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1. Cleft lip
Asok kumar RS OMFS

2. Introduction
 Cleft - Fissure, split or gap
 Congenital deformity
 Abnormal lack of continuity of the lip musculature, skin and mucous
membrane.
 Most commonly occurs in the upper lip
Asok kumar RS OMFS

3. History
 390 BC-First documented Cleft Lip surgery performed in china.
 13 TH CENTURY- First description of unilateral and bilateral cleft lip repair given by JEHAN YPERMAN
 1564-AMBROSE PARE gave the first diagrammatic representation of cleft lip repair and use of cleft obturator
1789- External compression premaxillary segment, by head bandage for protruding premaxilla described by
DESAULT and BICHAT
 1833- ROSE used curved incisions with concavity for cleft lip repair.
 1844-MIRAULT Introduced the modern cross flap technique of lip closure
 1884 - HAGEDORN modified Mirault technique by rectangular flap technique to prevent linear contracture
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4.  1912- THOMPSON described a straight line incisions running obliquely for lip repair
 1950-ASENSIO described a novel technique of cleft lip repair.
 1950- ARSENO used a quadrangular flap. Philtral segment is rotated inferiorly and lateral segment advanced
medially.
 1952- TRIANGULAR FLAP REPAIR initially described in TENNISON.
 1957- RALPH MILLARD (Miami) described the classic rotational-advancement technique.
 1959 – RANDALL modified Tennison technique.
 1960-TORD SKOOG gave descriptions of Gingivoperiosteoplasty
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5. Incidence
 Incidence widely depends on geographic origin, racial and ethnic group, environmental exposures, and
socioeconomic status.
 1 in 1,000 births in whites
 1 in 500 births in Asians and Native Americans
 Approximately 1 in 2,400 to 2,500 births in people of African descent
 India- 1:800–1:1000 births .
 Cleft lip is more common among males
Reddy S et al. Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India. Indian J Plast Surg. 2010 Jul-Dec; 43(2): 184–
189.
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6.  Cleft palate is more common among females.
 Unilateral clefts accounts 80% and bilateral cleft 20%.
 Among unilateral clefts, clefts involving left side are seen in
70% of cases.
 ACCORDING TO A WHO STUDY [2001]
 A child is born with a cleft somewhere in the world every
2½minutes
• INDIA -Three infants are born with cleft every hour
Incidence
Reddy S et al. Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India. Indian J Plast Surg. 2010 Jul-Dec; 43(2): 184–
189.
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7. Ase Sivertsen et al.Familial risk of oral clefts by morphological type and severity: population based cohort study of
first degree relatives. doi:10.1136/bmj.39458.563611.
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8. Etiology
 Multi-factorial with a number of potential contributing factors.
 Genetic and environmental factors playing an important role
ENVIRONMENTAL FACTORS:
 Advanced parental age
 Maternal smoking and alcohol consumption
 Intake of drugs [anticonvulsant (phenobarbital and phenytoin), retinoic acid Cortisone/
steroids, Mercaptopurine, Methotrexate, Valium during pregnancy]
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9. ENVIRONMENTAL FACTORS
 Intrauterine exposure to rubella.
 Deficiency vitamin B-folic acid.
 Excessive intake of vitamin A/retinoids
 Anemia
 Anorexia
 Maternal hypoxia
 Radiation
 Consanguineous marriages
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10. Genetics
 Transforming growth factors alpha and beta (TGF
alpha, TGF beta 2, TGF beta 3).
 Retinoic acid receptor (RAR), the methylene
tetrahydrofolate reductase receptor (MTHFR) and
the folic acid receptor (FOLR1).
 MSX-1 and MSX-2.
 LHX and DLX genes.
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11. Associated syndromes
 Velo-cardio-facial syndrome
 Treacher Collins syndrome
 Apert syndrome
 Di George syndrome
 Van der Woude syndrome
 Pierre Robin Syndrome
 Goldenhar syndrome
 Fetal alcohol syndrome
 Fetal phenytoin syndrome
 Fetal valproate syndrome
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12. CLASSIFICATION
DAVIS AND RITCHIE [1992]:
 Group I- Prealveolar clefts involving only lips.
I. Unilateral
II. Bilateral
III. Median
 Group II- Post alveolar clefts that comprises hard and soft palate clefts upto the
alveolar ridge
