Surgery of lip and palate.

1. FACIO-MAXILLARY DISEASES.
Cosmetic.
Visible.
Deformity- Symmetry
swelling
Ulcer
LN

2. Clinical Aspects of Cleft Lip/Palate.
Most common cong. anomaly of orofacial area associated
with Cong. Heart Disease.
Incidence – Cleft lip is 1:600 live births.
Cleft palate is 1:1000 live births
Unilateral 75%, Left side 60%.
Subgroups- CL/P, CP, SubMucusCP.
Cleft lip alone: 15-25%.
Cleft lip & palate:25-45%.
Isolated Cleft palate: 40%.
CL/P, M:F :: 2:1.
CP , F:M::1.5:1.

3. Anatomic Principles
Normal Lip
1) Central Philtrum
Lateral margins - philtral columns
Inferior border - Cupids bow and tubercle
2) Vermillion-cutaneous border
Clinical Aspects of Cleft Lip/Palate Reconstruction

4. Anatomic Principles
3) Muscles
Nasolabial muscles.
Bilabial muscles
Labiomental muscles.
End result of cleft lip:
Disruption of the normal termination of the muscle fibers that
cross the embryologic fault line of the maxillary and nasal
processes, resulting in abnormal muscular forces between the
normal equilibrium that exists with the nasolabial and oral
groups of muscles Clinical Aspects of Cleft Lip/Palate Reconstruction

5. Anatomic Principles
Normal Palate
Primary palate
Secondary palate
Soft palate
Hard palate
Clinical Aspects of Cleft Lip/Palate Reconstruction

6. Embryology of Clefting
Facial Development - 4th - 10th week of development
Formed by the fusion of five prominences
Unpaired frontonasal process
- lateral/medial nasal processes
Paired maxillary swellings
Paired mandibular swelling
Nose/Philtrum of upper lip
Cheeks/Upper lip (-philtrum)
Lower face (lower lip/chin)
Clinical Aspects of Cleft Lip/Palate Reconstruction

7. Embryology of Clefting
Facial Development
Medial nasal processes (green) migrate toward
each other and fuse
Inferior tips of medial nasal processes expand
laterally to form the intermaxillary process
Tips of maxillary swellings (yellow) grow to meet the
intermaxillary process and fuse
6th week
7th week
Failure of maxillary swellings to fuse with intermaxillary process = cleft lip
Clinical Aspects of Cleft Lip/Palate Reconstruction

8. 8th - 9th week
2) Medial walls of maxillary processes produce palatine shelves
3) Shelves grow downwards, parallel to lateral suface of
tongue
4) End of week 9, rotate upward into a horizontal position
and fuse with each other and primary palate to form
secondary palate
Clinical Aspects of Cleft Lip/Palate Reconstruction

9. LAHSHAL Classification.
Site, size, extent & type of cleft.

10. Aetiology.
Genetic:- family h/o 1st deg relative 1:25 chance in
cleft lip & palate combined.
Environmental:- Maternal Epilepsy, Radiation,
Rubella.
Drugs:- steroids, diazepam & phenytoin.
Def. of antenatal folic acid / protein.
Chromosomal abnormalities.
Syndromes:-1. Pierre Robin with cleft palate,
retrognathia & glossoptosis.
2.Stickler’s with eye & musculoskeletal
abnormalities.
Shprintzen’s –cardiac.
Down’s, Apert’s & Teacher-Collin’s.

11. Cleft Lip
• Commonest; Lateral-maxillary & median nasal
process; can be unilateral or bilateral.
• Central- Rare; Hare lip between two median N P.
• Incomplete- no nasal extension.
• Complete- extends into nasal floor.
• Simple- only cleft in the lip.
• Compound- cleft lip with cleft alveolus.

12. Cleft lip
1) Isolated Incomplete
Intact skin/muscle between the lip and nose
Less distortion brought on by abnormal muscle pull
Bilateral/Unilateral
Expressed in structures anterior to incisive foramen
- prepalatal alveolus, maxilla, lip, nasal structures
Gaping cleft of alveolus/lip structures to mere ‘scar’
(forme fruste)
Deficiency in skin, muscles, mucous membranes,
maxillary/nasal bones, nasal cartilages
Clinical Aspects of Cleft Lip/Palate Reconstruction

13. 2) Isolated Complete *
Bilateral/Unilateral
Cleft runs entire length of lip to floor of nose
Abnormal muscle pull distorts nose extensively and creates wide
clefts between the lip segments
Clinical Aspects of Cleft Lip/Palate Reconstruction

14. Cleft Palate Variants
Isolated Cleft Palate
Complete/Incomplete
Soft Palate
-cleft can extend into the hard palate to
any extent
Hard Palate
Primary Palate (CL)
Secondary Palate
Clinical Aspects of Cleft Lip/Palate Reconstruction

15. Cleft Variants
Combined Clefts
Complete lip/palate
Incomplete lip/palate
Clinical Aspects of Cleft Lip/Palate Reconstruction

16. Clinical Problems
Feeding problems- suckling, swallowing.
Ear Infections & hearing loss. Ch.OM
Speech & language delay.
Dental prob/supernumerary teeth.
Rec . URTI, Resp. Obst.
Cosmetic/ Maxillary hypoplasia.

