this presentation on cleft lip including the aetiology classification and treatment with recent advancement

1. dr.nikil jain
CLEFT LIP

2. Cleft: means fissure.
FACIAL CLEFT: a fissure resulting from
incomplete merging or fusion of embryonic
processes normally uniting in the formation of the
face

3. EPIDEMOLOGY
INDIAN EPIDEMIOLOGICAL DATA STATES
FREQUENCY IN THE RANGE OF 1:700 TO 1:1000 .
FOGH-ANDERSON (1942) FROM DENMARK ,
WOOLF AND BROADBENT (1963) FROM US AND
WILSON (1972) FROM BRITAIN ALL REPORTED
THE OVERALL FREQUENCY OF CLEFT LIP AND
PALATE AS 1.47 PER 1000 LIVE BIRTHS

4.  There is an excess of males with cleft
lip/palate 2 : 1
Female excess has been reported in isolated
cleft palate cases.
45% - CLEFT LIP AND PALATE
25% - CLEFT LIP
 30% - CLEFT PALATE

5. FOGH – ANDERSON ET AL
IN ALMOST ALL THE
SERIES, THERE IS A LEFT
SIDED PREPONDERANCE
OF CLEFT LIP
68 % OF UNILATERAL
CLEFT LIP ARE ASSOCIATED
WITH CLEFT PALATE -
FRASER ( 1970 )

6. RACIAL INFLUENCES
Aylsworth (1985)
ORIENTALS
BLACKS
CAUCASIANS
EUROPIANS

7. PARENTAL AGE
THERE IS SOME EVIDENCE THAT THE RISK
OF PRODUCING AN AFFECTED CHILD IS
DECREASED IN YOUNGER PATIENTS.
FRASER AND CALNAN (1951) CONCLUDED
THAT THE MOST IMPORTANT FACTOR WAS
ELEVATED PARENTAL AGE AND NOT
MATERNAL AGE ALONE.

8. EMBRYOLOGY AND CLEFT
PATHOGENESIS

9. Neural crest cells plays an important role in facial
morphogenisis
Just before neural fold fuse to form neural tube neuro
ectodermal cells adjacent to neural plate migrate to
facial region
 These cells form the skeletal and connective tissue of
the face like bone, cartilage, fibrous tissue, dental
tissue (except enamel)

10. Devolopment of face is controlled by 2 organic centres
1. Procencephalic organizer – induces the formation of
upper 3rd
of the face
2. Rombencephalic organizer – forms the middle and
caudal 3rd
of face

11. 4th
week – stomedium (primitive oral cavity) is
covered by maxillary, mandibular and fronto nasal
prominence

12. 5TH
WEEK – Nasal placods arise as thicknening of either
side of the frontal prominence
Horse shoe shaped ridge consisting of medial and nasal
swelling sorrounds each nasal placodes
As mesenchyme elevates the ridge the nasal pits are
formed

13.  6TH
AND 7TH
WEEK
 TWO MANDIBULAR PROMINENCE EMERGE IN THE MID LINE
 THE MAXILLARY PROMINENCE FUSE WITH MEDIAL NASAL
PROMINENCE

14. MEDIAL NASAL
PROMINENCE MERGE WITH
EACH OTHER FORMING 3
PARTS
1. PHILTRUM
2.DENTAL ARCH
COMPONENT FOR
MAXILLARY INCISORS
3. PALATAL PART UP TO
INCISIVE FORAMEN ANT.
PART

15. A UNILATERAL CLEFT LIP RESULTS FROM FAILURE
OF FUSION OF THE MEDIAL NASALPROMINENCE
WITH THE MAXILLARY PROMINENCE.

16. AETIOLOGY

17. HEREDITY ( 25 % )
CONGENITAL
ENVIRONMENTAL
Nutritional Deficiency
Radiation Energy
Steroid Injection
Hypoxia
Drugs
Amniotic Fluid Altrns

18. GENETICS
Genetic factors are assosiated with orofacial clefting
Incidence cleft lip palate is more for monozygotic twins
than for dizygotic twins

19. Some genes assosiated with orofacial clefting
TGF – ALPHA
TGF – BETA
MSX1 (HOMEOBOX GENE)
RETINOIC ACID RECEPTOR ALPHA

20. Some syndromes associated with clefting
 VANDER WOUDE SYNDROME
TREACHER COLLIN SYNDROME
DEL SYNDROME
EEC SYNDROME – ECTRODACTYLY ECTODERMAL
DYSPLASIA, CLEFT LIP
OROFACIAL DIGITAL SYNDROME
VELO CARDIOFACIAL SYNDROME

21. HUMAN TERATOGENS CAUSING
CLEFT
ETHYL ALCHOL
DIPHENYL HYDANTOIN
TRIMETHADIONE
RETINOIDS
METHOTREXATE
HYPERTHERMIA
SMOKING

22. THEORIES
THEORY OF DURSY & HIS:
Put forward the hypothesis of failure of fusion of the various
facial process.In fact it sounded a very convincing theory
The fusion theory is no longer because it is realized that
importance is for localized prominence.