 Group III- Alveolar clefts. Complete clefts involving the palate, alveolar ridge and lips.
I. Unilateral
II. Bilateral
III. Median
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13. Kernahan’s stripped ‘Y’ classification
 Block 1 and 4 – Lip
 Block 2 and 5 – Alveolus
 Block 3 and 6 - Hard palate anterior to incisive foramen
 Block 7 and 8 – Hard palate posterior to incisive
foramen
 Block 9 – Soft palate
Millard’s modification [1976]
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14. Veau’s classification
 GROUP 1 – Cleft involving soft palate only
 GROUP 2 - Cleft of hard and soft palate
extending upto incisive foramen
 GROUP 3 – Complete unilateral clefts
involving soft palate, hard palate, lips and
alveolar ridge
 GROUP 4 - Complete bilateral clefts affecting
the soft palate, hard palate, lips and alveolar
ridge
a b
d
c
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15. classification
LAHSHAL -Okriens (1987)
Paraphrase of the anatomic areas affected by the cleft.
 L – Lip
 A – Alveolus
 H – Hard Palate
 S – Soft Palate
 H – Hard Palate
 A – Alveolus
 L – Lip
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16. American Cleft Palate–Craniofacial Association
(ACPA) classification (Harkins et al 1962)
1. Clefts of the prepalate (cleft of lip and embryologic primary
palate)
a) Cleft lip (cheiloschisis)
b) Cleft alveolus (alveoloschisis)
c) Cleft lip, alveolus, and primary palate
(cheiloalveoloschisis)
2. Clefts of the palate (cleft of the embryologic secondary palate)
a) Cleft of the hard palate (uranoschisis)
b) Cleft of the soft palate (staphyloschisis or veloschisis)
c) Cleft of the hard and soft palate (uranostaphyloschisis)
3. Clefts of the prepalate and palate
(alveolocheilopalatoschisis)
4. Facial clefts other than prepalatal and
palatal
a) Cleft of the mandibular process
b) Naso-ocular clefts
c) Oro-ocular clefts
d) Oroaural clefts
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17. Indian classification
[Prof.Balakrishnan (1975)]
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18. Nyberg classification[1995]
 Antenatal ultrasound classification for oral clefts .
I. Type 1 -Isolated cleft lip without palate
II. Type 2 -Unilateral cleft lip and palate.
III. Type 3 -Bilateral cleft lip and palate.
IV. Type 4 -Median cleft.
V. Type 5 -Clefts associated with amniotic bands or limb-body-wall complex.
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19. embryology
Face is formed by fusion of number of embryonic processes.
 Around the 4th week of intrauterine life, five brachial arches
develop at the site of future neck.
Mandibular arch gives rise to maxillary process from the
dorsal end
Around 6 weeks, the median nasal prominence fuses with the
lateral nasal prominences and maxillary prominences to form
the base of the nose, nostrils, and upper lip.
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20.  Upper lip is formed by the two medial nasal
prominences and the two maxillary
prominences
 Lower Lip is formed by the fusion of
mandibular process of two sides.
 When this mechanism fails, clefts of the lips
occur.
 Failure of mesenchymal penetration in midline
also results in a wide spectrum of cleft
presentations
 Clefts may be complete or incomplete based on
the degree of this failure of fusion
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21. Surgical anatomy
 Cleft lip usually results from deficiency and displacement
of soft tissues in the area of the cleft.
 In the cleft lip, there is discontinuity of the orbicularis oris
in the region of the cleft and the muscle fibers parallel the
cleft margin, inserting on the alar base on the lateral side
of the cleft, and on the columellar base and septum on the
medial side of the cleft
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22. Orbicularis oris
 Principle muscle of lip interdigitates with the muscles of the midface and lower face.
 Superficial part and deep part.
DEEP PART:
 Originates from the modiolus on each side.
 Act as a spinchter
 Horizontal with continuous fibres passing from one commissure to the other across the midline and lies
close to the inner mucosal surfaces
 Lower border curls upon itself forming the vermilion by everting and contributes to the pout of the lip on
profile.
SUPERFICIAL PART:
 Originate from muscles of facial expression
 Acts as a retractor.
 Consists of upper [nasal ]bundle and lower [nasolabial] bundle.
Asok kumar RS OMFS

