3. INTRODUCTION
• The enigma of cleft lip and the historic journey to repair the defect has
been well described in the narrative book by Millard
• The documentation of the first cleft lip repair in the year 390 AD where an
unidentified Chinese physician cut the edges of the cleft and stitched it
together with a postoperative order of limited lip movements for the next
100 days.
• The need to identify an ideal technique was derived on the basis of the an
atomical outcome of the repair and also the postoperative scarring.
• The concepts of cleft lip repair have evolved from straight line repairs to a
variety of techniques using various cutbacks, triangles, z-plasties and
other flaps.
8. Theories of cleft
1.CLASSICAL THEORY
• Dursy (1869) and His (1874) postulated that there were five
processes of the face, namely the frontonasal, the paired
maxillary and mandibular processes.
• These processes grew towards and fused with each other, to
form the face.
• Failure to fuse was thought to lead to cleft formation.
• This theory was too pat and did not serve to explain the
formation of median clefts.
9. 2. MESODERMAL REINFORCEMENT
Stark (1954) managed to six
cleft embryos, three of which
had bilateral clefts, and after
serial coronal section and
planimetric measurements,
he found of deficiency of
mesoderm on the cleft side
in every case and postulated
his theory of mesodermal
penetration .
10. • His theory states that there are three mesodermal
masses within that epithelial wall which constitutes
the primitive palate.
• If mesoderm is deficient on one side, then the
epithelial wall rupture on that is lacking, the cleft is
either complete or incomplete .
11. ETIOLOGY
• The embryological event occurs leading to
cleft lip with or without cleft palate during 3–7
weeks and leading to cleft palate occurs
during 5–12 weeks.
12. Syndromic Cleft Lip with or without Cleft Palate
1. Trisomy 13 and trisomy 21
2. Waardenburg’s syndrome
3. Van der Woude syndrome
4. Velocardiofacial syndrome
5. Stickler syndrome
6. Treacher-Collins syndrome
7. Downs syndrome
8. Goldenhar syndrome
9. Fetal alcohol syndrome
13. Van der Woude syndrome Syndactyly: Right unilateral cleft lip
14. Bilateral cleft lip and palate with chest wall
deformity
Congenital deformity of right upper limb
with bilateral cleft lip
15. Environmental Factors
1. Vitamin B deficiency
2. Vitamin A deficiency and vitamin A excess
3. Viral infection during first trimester
4. Influence of drugs
a. Cortisone
b. Deoxyguanosine
c. Insulin
d. Alcohol
e. Cyclopamine
5. Exposure to radiation
6. Anoxia
7. Stress
8. Smoking.
16. EPIDEMIOLOGY
• CL/P affects about one in 700 births, with wide variability
across geographic origin
• Asian or American Indian populations have the highest
birth prevalence, often as high as 1: 500, with European-
derived populations intermediate at about 1:1000 and
African-derived populations the lowest at 1:2500.
• There is a 2:1 male: female ratio and a similar 2:1
left-side: right-side ratio for unilateral clefts.
19. VEAU (1931)
Group 1: Cleft of soft palate only.
Group 2: Cleft of hard and soft palate extending
no further than the incisive Foramen
Group 3: Complete unilateral cleft
Group 4: Complete bilateral cleft
28. Normal upper lip anatomy
1. Skin, mucous membranes and vermillion with labial
mucosal glands.
2. Muscles: orbicularis oris insertion is displaced in
unilateral and bilateral cleft patients.
3. Vascular supply: superior labial artery, inferior
labial artery and septal arteries are the major blood
supplies of the lips and the nose.
41. Presurgical Nasoalveolar Moulding
• presurgical maxillofacial orthopaedic appliances mould
the nasolabial structures through specifically directed
forces, thus reducing the deformity before surgery for
an easy repair
• based on the theory that increased hyaluronic acid
content is present in the infant cartilage, which makes ,
the cartilaginous structure more pliable and plastic.
42. • PNAM is based on the principles of negative sculpting
and passive moulding of the alveolus, lip and nasal tissues.
• An initial impression is obtained, and custom-made plates are
fabricated.
• A series of modifications are made to the surface of the appliances
with the addition and deletion of materials in certain areas.
• The purpose of this is achieving approximation and symmetry of
the two maxillary alveolar segments and addressing the nasal
deformity by moulding the cartilage in anatomical position
43.
44. Grayson’s technique
• The protruding premaxilla is molded first into proper
position with passive type of orthopedic appliances
and tapping of the lip in bilateral cleft lip and palate
and alveolar approximation in unilateral cleft lip with
palate
• A nasalmolding device is added to orthopedic applian
ces to increase the columellar length, reshape alar do
me.
• This two-stage procedure avoid overstretching of
nasal cartilage.
45.
