care – establishes feeding • complete clefts preclude feeding – breast feeding not possible – a soft, large bottle with large hole is required – a palatal prosthesis may be required • Feeding bottle large hole
  39. 39. The Neonatal Period • Presurgical Orthodontics (Baby Plates) – Moulds palate into more anatomically correct position – decreases tension – may improve facial growth – Grayson, presurgical nasal alveolar moulding (PSNAM) • c
  40. 40. The Neonatal Period
  41. 41. The Neonatal Period • Surgical Repair – Cleft Lip • In US - “THE RULE OF TENS” - 10 wks, 10 lbs, Hgb 10gm% • Lip adhesion vs baby plates – Cleft Palate • Varies from 6-18 Months - most around 10 mo • Early repair may lead to MIDFACE RETRUSION • Early repair improves SPEECH Different institutions = different practiceDifferent institutions = different practice
  42. 42. Management Schedule Palatal obturatorPalatal obturator Repair cleft lipRepair cleft lip Repair of PalateRepair of Palate Repair of Hard palateRepair of Hard palate Tympanotomy tubeTympanotomy tube Speech therapy/pharyngoplastySpeech therapy/pharyngoplasty Bone graftingBone grafting OrthodonticsOrthodontics Jaw surgeryJaw surgery
  43. 43. Surgical Principles • Release the musclesRelease the muscles from abnormalfrom abnormal insertionsinsertions • Repair them inRepair them in anatomical positionanatomical position • Lengthen medial sideLengthen medial side of cleft so that itof cleft so that it attains normalattains normal anatomical lengthanatomical length
  44. 44. Surgical ManagementSurgical Management Unilateral Complete Cleft LipUnilateral Complete Cleft Lip GOALSGOALS • SYMMETRY: Nostrils,SYMMETRY: Nostrils, Nasal Sill, and Alar BasesNasal Sill, and Alar Bases • WELL DEFINEDWELL DEFINED PHILTRUM: Dimple andPHILTRUM: Dimple and ColumnsColumns • CUPID’S BOW: NaturalCUPID’S BOW: Natural appearingappearing • FUNCTION: Good muscleFUNCTION: Good muscle repairrepair SURGICAL PRINCIPLESSURGICAL PRINCIPLES • Lengthen medial side ofLengthen medial side of cleft so that it equals thecleft so that it equals the vertical dimensions of non-vertical dimensions of non- cleft sidecleft side • Flap designs:Flap designs: – Triangular (Tennison-Triangular (Tennison- Randall)Randall) – QuadrangularQuadrangular – Rotation-advancementRotation-advancement (Millard)(Millard) • MuscleRepair:MuscleRepair:
  45. 45. Surgical ManagementSurgical Management Unilateral Complete Cleft LipUnilateral Complete Cleft Lip TENNISON-RANDALLTENNISON-RANDALL
  46. 46. Millard TechniqueMillard Technique • Cleft Lip Repair • Unilateral • Rotation(a &c)-advancement (b)flap developed by Millard – Medial flap(a)Medial flap(a) rotatesrotates downward to achieve necessarydownward to achieve necessary lengtheninglengthening – Lateral flap (b)Lateral flap (b) advances intoadvances into the defect produced by downwardthe defect produced by downward displacement of medial flapdisplacement of medial flap – Small pennant-shapedSmall pennant-shaped medial flap (c)medial flap (c)c an be used toc an be used to restore nostril sill or lengthen therestore nostril sill or lengthen the columellacolumella 3 Flaps a,b & c
  47. 47. Millard TechniqueMillard Technique ADVANTAGES – ““Cut as you go” techniqueCut as you go” technique – Preserves’ cupid’s bow andPreserves’ cupid’s bow and philtral dimplephiltral dimple – Scar placed in anatomical position along philtral column – Tension of closure under theTension of closure under the alar base; reduces flair andalar base; reduces flair and promotes better molding of thepromotes better molding of the underlying alveolar processesunderlying alveolar processes
  48. 48. Millard TechniqueMillard Technique • COMPLICATIONS – Tightness at white roll/ cupids bow – Peaking of vermillion – Notching of stomal margin – Residual nasal deformity – Tension?/ dehisence?/ HTS?/infection? – scar stretching