17. ORTHOPANTOMOGRAM (OPG).
• Plain X ray shows full mandible in a single plain.
• Highlights dentition, inner & outer plates & joints.
 Jaw tumors- Adamantinoma, dental cyst, dentigerous cyst,
osteoclastoma.
 Osteomyelitis of mandible.
 Fracture mandible.
 Oral cancers to show mandibular infiltration.

18. Surgical Management
Multidisciplinary approach
Beyond lip repair are other issues:
Hearing (otolaryngologists)
Speech (speech pathologists)
Dental (oromaxillofacial surgeons)
Psychosocial
Integration with team-based approach
Cleft Lip and Palate
Nutrition
Clinical Aspects of Cleft Lip/Palate Reconstruction

19. Principles of Cleft Surgery.
Aim for a normal lip, nose & face appearance.
Normal speech, dentition & facial growth.
Timings of surgery.
Cleft Lip : 3 – 6 mths.
Cleft Palate : Soft : 6 mths.Hard 6 - 18 mths.
Millard criteria.
Rule of 10’s.
Hb. 10 gm.%.
Wt. 10 lbs.
Age 10 weeks.

20. Millard’s Technique.

21. Post-op Management
1) Feedings administered with catheter tip syringe fitted
with small red rubber catheter for the first 10 days post-
op
2) Nipples are avoided to minimize strain on the
muscle/skin sutures
3) Velcro arm restraints to protect repair from
flailing hands/fingers
4) Suture line care: cleansing with half strength peroxide
followed with polymixin B-bacitracin ointment
Cleft Lip
Clinical Aspects of Cleft Lip/Palate Reconstruction

22. Post-op Management
Scar contracture
Erythema
Firmness
Inform the parents of:
Avoid placing in direct sunlight until the scar fully matures
Clinical Aspects of Cleft Lip/Palate Reconstruction

23. Complications
Post-op Management
• Aesthetic
– vermilion-cutaneous
mismatch
– vermilion notching
– tight appearing lateral
lip segement
– lateral muscle bulging
– laterally displaced ala
– constricted appearing
nostril
• Other
– dehiscence
– excessive scar
formation
Clinical Aspects of Cleft Lip/Palate Reconstruction

24. Surgical Management
Cleft Palate
Goal: Production of a competent velo pharyngeal sphincter
Two most common repairs:
1) V-Y (Veau-Wardill-Kilner)*
2) von Langenbeck
Main difference: V-Y repair involves elongation of the palate, while
von Langenbeck does not
Clinical Aspects of Cleft Lip/Palate Reconstruction

25. Wardill-Kilner
1) Incisions made along free margins of cleft and extend
anteriorly to apex
2) Dissection continued posteriorly along oral side of
alveolar ridge to retromolar trigone
Clinical Aspects of Cleft Lip/Palate Reconstruction

26. Wardill-Kilner
3) Mucoperiosteal flaps are elevated from
nasal/oral surfaces of bony palate
4) Dissection of the greater palatine vessels from
the foramen lengthens the pedicle
5) Tensor veli palatini muscle is elevated off the
hamulus to aid in relaxing the midline closure
Clinical Aspects of Cleft Lip/Palate Reconstruction

27. Wardill-Kilner
6) Nasal mucosa freed from bony palate
and closed to either side, or if necessary
closed by using vomer flaps
7) Muscle and oral mucosa closed in a
second single layer in a horizontal fashion
Clinical Aspects of Cleft Lip/Palate Reconstruction

28. Wardill-Kilner
8) Anteriorly, the oral mucoperiosteal flaps are
attached to the third flap (mucosa overlying the
primary palate
9) Posteriorly, the palate is closed in 3 layers
Nasal mucosa
Levator muscle
Oral mucosa
Clinical Aspects of Cleft Lip/Palate Reconstruction

29. Post-op Management
Cleft Palate
Immediate concerns:
1) Airway management
2) Analgesia
Risk of oversedation and subsequent airway comprimise
Acetominophen, Codeine sufficient: cont’d for 7-10 days
Arm restraints to prevent placing fingers in mouth
Diet restricted to liquids, soft foods (x3wks): bottles avoided
Change in nasal/oral airway dynamics
Clinical Aspects of Cleft Lip/Palate Reconstruction

30. Post-op Management
• Airway obstruction
• Intraoperative bleeding
• Palatal fistula
• Midface abnormalities.
Complications
Clinical Aspects of Cleft Lip/Palate Reconstruction

31. Cleft Palate Clinics..
Through a protocol of sequential, regular evaluations by a
team composed of plastic surgeon, speech pathologist,
orthodontist, and audiologist, great strides have been made in
improving all aspects of care of the child with cleft palate.
Antenatal diagnosis:- is possible by Ultrasound scan.
Counselling & Support Groups allay’s the fear from parents
who are shown photos of ‘before & after’ surgery.
Clinical Aspects of Cleft Lip/Palate Reconstruction

32. Thank you