46. Figuera’s technique
• Alveolar molding and nasal molding are performed
simultaneously with an acrylic plate and rigid acrylic
nasal extension.
• A soft resin ball attached to acrylic plate across the
prolabium maintains nasolabial angle.
• Rubber bands help gentle retraction of premaxilla
backwards.
47. Liou’s technique
• The nasoalveolar molding device is composed of a dental
plate, nasal component for nasal molding and micropore
taps for premaxillary retraction.
• Dental plates are kept on lateral maxillary segments with
dental adhesive.
• It increases columellar height and supports nasal tip and
cartilages.
49. Principles of Cleft Lip Repair
Steffensen, 1953
••Achieving accurate skin, muscle, and mucous
membrane union.
••Reconstruction of symmetrical nostril floor.
••Symmetrical vermilion border.
••Slight eversion of the lip.
••Minimal scar whose contractions will not jeopardize
the remaining objectives mentioned.
59. Reference points for Millard rotation-advancement technique
Point 1: Center or low point of Cupid’s bow
Point 2: Peak of Cupid’s bow on noncleft side
Point 3: Peak of Cupid’s bow, medial side of cleft
Point 4: Alar base, noncleft side
Point 5: Columellar base, noncleft side
Point 6: Commissure, noncleft side
Point 7: Commissure, cleft side
Point 8: Peak of Cupid’s bow, lateral side of cleft
Point 9: Superior extent of advancement flap
Point 10: Alar base, cleft side
Point x: Back-cut point
Ness JA, Sykes JM. Basics of Millard rotation-advancement technique for repair of the unilateral cleft lip deformit
y. Facial Plast Surg 1993;9:169
60.
61. Once the markings are made, the rotation and advancement flaps are
designed.
The basic aim is to achieve symmetry of the philtral columns.
1. Curve the incision on the rotation side; this helps in gaining length
on the cleft side philtral column.
2. Back cut: The role of the back cut comes into force when the rotatio
n is not adequate to provide enough length to match the normal philtr
al column. It can be made to cross the midline or made parallel to the
normal side philtral column.
3. Role of “C” flap: The “C” flap can be designed to accomplish either
of the following goals: closure of nasal sill, columellar lengthening or b
ack into the defect created by rotation of the flap
64. Modifications to Millard’s Technique
Mohler (1987)
• The medial lip rotation incision was modified to extend onto the
columella.
• The back cut was added which was confined to the columella.
• The C flap is used to fill the defect created by rotating the
medial lip element at the base of the columella.
• Thus it is used for lengthening the shortened columella
65.
66. curvilinear incision that extends up and parallels the medial cleft margin
but stops near the medial edge of the base of the columella.The lateral
lip element advancement incision curves outward and then medially as
it extends superiorly before it again extends to the alar base
Delaire repair.
67. Pfeifer described a wavy-line repair that allowed downward rotation as
the curves were approximated into a straight line.The two curves are
brought together such that the highest and lowest points of one curve
are approximated with the corresponding highest and lowest points of
the other, thus creating a straight line .
Pfeiffer repair.
68. Afroze repair.
The Afroze incision is a combination of two incisions—the Millard incision
on the medial non cleft side and the Pfeiffer incision on the cleft side
69. Fisher repair.
The repair allows for a repair line that ascends the lip at the seams of
anatomical subunits
72. Millard’s Repair
• Millard’s repair allowed rotation of the Cupid’s bow with the
gap filled from skin advanced from the lateral element .
• It allowed complete elevation of the prolabium and suturing
of the orbicularis across the premaxilla.
• In addition, Millard created lateral segments of the
prolabium as “forked flaps”.
• These flaps were banked to add columellar height at a later
stage, thus addressing the vertical height deficiency, and it
also corrected the wide alar bases
73.
74. Mulliken’s Repair
• Mulliken designed a narrow prolabial f
lap with slightly concave sides; 2; 2.5
mm at base and 3.5–4 mm between
Cupids bow peak.
• The surgical stratagem is symmetrical
labial repair and synchronous
anatomic positioning of the alar
cartilages with sculpturing/draping of
the nasal soft tissues.
75. • Suture of the orbicularis oris in the midline.
• Fixation to anterior nasal spine.
• Positioning dislocated lower lateral cartilages: interdomal
suture.
• Suspension over ipsilateral upper lateral cartilage with
Inter cartilaginous suture.
78. Microform Cleft Lip
Mulliken has classified microform clefts into:
••Mini microform, where the cleft is confined to a
vermillion notch with the Cupid’s bow points at the
same level.
••Microform, where the cleft involves the vermillion
and less than 3 mm of the lip above the Cupid’s bow
••Minor form, where more than 3 mm of the body of
the lip above the Cupid’s bow is cleft. These are to
be treated like partial cleft lips.