  49. 49. Bilateral Cleft Lip Repair • MILLARD’S ADAPTATION: – Philtral from central prolabium – Prolab paring banked for collumelar lengthening – Prolabial white roll & vermillion discarded – Cupids bow tubercle from lateral lip segments
  50. 50. Bilateral Cleft Lip Repair • MODIFIED MANCHESTER – Preserves white roll vermillion of prolabium – Philtral flap cut to desired width – Prolabial paring used for nasal floor – Lateral muscle are sutured to prolabial sub cut tissues
  51. 51. Bilateral Cleft Lip Repair • BLACK’S METHOD
  52. 52. Post-op ManagementPost-op Management 1) FEEDINGS administered with catheter tip syringe1) FEEDINGS administered with catheter tip syringe fitted with small red rubber catheter for the first 10 daysfitted with small red rubber catheter for the first 10 days post-oppost-op 2) AVOID SUCKING Nipples are avoided to minimize2) AVOID SUCKING Nipples are avoided to minimize strain on the muscle/skin suturesstrain on the muscle/skin sutures 3) ARM RESTRAINT Velcro arm restraints to3) ARM RESTRAINT Velcro arm restraints to protect repair from flailing hands/fingersprotect repair from flailing hands/fingers 4) SUTURE LINE CARE: PRN cleansing with half4) SUTURE LINE CARE: PRN cleansing with half strength peroxide followed with polymixin B-bacitracinstrength peroxide followed with polymixin B-bacitracin ointmentointment Cleft LipCleft Lip Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  53. 53. Post-op ManagementPost-op Management Scar contractureScar contracture ErythemaErythema FirmnessFirmness Inform the parents of:Inform the parents of: Avoid placing in direct sunlight until the scar fully maturesAvoid placing in direct sunlight until the scar fully matures Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  54. 54. ComplicationsComplications Post-op ManagementPost-op Management • AestheticAesthetic – vermilion-cutaneousvermilion-cutaneous mismatchmismatch – vermilion notchingvermilion notching – Whistle deformityWhistle deformity – tight appearing lateraltight appearing lateral lip segementlip segement – lateral muscle buldgelateral muscle buldge – laterally displaced alalaterally displaced ala – constricted appearingconstricted appearing nostrilnostril • OtherOther – dehiscencedehiscence – excessive scarexcessive scar formationformation Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  55. 55. Surgical ManagementSurgical Management Cleft PalateCleft Palate Goal: Production of a competent velopharyngeal sphincterGoal: Production of a competent velopharyngeal sphincter Two most common repairs:Two most common repairs: 1) V-Y (Veau-Wardill-Kilner)*1) V-Y (Veau-Wardill-Kilner)* 2) von Langenbeck2) von Langenbeck Main difference: V-Y repair involvesMain difference: V-Y repair involves elongation of the palateelongation of the palate, while, while von Langenbeck does notvon Langenbeck does not Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  56. 56. Wardill-KilnerWardill-Kilner 1) Incisions made along free margins of cleft and extend1) Incisions made along free margins of cleft and extend anteriorly to apexanteriorly to apex 2) Dissection continued posteriorly along oral side of2) Dissection continued posteriorly along oral side of alveolar ridge to retromolar trigonealveolar ridge to retromolar trigone Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  57. 57. Wardill-KilnerWardill-Kilner 3) Mucoperiosteal flaps are elevated from3) Mucoperiosteal flaps are elevated from nasal/oral surfaces of bony palatenasal/oral surfaces of bony palate 4) Dissection of the greater palatine vessels from4) Dissection of the greater palatine vessels from the foramen lengthens the pediclethe foramen lengthens the pedicle 5) Tensor veli palatini muscle is elevated off the5) Tensor veli palatini muscle is elevated off the hamulus to aid in relaxing the midline closurehamulus to aid in relaxing the midline closure Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  58. 