23. THEORY OF FAILURE OF MESODERMAL MIGRATION
Fleischmann, a zoology prof in (germany1910)
stated that cleft palate isthe arrest of the
disappearence of the epithelial membrane,which
remains intact,not penetrated by the adjacent
mesoderm.This theory was further supported by
victoe veau (1935) & by stark

24. Failure of sufficient mesoderm to migrate into a
specific area is responsible for the persistance of a
groove. With subsequent breakdown of the
epithelium, the persistant groove gives way to an
established cleft

25. IT IS NOW ACCEPTED THAT NO THEORYIT IS NOW ACCEPTED THAT NO THEORY
UNIVERSAL ACCEPTANCE.UNIVERSAL ACCEPTANCE.

26. CLASSIFICATION

27. DAVID AND RITCHIE (1922)
on anatomical basis
GROUP III – ALVEOLAR CLEFTS
UNILATERAL BILATERAL OR MEDIAN.
GROUP I – PRE-ALVEOLAR CLEFTS
UNILATERAL , BILATERAL OR MEDIAN
GROUP II – POST-ALVEOLAR CLEFTS
• SOFT PALATE ONLY
• SOFT AND HARD PALATES
• SUBMUCOUS CLEFT

28. VEAU (1931)
1 ) Cleft of soft palate only.
2 ) Cleft of hard and soft palate
extending no further than incisive
foramen, thus involving secondary
palate alone.
3) Complete unilateral cleft, extending
from the uvula to the incisive foramen
in the midline, then deviating to one
side and usually extending through
alveolus at the position of the future
lateral incisor tooth.
4) Complete bilateral cleft, resembling
Group III with two clefts extending
forwards from the incisive foramen
through the alveolus

29. FOG ANDERSONS - 1942
GP -1 – CLEFT LIP – U/B
GP -2 – CLEFT LIP & PALATE – U/B
GP -3 – CLEFT OF PALATE UP TO INCISIVE
FORAMEN

30. INTERNATIONALLY APPROVED
 CLASSIFICATION (landmark-incisive foramen) –
sanvenelo – roseli 1967
GROUP I: cleft of ant palate
a.LIP – R&/L
b.Alveolus - R&/L
GROUP II : CLEFT OF ANT & POST PALATE
a. LIP – R&/L
b. Alveolus – R&/L
c. HARD PALATE – – R&/L

31.  GROUP III: CLEFTS OF POST PALATE
a. Hard palate : r& / l
b. Soft palate
 GROUP IV: RARE FACIAL CLEFTSRARE FACIAL CLEFTS

32. KERNAHAN (1971)
1,4 – LIP
2,5 – ALVEOLUS
3,6 – PALATE ANT TO INCISIVE FORAMEN
7,8 – PALATE POST. TO INCISIVE FORAMEN
9 – SOFT PALATE

33. The LAHSAL code splits the relevant
parts of the mouth into six parts:
 Right Lip
 Right Alveolus
 Hard Palate
 Soft Palate
 Left Alveolus
 Left Lip
The first character is for the patient's
right lip, and the last character for the
patient's left lip. Example –
. . HS . L – Complete Cleft of Hard &
Soft Palate with Left Complete Cleft Lip
LAHSAL CODE 1987

34. SCHUCHARDT & PFEIFERS

35. PFEIFERS MORPHOGENIC
CLASSIFICATION
1- generalized
malformations
2- malformation in
fronto nasal region
3- malformation in
diacephalic border
4- malformation in post
lat region
5-malformation in the
neck

36. PAUL TESSIER - 1976

37. ANATOMY OF UNILATERAL
CLEFT LIP

38. MUSCULAR ANATOMY
It is devided into 3
rings
Upper ring
Transversus nasi
Levator labi superioris
alaeque nasi
Levator labi superioris
Zygomaticus minor
MIDDLE RING
It represent the
oral sphincter
Consist of upper
and lower lip
orbicularis oris
muscle
LOWER RING
Orbicularis
inferior
Triangularis labi
Quadratus labi
inferioris

39. The upper lip orbicularis oris is made up of 3 strata
Horizontal band – internal orbicularis
Oblique band – external orbicularis
Incisal bands
Mytriformis