79.
80. Primary Chielorhinoplasty
• A variety of options exists to address the nasal deformity
with cleft lip.
• These include preoperative nasoalveolar moulding,
overcorrection of nostril width and alar cartilage at the time
of lip repair and postoperative use of nasal conformers.
• Primary treatment of the nose at the time of lip repair has
become popular, in order to gain early restoration of the
symmetry by repositioning the alar cartilage and
lengthening the columella.
81. Postoperative Wound Care
and Outcome Assessment
1. Suture area should be cleaned daily with saline and baby
soap twice; topical application of antibiotics is recommended
for 10 days.
2. 3 weeks post-op, we recommend to massage the scar
towards the mucosa to prevent scar contracture.
3. Massage can be done with vitamin E cream/silicone gel/
oil. It is recommended to massage for at least 6 months.
82. Outcomes
Mucosal notching
• mucosal dissection should always be in the plane
between the muscles and the mucosa plus minor
salivary glands.
• Failure to maintain that results in a thin mucosa th
at inverts after suturing. This leads to mucosal not
ching.
• In case of very mild mucosal notching presenting
at 3 weeks, it is advised to continue the massage.
• If notching persists after 6 months of lip repair, it
can be treated by surgically improving placement
of muscle.
83. Scarring
• A scar can present in various forms.
• A scar can be linear but hypertrophic in appearance.
• Such scars can be avoided if proper massaging is done in
the postoperative phase.
• If the scar has keloid tendency, triamcinolone injections are
to be given at an interval of 15 days followed by vigorous
massage
84. Contracture
• A scar can also present as a gross or mild vertical contracture.
This usually results due to inadequate rotation, thus pulling the
lip towards the nose resulting in vertical shortening of cleft side
philtral column.
• Improper muscle closure or overzealous separation of the skin
from the muscle can lead to scarring of the skin.
85. Inadequate philtral column matching
• This again results due to lack of a proper design and
improper mobilization of the rotation flap.
• Complete breakdown of the surgical wound may be the most
severe adverse outcome in the immediate post-operative ph
ase.
86. The basic indications for a lip revision surgery are:
1. Unilateral.
• The scar is not in line with
the natural philtral column.
• The lip length is short.
• There is a mucosal notching.
• There is a white roll to
Cupid’s bow mismatch.
• There is a nasolabial fistula.
2. Bilateral.
• There is a wide philtral
column.
• Mucosal notching.
• Whistling defect.
• No sulcus depth.
87. Intrauterine Cleft Repair
• Fetal surgery is an emerging technology in which the patients are
not born and interventions have to be done in intrauterine life.
Indications:
• 1. A defect that if not corrected can cause the fetus not to survive
till delivery.
• 2. A defect that if not corrected before birth can cause the
permanent anatomic or physiological loss of organs.
• 3. A defect if not intervened before birth can advanced to such a
degree that cannot be retrieved postnatally
88. Milestones of fetal cleft lip/palate
• Because of fetal scarless wound healing, fetal surgery had
become a promising option for CLP .
• Similar to the other indications of fetal surgery, animal studies
on CLP repair started in the mid 1980s .
• There is only one case of human fetal CLP in literature reported
by Ortiz Monasterio in 1997.
• After a premature birth and 2-month intensive care the infant
had been discharged well.
• Unfortunately, the infant died two months after the discharge
89. De Boutray M, Et Al., Median Cleft Of The Upper Lip: A Newclassification To
Guide Treatment Decisions, Journal Of Cranio-maxillo-facial Surgery (2016),
• extremely rare group of facial clefts defined by a cleft
involving the upper lip, situated on the median line.
• MCL have different clinical expressions, from a small
notch of the vermilion to a cleft of the entire length
of the philtrum with nasal and maxillary extension
90.
91. Complete Midline Cleft of Lower Lip, Mandible, Tongue, Floor of Mouth wit
h Neck Contracture: A Case Report and Review of Literature. Anantheswa
r Y. N.
• The median cleft of the lower jaw was first described by Couronne in 1819.
• Since then, only 80 cases have been reported so far
92.
93.
94. REFERENCES
1. Peter Wardbooth – Vol 1
2. Principles Of Oral And Maxillofacial Surgery – Peterson Vol.2
3. Fonseca –Oral And Maxillofacial Surgery Volume 3
4. Art And Science Of Cleft Lip And Cleft Palate Repair- Girish N Amlani
5. Atlas Of Cleft Lip And Palate & Facial Deformity Surgery- Jian-min Yao • Ji
ng-hong Xu
6. Cleft Lip Surgery A Practical Guide- Bart Van De Ve
7. Sayler And Bardachs Atlas Of Craniofacial Surgery
8. Cleft Lip and Palate Primary Repair –brian c sommerald