58. Wardill-KilnerWardill-Kilner 6) Nasal mucosa freed from bony palate6) Nasal mucosa freed from bony palate and closed to either side, or if necessaryand closed to either side, or if necessary closed by using vomer flapsclosed by using vomer flaps 7) Muscle and oral mucosa closed in a7) Muscle and oral mucosa closed in a second single layer in a horizontal fashionsecond single layer in a horizontal fashion Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  59. 59. Wardill-KilnerWardill-Kilner 8) Anteriorly, the oral mucoperiosteal flaps are8) Anteriorly, the oral mucoperiosteal flaps are attached to the third flap (mucosa overlying theattached to the third flap (mucosa overlying the primary palateprimary palate 9) Posteriorly, the palate is closed in 3 layers9) Posteriorly, the palate is closed in 3 layers Nasal mucosaNasal mucosa Levator muscleLevator muscle Oral mucosaOral mucosa Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  60. 60. Post-op ManagementPost-op Management • Cleft PalateCleft Palate – Immediate concerns:Immediate concerns: • AIRWAY MANAGEMENT: Change in nasal/oral airwayAIRWAY MANAGEMENT: Change in nasal/oral airway dynamicsdynamics • ANALGESIA: Risk of over-sedation and subsequentANALGESIA: Risk of over-sedation and subsequent airway compromiseairway compromise • ARM RESTRAINTS to prevent placing fingers in mouthARM RESTRAINTS to prevent placing fingers in mouth • DIET restricted to liquids, soft foods (x3wks): bottlesDIET restricted to liquids, soft foods (x3wks): bottles avoidedavoided Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  61. 61. Post-op ManagementPost-op Management • Airway obstructionAirway obstruction • Intraoperative bleeding/ AspirationIntraoperative bleeding/ Aspiration • Palatal fistula/ DehisencePalatal fistula/ Dehisence • Midface abnormalities (early interventions)Midface abnormalities (early interventions) COMPLICATIONSCOMPLICATIONS Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  62. 62. Cleft Palate ClinicsCleft Palate Clinics Through a protocol of sequential, regular evaluations by aThrough a protocol of sequential, regular evaluations by a team composed of plastic surgeon, speech pathologist,team composed of plastic surgeon, speech pathologist, orthodontist, and audiologist, great strides have been made inorthodontist, and audiologist, great strides have been made in improving all aspects of care of the child with cleft palateimproving all aspects of care of the child with cleft palate Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
  63. 63. The Toddler Years • Priority: Speech • VELOPHARYNGEAL DYSFUNCTION – A. VELOPHARYNGEAL MISLEARNING “i.e. Phoneme Specific Nasal Air Emission” – B. VELOPHARYNGEAL INCOMPTENCY i.e.“apraxia”, neurological deficit – C. VELOPHARYNGEAL INSUFFICENCY i.e. Anatomical deficit
  64. 64. The Toddler Years • Priority: Speech – “CLEFT ERRORS OF SPEECH” in 30% • PRIMARY DEFECTS - due to VPD (hypernasality) – consonants are most difficult sounds (plosives) • SECONDARY DEFECTS - due to attempted correction – Glottic Stops, Nasal Grimace – VELOPHARYNGEAL DYSFUNCTION • diagnosed by fiberoptic laryngoscopy or BaSw • surgical repair after failed speech therapy - usually around age 4
  65. 65. VELOPHARYNGEAL DYSFUNCTION • SIGNS AND SYMPTOMS – History of NASAL REGURGITATION post cleft palate repair – History of need for multiple placement of PE tubes – Nasal GRIMACE – HOARSE Vocal Quality – Decreased INTELLIGIBILITY

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