40. Internal orbicularis –
 horizontal fibers from one commisure to another
Muscles are superficialy inserted into the mucocutaneous
junction giving the prominence “ white roll”
External orbicularis –
 these are superficial to internal orbicularis
This determines the presence of philtral crest
Oblique in nature
This fibers fans out from nasal spine runs to commisures
and intermingles with other fibers

41. Incisal fibers –
They lie deep to the oblique fibers
Get inserted into border of mitriform fossa ( apex of the
latral incisors) and then move towards the commisures
Mytriformis –
Small fibers which get attached to mitriform fossa and
then with fibers of transverse nasi

42. Triangularis labi –
Begins at the lower mandibular border latral to chin
It intermingles with the orbicularis oris
Quadratus labi - orginates more medially from lower
border of mandible and insert into inferior orbicularis

43. NORMAL LIP ANATOMY
THE ELEMENTS OF THE NORMAL
LIP ARE - CENTRAL PHILTRUM,
PHILTRAL COLUMNS , CUPID'S
BOW
THE MUCOCUTANEOUS RIDGE
ABOVE THE JUNCTION OF THE
VERMILION-CUTANEOUS BORDER
IS A FREQUENTLY REFERRED TO
AS THE WHITE ROLL.
WITHIN THE RED VERMILION OF
THE LIP IS A NOTICEABLE
JUNCTION DEMARCATING THE
DRY AND WET VERMILION.

44. LEVATOR LABII SUPERIORIS
ARISING FROM THE MEDIAL ASPECT OF THE
INFRAORBITAL RIM, SWEEP DOWN TO INSERT
NEAR THE VERMILION CUTANEOUS JUNCTION.
ITS MEDIAL-MOST FIBERS SWEEP DOWN TO
INSERT NEAR THE CORNER OF THE IPSILATERAL
PHILTRAL COLUMN AND VERMILION-
CUTANEOUS JUNCTION, HELPING TO DEFINE
THE LOWER PHILTRAL COLUMN AND THE
PEAK OF THE CUPID'S BOW.
LEVATOR SUPERIORIS ALAEQUE
ARISES ALONG THE FRONTAL PROCESS OF THE
MAXILLA AND COURSES INFERIORLY TO INSERT
ON THE MUCOSAL SURFACE OF THE LIP AND
ALA.

45. TRANSVERSE NASALIS
ARISES ALONG THE NASAL DORSUM
AND SWEEPS AROUND THE ALA TO
INSERT ALONG THE NASAL SILL FROM
LATERAL TO MEDIAL INTO THE
INCISAL CREST AND ANTERIOR NASAL
SPINE.
DEPRESSOR SEPTI ( MYTRIFORMIS )
WHICH ARISES FROM THE ALVEOLUS
BETWEEN THE CENTRAL AND
LATERAL INCISORS TO INSERT INTO
THE SKIN OF THE COLUMELLAR TO
THE NASAL TIP AND THE FOOTPLATES
OF THE MEDIAL CRURA.

46. ORBICULARIS ORIS
DEEP (INTERNAL) FIBERS RUN
HORIZONTALLY FROM COMMISSURE
(MODIOLUS) TO COMMISSURE AND
FUNCTIONS AS THE PRIMARY
SPHINCTERIC ACTION FOR ORAL
FEEDING.
SUPERFICIAL (EXTERNAL) FIBERS
RUN OBLIQUELY, INTERDIGITATING
WITH THE OTHER MUSCLES OF
FACIAL EXPRESSION TO TERMINATE
IN THE DERMIS.
THE SUPERFICIAL FIBERS OF THE ORBICULARIS DECUSSATE IN THE MIDLINE
AND INSERT INTO THE SKIN LATERAL TO THE OPPOSITE PHILTRAL GROOVE
FORMING THE PHILTRAL COLUMNS. THE RESULTING PHILTRAL DIMPLE
CENTRALLY IS DEPRESSED AS THERE ARE NO MUSCLE FIBERS THAT DIRECTLY
INSERT INTO THE DERMIS IN THE MIDLINE.

48.  Lateral displacement of non-cleft premaxilla and tilts upwards into the cleft.
 Nasal septum and columella is bent laterally towards the non-cleft side .
 The orbicularis oris muscle is inserted laterally into the maxillary bone in the
region of the alar base and also into the lateral crus of the alar cartilage.
Medially, it inserts into the bony margin of the cleft and into the nasal spine.
 The nose is asymmetrical and there is no nostril sill.
 On the cleft side, the alar base is displaced posteriorly, inferiorly and laterally.
 The alar cartilage is usually unfolded and droops down .