23.  Deep to the skin, orbicularis oris muscle (OOM) forms a compact
decussation at the midline with fibers inserting into skin on either side of the
philtral ridges.
 Orbicularis oris is hypoplastic in the area of the cleft
 Abnormal muscular forces and maxillary osseous discontinuity result in an
outward rotation of the premaxillary-bearing medial segment and
retrodisplacement of the lateral segment
 Muscular attachment to the caudal septum results in its displacement of
vomerine groove into the noncleft nostril and shortening of the columella.
 The philtrum is short on the cleft side, the peak of Cupid’s bow is rotated
superiorly, and deficient vermilion
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24. Anatomy of lip
VERMILLION :
 Red part of the lip that is exposed and dry.
 Composed of keratinized squamous epithelium and has an abundance of superficial
capillaries.
WHITE ROLL:
 Shiny convex prominence above the vermilion that is characterized by sparse vellus hair.
VERMILION BORDER :
 Junction between vermillion and white roll.
CUPID’S BOW:
 Defined by the horizontal double curve of the lip and has two peaks.
PHILTRUM:
 Defined by a central depression flanked by philtral columns.
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25. Asok kumar RS OMFS

26. Incomplete
Complete cleft lip
&alveolus Wide cleft
Severe premaxilla protrusion
Incomplete Complete
Microform
Microform
BILATERAL CLEFT
UNILATERAL CLEFT
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27. Prenatal Diagnosis
 First antenatal ultrasound diagnosis of cleft lip and palate reported in 1981
 Prenatal ultrasound screening has become widely accepted for the diagnosis
and visualized as early as 16 weeks
 3D ultrasound images of the face were first obtained in 1986.
 Stoll et al. [2000] reported the detection rates using ultrasound improved from
5.3 to 26.5%
 Detection rates for CL/CP range from 20 to 88%
 Prenatal consultation provides an excellent opportunity to explain the
diagnosis, review the different stages of cleft lip and palate reconstruction and
prepare the parents for practical considerations.
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28. Prenatal couselling
 Initial counselling in a cleft of significant importance
 Basic information about the malformation and a long-lasting confidential relationship between the
cleft team and the family needs to be established
 GOAL- Reduce anxiety and uncertainty, clear and consistent information about the treatment and
prognosis anomaly
 Consultation should be individually tailored to meet the parents needs and expectations
 Written information and booklets including photographs of children undergone cleft surgery may be
helpful and well accepted
J. Kuttenberger et al. Initial counselling for cleft lip and palate: Parents evaluation, needs and expectations. Int. J. Oral
Maxillofac. Surg. 2010; 39: 214–220
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29. Psychosocial status
MOTHER:
 Difficulties in mother-child interactions may be
relevant, and could be affected by the timing of lip
repair(Murray et al 2008).
 Parents with child of cleft lip and palate suffer
from shock, disbelief/ denial, sadness, self-
blame, disappointment, desperation and
anxiety.
CHILDREN :
 Lack of satisfactory diet
 Decreased skill development
 Difficulty in getting along with other children
and family members induce stress in parents
 Decreased social acceptance
P. Thamilselvan, M. Suresh Kumar, Jyotsna Murthy, Manoj Kumar Sharma, N. Rajeev Kumar. Psychosocial issues of parents of children with cleft lip and
palate in relation to their behavioral problems
Parents with cleft lip and palate children's are at risk for psychological problems.
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30. Feeding problems
 Cleft children are unable to exert adequate pressure due to the loss of muscle
continuity in the lip and the communication between mouth and nose.
 Posture should be more upright to prevent regurgitation.
 FEEDING PLATE : An acrylic palatal plate that serves as an obturator
 Special feeding bottles have been designed for cleft children to provide nutrition till
the baby’s weight is adequate for performing the cleft lip repair surgery
 Each infant should have approximately 2 to 3 ounces of milk for each pound of
weight for 24 hours.
 Feeding sessions should last no longer than 35 minutes as it burn more calories
than the baby consume
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31. Haberman feeder Mead Johnson feeder Pigeon feeder
Bowl and spoon Dropper syringe Feeding tube
Jindal MK, Khan SY. How to Feed Cleft Patient? Int J Clin Pediatr Dent 2013;6(2):100-103
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32. Presurgical orthopedics
 Success of surgery depends on the degree of preoperative deformity.
 Larger the width of the cleft, more displaced the nose, worser the deformity and consequently the postoperative
result.
 Alveolar fragments supporting lip and the nasal cartilages manipulated orthopedically to promote tension-free
closure and improve the postoperative result.
OBJECTIVES :
I. Facilitate intra-oral feeding
II. Improve maxillary growth
III. Improve the projection of the nasal tip
IV. Reduce nasal deformity
V. Facilitate primary lip, nasal, and alveolar surgeries; and
VI. Retract and repositioning the premaxilla more posteriorly in patients with bilateral cleft
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33. Nasoalveolar moulding
 Hyaluronic acid found to be high in infant blood and contribute to the elasticity of
the nasal cartilages.
 Composed of a custom-made acrylic base plate with nasal stent that provides
improved anchorage in the molding of lip, nasal, and alveolar structures
 Presurgical nasoalveolar moulding is the technique by which the alveolus and the
nasal cartilages are moulded to a more favourable position.
 Presurgical reduction in osseous and soft tissue cleft deformity is to reduce the
magnitude of the surgical challenge and ensuing in improved surgical outcomes.
Asok kumar RS OMFS