49. BILATERAL CLEFT
Short columella
medial crus
Malinsertions of muscles
No nasal sil
Broad nasal tip
Dome ofAlar cartilage-down
rotation
The base of the ala are
broadened and withdrawn as a
result of back ward position of
underlying skeleton and also
muscle insertion stops at this
level

50. Effect of 3 muscle rings on skeletal growth
The muscle rings anatomy and function greatly affect the
growth of the underlying skeleton
The integrity of 1st
ring ( often disrupted in cleft lip) is
fundamental for sustaining and allowing the normal
function of other 2

51. PATHOLOGICAL ANATOMY

52. TOTAL UNILATERAL CLEFT
ALTERATIONS IN
NASOLABIAL MUSCULATURE
-;
Lack of fusion of maxillary and
nasal process - prevents the
nerve, muscle and blood supply
reaching the mid line
All the muscle which attaches to
nasal spine ,septum, premaxilla,
gets attached to the latral
border of the cleft

53. The absence of central incisor
lead to disequilibrium b/w 1st
and 2nd
ring
Nasal abnormalities
Nasal septum , columella will
be deviated to contralatral
side of the cleft due to
unbalanced traction of
muscles

54. Alar cartilae on affected side is ptotic streched and rotated
Cartilagenous structures are deformed and dislocated but not
hypoplastic
Premaxillary contralatral deviation

55. MUCOCUTANEOUS ABNORMALITIES
From both external and internal stump of the cleft
the skin of the nasal floor has to be defferentiated
from lip
Nasal skin – 1.Fine grained appearance
 2. Skin is much flatter
Lip skin – has cutaneous retraction associated with
insertion of muscles

56. SKELETAL
ABNORMALITIES
The main stump is rotated
out wards due to the pressure
from tongue and traction of
the muscle of the healthy
side, whch is not counter
balanced by the cleft side
Hypoplasia of the
alveolomaxillary portion of
the premaxilla which lies b/w
cleft and median suture

57. Increase in transverse
diametre of maxillary
tuberosity and pterygoid
process because of the non
fusion of palatine
musculature along the mid
line
Both bony and cartilagenous
part of the nasal septum is
streched towards healthy part

58. MUSCULOMUCOSAL HARD AND SOFT PALATE
ALTERATIONS
Reduction in the fibro mucosa of palatine lamina in
the lateral stumps
Where as the maxillary and gingival fibromucosa
remain practically normal

59. BILATERAL CLEFT
Alteration in nasolabial musculature
In lateral stumps similar to unilateral cleft
But in medial tubercle no trace of muscles because
muscles orginating from sides and stops at the border of
the cleft

61. NASAL ALTERATIONS
Nasal alterations are similar to unilatral cleft only
difference is they are symetrical
The base of the ala are broadaned and withdrawn as
a result of back ward position of underlying skeleton
and also muscle insertion stops at this level
The domes of the alar cartilage shows downward
rotation

62. SKELETAL ABNORMALITIES
 The pre maxilla is protrubrant and rotated
forward( with its fulcrum at the level of the nasal
spine
Transverse dimension of the pre maxilla are
reduced because of the under activity of the median
suture which does not under go musculo periosteal
traction leading to its traction

63. MUSCULO MUCOSAL HARD AND SOFT PALATE
ALTERATIONS
The posterior part of the nasal septum is vertically under
devoloped and does not reach the level of the palatine
process

64. EVOLUTION OF CLEFT LIP SURGERY
390AD in china and document the cutting and
suturing of cleft lip edges
Ambroise pare in 1564 did a straight line freshening
of cleft edges by introducing long needle through
both lip elements wrapped with a thread in fig of 8

66. Rose (1891) and
thompson(1912)
described angled
excisions of short cleft
edges to obtain length
with closure
Mirault (1844)
described latral inf
triangular flap to be
aproximated to a
medial parring

67. In 1949 le mesurier –
latral quadilatral flap
introduced into a
releasing incison in the
medial element created
an artificial cupids bow
Tennison 1952
designed an z - plasty

68. In 1959 randal modified
tennison method with
mathematical markings
Skoog 1969 later
modified his approach by
keeping the inferior latral
flap

69. TIMING OF THE OPERATION
Most surgeons delay lip repair until 10 weeks after birth to
get sufficient tissue bulk .
RULE OF TENS states that cleft lip surgery should be delayed until
the child is 10 pounds heavy, has a haemoglobin level of 10 gm% and a
WBC count of 10,000/mm3 and is at least 10 weeks old.

70. TIMING OF REPAIR
MILARD
INITIALLY – 3MONTHS OF AGE
LIP ADHESION – 2-3 WEEKS
DEFINITIVE CLOSURE – 5 – 7 MOTHS LATER

71. Later
Incomplete lip – 3 – 6 months
Complete clefts
Lip adhesion – 3weeks
Definitive closure 6 – 8 months
Soft and hard palate – 1 ½ - 2 ½ yrs

72. Delaire
Unilatral cleft lip – end of 6 months
Bilatral cleft lip – 4th
month
And during 7th
month dento alveolar element of pre
maxilla and latral segments are realinged for gingivo
perioplasty

73. Recent concept
Talamant
Primary lip nose repair – 6 months in same step as
that of closure of soft palate
Hard palate – 18 months of age in 2 planes with a
mid line approach with out vomerine flap or
denude bone area

74. Problems???
Dental (Cleft alveolus & teeth)
Congenital absence
Supernumerary
Malpositioned teeth
Deformed teeth
Hypomneralised

75. Problems???
Malocclusion
Often class III
Crowding of teeth
Narrow arch as in unilateral cleft
Narrow arch in posterior and protruded anterior
segment as in bilateral clefts

76. Problems???
Nasal deformity
Alar cartilage flared to affected side
Columnella pulled to non-cleft side
Feeding
Swallowing normal (hypo pharynx)
Ineffective sucking (lack in Negative pressure
+ poorly developed musculature)

77. Problems???
Ear
Ear function disturbed
Ear infection (due to lack of muscle function)
Otits Media (due to fluid accumulation)
Chronic Otitis Media *threat to hearing

78. Problems???
Speech
Retardation of carsonant sounds (p, b, t, d, k, g)
These are necessary for early development of
vocabulary
 Hyper nasality (Due to loss of velopharyngeal
function)
Articulation suffers (due to dental malformations)

79. SURGICAL GOAL
Approximation of the cleft edges should
be achieved with out loss of natural land
mark
There should be little to no discard of
tissue
The cupids bow should end in a balanced
position

80. The scar of union should be placed along a
natural line
The muscle should be brought together with
full bodied alingment resulting eversion of lips
free border
Alar base should be balanced and columella
equal on both sides

81. The defenite result should be symetrically
functional and esthetically natural
A symetrical red border

82. STEFFENSON (1953) HAS LISTED FIVE
CRITERIA FOR A SATISFACTORY LIP REPAIR.
 Accurate skin, muscle and mucous membrane union
with adequate lip lengthening
 Symmetrical nostril floor
 Symmetrical vermilion border and white roll
 Slight eversion of the lip
 A minimal of scar which by contraction will not interfere
with the other stated requirements.
TWO CRITERIAS WERE ADDED LATER BY MUSGRAVE (1971)
• Preservation of the cupid’s bow
• Production of symmetrical nostrils

83. GENERAL MANAGEMENT
Immediately after birth –
Pediatric consultation
Counseling
Feeding instructions
Evaluation by genicist
Diagnostic tests

84. Team evaluation
Hearing testing
After surgery
Speech and language assessment
Speech therapy
Fistula repair
Soft palate lengthening
Psycho social evaluation

85. 5-6yrs – lip and nose revision if needed
7yrs – orthodontic treatment
9-11yrs – bone grafting of alveolar bony defect
Implant placement

86. UNILATERAL CLEFT LIP REPAIR

87. DELAIRE TECHNIQUE
A- upper corner of
healthy nostril
A1- upper corner of
cleft nostril
B- base of the healthy
columella
C- mid point of the
philtrum at the
mucocutaneous
junction

88. D- summit of the
cupids bow on the
non cleft side
1- base of columella
cleft side at equal
distance from
midline to B
2- continuation from
B-1 intersects the
mucocutaneous line

89. 3- point in
mucocutaneous line
whose distance from
mid line is little less
than distance from C-
D ( CD =C3)
4- point in straight
line from 3 ,between
vermillion and wet
mucosa
5- base of the nasal ala
on the cleft side

90. 6- point on the
mucocutaneous line
perpendicular from
land mark 5
7- point on greatest
vermilion width on the
cleft side where the
mucocutaneous rim
begins to diminish
(future lateral peak of
cupids bow)

91. 8- Point on line with 7
between vermilion and
wet mucosa
Cutaneous incision
begins at the inner
stump, passes to 2-3-4
From 2 it goes up
along the
mucocutaneous
junction until it
reaches the base of the
alveolar process

92. The mucosa and the
mucocutaneous border of
the free side of the main
stump is discarded
in the small stump the
incision 5-6
And then if the
mucocutaneous line is
not pronounced from 6-
7-8

93. If the mucocutaneous
line is pronounced
then it is necessary to
preserve the white roll
from 7-E in the form
of a triangular flap
Once the cutaneous
incision, excision, and
preservation of the
free border is
performed