34. UNILATERAL CLEFT LIP
 Nose is asymmetric at the alar base due to collapse of cleft side alveolar segment with a tilted
columella and a flattened, concave and depressed lateral crus.
 Aim is to align and bring the alveolar cleft segments as close together for achieving
correction of the nasal cartilage and soft tissue deformity.
 Nasal stent and alveolar moulding plate are adjusted over a period of 3 months to achieve
nasal and alveolar symmetry, nasal tip projection and contact of the cleft alveolus just before
primary lip, nasal and alveolar surgical repair.
 Appliance is retained in position with surgical tapes and elastics applied to the cheeks and
cleft lip segments.
Nasoalveolar moulding
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35. BILATERAL CLEFT LIP
 Nasal deformity presents with the short or absent columella and the excessively wide prolabium.
 Columella elongation and posterior lateral alveolar ridges are moulded to an appropriate width.
 Premaxilla is then retracted by using the moulding plate in conjunction with external tape and
elastics.
 Bilateral nasal stents are extended into the nostril aperture from the vestibular flange of the intraoral
moulding plate.
 Band of soft acrylic presses against the nasolabial fold.
 Combined effect of pushing the nasal tip forward and pressing back on the nasolabial fold results in
gradual tissue expansion ,lengthening of the columella and domes of the lower lateral nasal cartilages
are also brought together in the midline
Nasoalveolar moulding
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36. Alveolar molding
 Goal is to attain an end-to-end position of the alveolar processes
before lip operation.
 Appliances may be active or passive
 ACTIVE APPLIANCE - Mold alveolar processes into position by
applying active forces and direct them to grow or to be moved into a
preplanned position
 PASSIVE APPLIANCE - Allow the alveolar processes to grow
passively as preplanned.
Active appliance
Passive appliance
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37. Lip strap/lip taping
 External tapes and elastics may be strapped to the cheeks to provide some
external forces in the alveolar molding process.
 Elastic forces will exert a retracting, backward pressure against the protruding
premaxilla improve their positions and allow definitive lip skin and muscle
repair.
 In asymmetric cases, a lip bumper or pillow can be added to the tape to help to
steer the segments to the desired position.
Asok kumar RS OMFS