94. Finding the muscles
The muscles and there insertions has to be
identified
Transverse nasi – can be identified immediately
beneath nasal skin ( above line of 5-6)
Levator labi sup. Alaque nasi - prolongation
of the line 5-6 to the base of the ala after under
mining a few mm of skin muscle can be found

95. Levator labi sup – mucosal level at the base of the fornix
– this fibers should not be detached these fibers will keep
the mucosa well raised once the reconstruction is over

96. SUB PERIOSTEAL UNDERMINING
In order to ensure tension free suturing of the nasolabial
musculature, the muscular insertion of the anterior face
of maxilla must be widely undermined

97. Ideal way of doing it is sub periosteally and not supra
periosteally – a procedure that does not have any effect
on facial growth
Through the incision made in the fornix , the sub
periosteal dissection has to be extended to frontal
branch of maxilla, orbital rim (going around the infra
orbital nerve), to the zygoma as far as the maxillo
malar buttress

98. Sub perichondrial undermining and releasing of alar
cartilage –

For a corrected nasal deformity to be symmetrical it is
necessary to free the pathological half of the nose
completely from its connection from its healthy half
Through incision 1-2 blunt dissection is done to the 2
medial cura – tip – skin separated from alar cartilage on
cleft side

99. Same under mining done on the dome of the healthy side
and dorsum over the triangular cartilage
The freeing of 2 half of nose is completed by sectioning
the mid line connective tissue in b/w the intercural
tunnel
Base of the columella on cleft side is released by sub
mucosal dissection

100. Superficial and deep levator labi muscle as well as the
external orbicularis are sutured to the nasal spine and
the corresponding contralateral muscle
Then the internal orbicularis is sutured to vermilion
Then skin is approximated in the most superficial part of
nasal floor and the upper half of the lip

101. Lower half of the lip is sutured subcutaneously
If while assessing the symmetry of the lip if it is too short
z- plasty done just above the mucocutaneous border
For optimal continuity of the mucosal layer should be
released for a few mm from under lying orbicularis
The innervention concludes with careful reconstruction
of vermillion

102. MILLARDS APPROACH

103. Surgical technique
Rotation
Components on cleft side –
2/3rd
– 3 quarters of cupids bow
Median tubercle on the vermillion
One column of philtrum and its associated dimple
All this is rotated down to the normal philtrum

104. MILLARD’S ROTATION
ADVANCEMENT REPAIR
ROTATION ADVANCEMENT MUSCLE DISSECTION
ALAR BASE CINCH SUTURING

105. Advancement
An advancement flap fills the gap and corrects the alar
flare and wide nostril
Advancement flap is marked generally to fit the rotation

106. Unilateral cleft lip repair
1- junction of mucocutaneous
junction in the middle of
cupids bow
2- placed in the height of the
bow on the non cleft side
The distance from 1-2
determines the exact distance
towards the cleft for point 3

107. 1
2
37
5
6
BA
8
9
4

109. Advisable to mark with dots
the normal philtral column to
indicate the ideal matching
philtral column position of
the scar of union during cleft
closure
Rotation incision starts at
point 3 freshening the cleft
with a gentle curve to the
base of the columella

110. This procedure provides 4mm
edge towards matching the
10mm of the normal side
At the columella base the
rotation incision continues
2/3rd
the way across closely
hugging the base, which
provides another 3mm of edge

111. The rotation is increased with
a acute back cut approximately
90 degree running parallel but
medial to the normal philtral
column
This provide another 2-3 mm
edge on the rotation side
The rotation incision is carried
through the muscles to liberate
the labial mucosa from
maxilla

112. The skin and the mucosa of
the rotation edge is elevated
no more than 1-2mm from
the muscle
Flap – c – which during
incision is cut from lip but is
left attached to the side of
the columella

113. Flap- c – is rotated into
the back cut, this provides
extra length at the base of
the short columella
The lateral lip element
should be pared to equal
the length of rotation side

114. Release of the lip from
alar base by a horizontal
incision helps to free the
advancement flap
The lateral lip element is
detached from
attachements to maxilla
and advanced into the
rotation gap to observe
the fit

115. MUSCLE DESSECTION
Latral lip element should
be freed genourously
from skin by careful
underminig
Usually tip of
advancement flap left
undessected so that
mucosa and skin
advanced together

116. ALAR BASE CINCH
The alar base is freed
from the lip by a circum
alar incison
The tip of the alar base
flap is denued of
epithelium and then
threaded under flap c and
sutured to the base of the
septum to cinch the alar
flare

117. Unilateral cleft lip repair Pros & Cons
Repair Advantages Disadvantages
Millard rotation
advancement
•Procedure allows adjustment
as operation proceeds
•Minimum amount of tissue is
discarded
•Scar are placed in anatomically
correct position, in line of
philateral coloumn
•Nostril sill is reinforced and
built up
•Revision is easy
•Most difficult for beginner
to master
•Approximation of two
convex curves leaves the
majority of bulk in the centre
of the lip and not on the
lower free border this may
cause pouting appearance in
wide clefts
•Tendency is to early
contracture of long vertical
lip scar
•Technically difficult in wide
clefts
•Tendency is toward a
constricted nostril on cleft
side

118. triangular flap
repairs
•Relatively inexperienced
surgeons can obtain
reasonable results
•Achieves excellent
lengthening of shortened
cleft side
•Horizontal scars at
triangle site
transgress normal
anatomical features of
lip
Tennyson
-Randall
•Cupid bow is preserved and well
aligned
•Procedure is of particular value
in wide cleft
•Only small amount of tissue is
discarded
•Cleft side may end up too
long, to avoid this cleft
side repair should be
designed 1 mm shorter
than non cleft side
Nakajima •Straight scar line is easy to
revose
•Triangular flap is hidden at
nostrill sil
•May form vertical
contacture
Rose -thompson •Scar orientation good
•Uncomplicated by small flaps
•May form vertical
contracture
•Poor procedure for wide
cleft
•Too much tissue
discarded

119. REPAIR OF TOTAL BILATERAL
CLEFT

120. If the pre maxilla is properly positioned surgery is
recommended – 4 th month
As in unilatral cleft lip the repair begins with repair of
soft palate
Nasal layer is not closed with vomerine flap – maxillary
growth will be hampered

121. Correction of lateral stumps
are similar to that of
unilateral cleft lip
But in the prolabium there is
absence of muscle distention
The skin of the columella
descent into prolabium

122. Its considered that, in dimensions running from upper
inside angle of the nares to the future top of the cupids
bow on the skin of the prolabium the upper half is the
columellar skin and the lower half is labial skin

123. Two symmetrical points 2 are
there fore marked on ideal
extension of lateral border of
columella
And the points at the top of the
two peaks of cupids bow is
identified
2-3 an incision is made
following a curve medially
concave

124. Then incision is continued to
the mid line following a
curve whose concave side is
downward( always remain
above the mucocutaneous
border)
At the mid line it meets the
corresponding contralateral
incision

125. From point 2 another
incision is made
perpendicular to
mucocutaneous border
once junction is reached it
is prolonged to the level of
the bone
The prolabial skin is lifted
by cleaving it from the
underlying periosteum

126. Nasal spine and the lower border of the septal cartilage is
reached ,these are exposed along with lower border of
piriform aperture
Sup periosteal and sub peri chondral undermining of the
septum is also done
Nasal layer closed, transverse nasi, orbicularis oris
muscle sutured to mid line( nasal spine) and the
vermillion border sutured

127. BILATERAL CLEFT REPAIR
This technique needs large prolabium
Lateral vermilion mucosal flaps with white rolls
are brought to the mid line while the prolabial
vermillion is turned downward

128. Muscle to mucosa and
mucosa to muscle is done
behind philtral strip of
prolabium
2nd
stage v-y advancement
is done to lengthen the
columella
This is done in pre school
period

129. Repair of columella
Most procedure – forked flap
technique by millard which
takes tissue from lateral
prolabium and brings it into
columella
New concept
States that there is no skin
deficiency in columella

130. The nasolabial angle is probably the only land mark that
separates the nose from the philtrum and should be
respected in ideal repair
Surgical repositioning of alar cartilage is enough alone to
build up a normal columella with out skin plasty to bring
tissue into it

131. ADVANTAGES
Allows adjustments as operation proceeds
Minimal amount of tissue discarded
Scars placed in anatomically correct position

Nostril sill is reinforced and built up
Ease of revision

132. DISADVANTAGES
Difficult technique to master
Two convex curves- pouting appearance
Contracture of long vertical lip scar

Difficult in wide scar
Inadequate length
Scar across base of columella

133. Complications
Wound infection
Wound disruption or spreading of scar – due to
excessive tension and infection can complicate the
problem
Tilting or retrusion of the premaxilla
Can be avoided by preventing excessive traction
The vomer should not be resected in the region of the
provomerne – vomeral suture

134. Whistle deformity – can be prevented by using
lateral muscle vermillion flaps to augment the
thickness of prolabium
Excessive long lip

135. RECENT CONCEPT – J C TALAMANT
Pre surgical nasoalveolar molding ,lip adhesion not
needed
Precise repositioning of the lower lateral cartilages
enough for columellar lengthening