38. Presurgical cleft lip and palate orthopedics: an overview. Ibtesam Alzain,Waeil Batwa,Alex Cash,Zuhair A Murshid.
Clinical, Cosmetic and Investigational Dentistry 2017:9 53–59
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39. Lip adhesion
 Preliminary procedure prior to definitive surgical repair to
convert a complete cleft lip into an incomplete cleft
 Facilitate final lip repair with reduced tension
 Partial suturing of the cleft lip segments in order to
approximate the lip and alveolar segments.
 Most commonly used in wide bilateral clefts [premaxilla is
protrusive and inadequate tissue] and wide unilateral cleft.
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40. Gingivoperiosteoplasty
 Used in conjunction with the PSO
 Use limited flaps to close the alveolus cleft during the primary repair of the lip or palate.
 Gingivoperiosteoplasty (GPP) removes the soft tissue barrier within an alveolar cleft and
replaces it with a gingivoperiosteal tunnel that facilitates bone healing without the need for
bone grafting.
 TORD SKOOG in 1960 gave descriptions of primary GPP or “boneless bone grafting”.
GOAL :
I. Aligment and stabilization of the anterior maxilla
II. Good alar base support with nasal symmetry
III. Elimination of oronasal fistula and mucosal recesses
IV. Spontaneous eruption and maintenance of permanent dentition into and adjacent to the cleft
alveolus
V. Prevent the need for secondary alveolar bone grafting and associated morbidity
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41. PRENATAL MEDICAL HISTORY
 Familial history with clefts
 Evaluation of family members should be undertaken to assess any genetic factors.
 Examination of child for congenital heart disease , limb and ocular abnormalities
 Diagnosis of cleft both syndromic and non syndromic.
TIMING OF REPAIRS
Millards “RULE OF TEN”
 Age-10 weeks old
 Weight - at least 4.5 kg (10 pounds)
 WBC count - 10,000 cells /cu.mm and
 Minimum haemoglobin concentration - 10 g/dL
PREOPERATIVE CONSIDERATIONS
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42. Management
 Anesthesiology
 Audiology
 Genetics
 Neurosurgery
 Nursing
 Ophthalmology
 Oral maxillofacial surgery
 Orthodontics
 Otolaryngology–head and neck surgery
 Pediatrics
 Pediatric dentistry
 Physical anthropology
 Plastic surgery
 Prosthodontics
 Psychology and
 Speech-language pathology
AMERICAN CLEFT PALATE ASSOCIATION recommends that the cleft team members include
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43. Cleft lip repair
GOALS- American Society of Maxillofacial Surgeons [1994]:
I. Restore lip and nasal form
II. Reconstruct oral competence and orofacial muscle
dynamicity
III. Improve cosmetic appearance
IV. Minimize maxillary growth disturbance
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44. Unilateral cleft lip repair
 SURGICAL TECHNIQUE- Straight line closure, Geometric
flap and rotation advancement flap.
 Rose (1833) used curved incisions with concavity apposed and
Thompson (1912) used straight incisions running obliquely
across the lip to gain length.
 Disadvantage of straight line closure-vertical scar contracture
leading to notching of the lip
 Aims of cleft repair is to obtain good muscle alignment, an
acceptable scar and an evenly balanced lip.
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45.  The triangular flap repair was initially described in 1952 by
Tennison.
 Randall modification [1959]- Reducing the size of the inferior
triangular flap, and defined the precise mathematics of the
method
 Simple, preserves the Cupid’s bow and gives a zigzag scar
 Cleft gap is filled with a triangle of skin, muscle and mucosal flap
from the lower end of lateral lip element
 Modifications of triangular flap :Mirault (1844), Blair (1926),
Brown (1945)and Cronin (1957).
Tennison – randall technique
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46. Asok kumar RS OMFS

47.  The rotation advancement repair of the unilateral cleft lip deformity as
described by Millard in 1957
 Millard described the rotation-advancement With the goal of
preserving the philtral unit.
 Emphasized minimal tissue discard, a “cut as you go” approach, and
placement of scars that better respect anatomic
 Medial side - Curvilinear incision extends upward from Cupid’s bow
peak toward the noncleft philtral column.
 Downward rotation of the philtrum corrects the deformity..
 Advancement of the lateral lip fills the defect, corrects the alar
flaring and narrows the nostril floor.
Millard rotational technique
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48. Superiorly-based C-flap is elevated and transposed for nasal floor closure
Millard II:
 Millard himself suggested acute back-cut at approximately 90° at the end
of the rotation incision..
 Tip of the advancement flap is sutured to the depth of the rotation back-
cut.
 Increases the rotation and ensures adequate lengthening and
horizontalisation of the cupid’s bow.
1 to 2 =1 to 3 =2–4 mm
2 to 6 = 8 to 7 = 20 mm
2 to 4 = 8 to 10 = 9–11 mm
3 to 5+ x = 8 to 9
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49. Mohler Modification
 Modified Millard’s repair and used the columella to lengthen the
lip .
 The rotation incision is designed to mirror the normal philtral
column and extends onto the columella.
 A back-cut is designed to end at the lip-columellar junction.
 C-flap is used to both fill the columellar defect and abut the rotated
lip segment.
 Lip closure follows anatomic subunits and the concept of using the
columella to lengthen the lip has gained popularity.
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50. Asok kumar RS OMFS

51. Delaire functional repair
 Enhanced the rotation advancement technique and performed a wide dissection of the
lateral lip and nasal elements with approximation of the muscles.
 DELAIRE – MUSCLE RING
I. UPPER RING: Transverses nasi, levator labii superioris alequi nasi, levator labii
superioris, zygomaticus minor and the levator anguli oris.
II. MIDDLE RING: Represents oral sphincter, consisting of the upper and lower lip
orbicularis oris muscle.
III. LOWER RING: Lower ring has an incomplete circumference and consists of
orbicularis inferior, triangularis labii and quadrates labii inferioris.
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52. 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 remodeling 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.
OBJECTIVE:
 Restore the anatomy of the nose and lip in a physiological manner and ensuring
the correct repositioning of nasolabial musculature.
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53. Afroze functional cheiloseptoplasty
 Afroze incision -Combination of two incisions
 Noncleft side -MILLARD INCISION
 Cleft side -PFEIFFER INCISION.
FLAP DESIGN
 Millard flap on the noncleft side is rotated downward
 Peak of the distal curve of the Pfeiffer flap is positioned in the triangular defect formed by the movement of the Millard flap
ADVANTAGE
I. No tension on the postoperative scar.
II. No pressure on the Cupid’s bow.
III. Septal repositioning
IV. Horizontal scar and
V. Good nasal symmetry.
Gosla Srinivas Reddy, Rajgopal R. Reddy Nilesh Pagari and Stefaan Berge. Afroze Incision for Functional Cheiloseptoplasty J Craniofac Surg 2009;20:
1733Y1736
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54. Surgical technique
Cleft side Non cleft side Deviated nasal septum
Nasalis muscle dissection
Repositioned septum Appoximation of flap Postop
Preop
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55. Asok kumar RS OMFS

56. Bilateral cleft repair
 Restoration the orbicularis muscle circumorally
 Formation of a midline lip pout or tubercle
 Appropriate alar base narrowing
 Creation of a philtral column that will widen with growth
 Providing normal function, growth and development.
TECHNIQUES OF BILATERAL LIP REPAIR INCLUDE:
 Straight-line closure (Veau III operation).
 Mulliken technique
 Adaptation of Tennison unilateral cleft lip repair.
 Millard repair of complete and incomplete bilateral clefts
 Byrd technique
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57. Straight-line closure without elevation
of the prolabial skin
No reconstruction in the continuity of
the orbicularis oris
Maintains the prolabial vermilion to create
the cupid’s bow and tubercle,
Did not involve repairing the orbicularis, as it
would create an overly tight lip
VEAU III TEHNIQUE MANCHESTER TECHNIQUE [1965]
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58. Total elevation of the prolabium and reconstitution
of the orbicularis across the premaxilla.
Central vermilion recreated from the lateral lip
portions
MILLARD’S TECHNIQUE [1967]
TENNISON AND RANDALL
TECHNIQUE
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59. Standard landmarks:
I. subnasale (sn),
II. subalaris (sbal),
III. labiale superius (ls),
IV. crista philtri superioris(cphs),
and
V. crista philtri inferioris (cphi).
Mulliken technique Asok kumar RS OMFS

60. Incisions Flap elevation Flap insetting
Alar base repositioning and
orbicularis oris repair.
Skin closure.
Byrd [2008] technique
Modification of Manchester and Millard technique
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61. Primary cleft rhinoplasty
 Timing of cleft lip nasal surgery :
I. Primary
II. Intermediate and
III. Secondary.
 PRIMARY-Surgery at the time of primary cleft lip repair
 INTERMEDIATE- Performed before the cleft patient enters school, between 4 and 6 years of age
 SECONDARY- 14 to 16 years old in female patients and 16 to 18 years old in male patients
 Focuses mainly on correction of the lower third of the nose.
 GOAL: Establish symmetric nasal tip and nostrils, repositioning of the alar base and closure of the
nasal floor and sill.
Asok kumar RS OMFS

62.  Nostril rim incisions are marked and extended along the inside edge of the upper columella.
 Three techniques have been described to suspend and secure the displaced lower lateral cartilages:
I. Bolster sutures
II. Transfixion sutures and
III. Intercartilagenous sutures.
Asok kumar RS OMFS

63. Asok kumar RS OMFS

64. Complications of cleft lip repair
 Inadequate re-approximation of the orbicularis oris muscle.
 Failure to reconstitute a competent oral sphincter
 Inaccurate alignment of the vermilion-cutaneous junction
 Scar.
 Notch in the vermilion
 Whistle deformity.
 Infection.
 Wound dehiscence
Asok kumar RS OMFS

65. Postoperative care
 Postoperative care of the patient with cleft lip includes pain control,
assuring adequate feeding and hydration and protection of the
cleft lip wound from excessive wound tension or infection
 Logan’s bow or steristrips used to protect the surgical site
 Arm restraints (“No-No’s”) are suggested by most to be useful for
up to 2 weeks postoperatively
 Nasal stents or conformers to mold the nostrils
 Feeding begun immediately after surgery.
 Bacitracin antibiotic ointment application
 One month after lip repair gentle massaging of the scar is begun
several times a day for 5 minutes.
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66. Scar management
 Cleft lip scar management involves:
I. Prevention of scar hypertrophy and contracture
II. Correction of cleft lip secondary deformities
 SILICONE GEL AND SILICONE SHEETING are an effective
method for postoperative care of cleft upper lip [Chang et al 2013]
 BOTULINUM TOXIN A - Reduce wound tension and subsequent
inflammation in wound edges
 CO2 LASER TREATMENT - Led to softening and flattening of
the cleft scars and reduced scar contraction. [Peng et al. 2018]
 TRIAMCINOLONE ACETONIDE, 10mg/mL per 1 cm length of
scar [McGregory 1989] is injected into the edges of the wound.
 Proper surgical technique, including minimization of tension and
meticulous closure with wound edge eversion, reduces scar width
and hypertrophy (Khansa et al. 2016). Patrycja Bartkowskadoi: et al.Scar management in patients after cleft lip repair –
systematic review.Cleft lip scar management 10.1111/jocd.13511
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67. Neonatal cleft repair
 Advances in neonatology and pediatric anesthesia made it possible to
perform cleft repair surgery during the neonatal period
 MAIN GOAL - Improve infant-mother relationship
 Improves feeding ,speech development and promotes growth
 Parents will gain a psychological benefit as their child will have earlier
surgery and look “normal” when they return home.(Galinier et al 2008)
 Use of sevoflurane in pediatric anesthesia due to significant hemodynamic
repercussions
 Weatherley-White et al compared the reported identical esthetic results in
children with early repair
Asok kumar RS OMFS

68. Philippe Galinier et al. Neonatal repair of cleft lip: a decision-making protocol. Journal of Pediatric Surgery (2008)
43, 662–667
 If the neonate has both a cleft lip and cleft palate, the palate is
repaired first so that the lip is not disrupted after it has been repaired.
 Only the children without an associated inborn defect were allowed to
pass the operation.
ADVANTAGES:
I. Safe
II. Improved appearance of surgical scars
III. Ease of feeding
IV. Very good wound healing
V. Accelerated weight gain
VI. Improved maternal-infant socialization.
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69. Transoral Robotic Cleft Surgery
(TORCS)
 Initiated in Philadelphia 2013.
 Ergonomic, safe and feasible
ADVANTAGES:
 Faster recovery
 Less post-operative complications
 Shorter hospital stay
 Adequate visualisation of the working field
 Greater instrument manoeuvrability
Yasser Al Omran, Ali Abdall-Razak,Nader Ghassemi,Samar Alomran.Robotics in Cleft Surgery: Origins, Current Status and Future Directions.
Robotic Surgery: Research and Reviews 2019:6 41–46
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70. Stem cells and tissue engineering
 Use of Umbilical cord stem cells
demonstrated regenerative, neovascular,
anti-inflammatory and tissue neoformation
properties in cleft repair.
 Less inflammatory response less scar
hypertrophy, there was no palate fistula or
dehiscence and less fibrosis
Marcelo Paulo Vaccari Mazzetti.Importance of Stem Cell Transplantation in Cleft Lip and Palate Surgical Treatment
Protocol.J Craniofac Surg 2018;29: 1445–1451
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71. In utero repair
 Hernadez et al [2012]- Repaired Cleft Lip In
Utero by Reactivating Craniofacial
Developmental Programs
 Restored normal facial morphogenesis Pbx-
deficient mice via genetic engineering and
subsequent reactivation of genetic programs that
control apoptosis
Hernandz.Repair of Cleft Lip In Utero by Reactivation of Craniofacial Developmental
Programs.Supplement to Plastic and Reconstructive Surgery. Vol. 130, No. 5S-1
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72. references
 FONSECA..Oral and maxillofacial suregry-3E
 PETERSON’S Principle of oral and maxillofacial surgery-3E
 STEVEN L GOUDY. Complete cleft care
 BERKOWITZ .Cleft lip and palate-2E
 RENE MALEK .Cleft lip and palate.
 H. Steve Byrd.Bilateral Cleft Lip and Nasal Repair.Plast. Reconstr. Surg. 122: 1181, 2008.
 Arosarena OA. Cleft lip and palate. Otolaryngol Clin North Am 2007;40:27-60, vi.
 Robert J. Tibesar, MD, Angela Black et al. Surgical repair of cleft lip and cleft palate.Operative Techniques in
Otolaryngology (2009) 20, 245-255
 John B. Mulliken.Repair of bilateral cleft lip and its variants.Indian J Plast Surg Supplement 1 2009 Vol 42.
 Jeffery Marcus. Principles of Cleft Lip Repair: Conventions, Commonalities, and Controversies. Plast. Reconstr. Surg. 139:
764e, 2017
 Bram Samarius.Accurate diagnosis of prenatal cleft lip/palate by understanding the embryology. World J Methodol 2017
September 26; 7(3): 93-100
 Karoon agarwal.Classifi cation of cleft lip and palate: An Indian perspective. Journal of Cleft Lip Palate and Craniofacial
Anomalies. July-December 2014 / Vol 1 / Issue 2
 Mulliken JB. Primary repair of bilateral cleft lip and nasal deformity. Plast Reconstr Surg 2001;108(1):181–194, 195–196
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73. Asok kumar RS OMFS