136. And there is no need for pre surgical naso alveolar
molding or bringing tissue from lip

The new concept is “ the columella is inside the nose”
Primary lip nose repaired at 6 months of age in same
step as that of closure of soft palate

137. The remaining cleft of hard palate is closed at 18 months
in 2 planes with a mid line approach with out vomerine
flap or denuded bone area
Dissection of nasal cartilage from the overlying skin
beginning medially on the septum and laterally of the
caudal end of the lateral cura is important

138. Repositioning secured
by custom made
appliance is necessary
Complete repositioning
of the alar bases of the
nose trills both on
horizontal and vertical
axis must be under
taken

139. Various other methods
Tennison method –
s: central part of vermillion
protrudes in a normal
manner than in straight line
closure
: result in zig zag scar
Revision difficult due to scars
Only 1 side repaired at a time

140. Manchester method:
Disadvantage:
Prolabial vermillion is
kept in a exposed position
so that appreciable differ
in color may occur
compared with labial
segments

141. Barsky technique
Not used now
Result in unnatural
appearance of lip

142. Wynn method
Can be used if
prolabium is small
It makes prolabium too
long
Does not provide
sufficient augmentation
for thin prolabial
vermillion

143. PRIMARY ABBE FLAP
NOT CONSIDERED AS A PRIMARY PROCEDURE
RECOGNIZED AS A SECONDARY TREATMENT
FOR TIGHT BILATERAL CLEFT LIP

144. Veau III procedure:
This procedure
provides a satisfactory
result

145. Secondary lip repair
Z- plasty is done to correct the notch in the
vermillion
Basic idea is to raise vermillion-muscle flaps and
transpose them in a way that they will fill the notch
and approximate the edges of the vermillion,
creating fullness and symmetry

147. All flap including the
vermillion and
orbicularis muscles
are raised

148. Vertical scar contracture
 After excision of the
scar, a triangular flap in
the upper portion of the
non cleft segment will
be transferred into the
defect created around
the base of the ala on
the cleft side.

149. Excision o f the existing
scar to release both lip
segments
Incision extended
around the base of the ala
on the cleft side and
bring it to symmetric
position with the ala on
the opposite side

150. To prevent secondary
secondary vertical scar
contracture additional
z plasty including
skin, muscle, in the
lower portion of the
lip

151. Intra uterine cleft lip 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.

152. Cleft lip and palate repair is one of the the condition
for which fetal surgery has been implicated
Modalities in Fetal Surgery:
Open Fetal Surgery
FETENDO (fetoscopic/endoscopic)
FIGS (fetal image-guided surgery)

153. Open Fetal Surgery:
This is the most invasive form of fetal surgery.
The mother is anaesthetized and an incision is given
in lower abdomen to expose uterus.
USG is used to localize the placenta. Fetus is injected
a narcotic analgesia and muscle relaxant.
Amniotic fluid is aspirated and preserved for
reperfusion.
Now uterus is opened using a special stapling device
to prevent hemostasis in highly vascularised uterus.
Warm saline is continuously infused around the
fetus.

154. Fetus is monitored by pulse oximetry and radio
telemetry.
 Fetus is intervened and uterine incision is closed
with absorbable sutures and fibrin glue.
It is interesting observation that fetal incisions heal
without scars.
 This revolutionized the repair for cleft lip and cleft
palate in intrauterine life.

155. EXIT (exutero intrapartum treatment):
This is special type of open fetal surgery.
 Usual open fetal surgery is performed round about
midgestation but this type (EXIT) is performed to
coincide with delivery i.e. fetus is intervened but not
returned in uterine cavity and delivered.
 In this type of open fetal surgery fetus is delivered
out of uterine cavity but cord is not clamped so that
fetus is sustained by mother’s placenta.

156. EXIT is performed in cases where there is airway
obstruction by large neck tumors such as cervical
teratoma and cystic hygroma etc.
 EXIT provides time to maintain the airway by
resecting the tumor or performing tracheostomy
before ligating the umbilical cord.

157. FETENDO (fetoscopic surgery):
This is developed in 1990s to avoid incision in uterus
and minimize preterm labor.
 In this technique fetoscopes are inserted through
mini-holes in uterus and then in fetus and procedure
is performed with less chances of preterm labor

158. FIGS (fetal image guided surgery):
This is the least invasive form of fetal surgery.
The manipulations are done entirely under crosssectional
view provided by sonograms.
It can be done under regional anesthesia even under local
anesthesia.
 FIGS was first used for amniocentesis and fetal blood
sampling but now is used for a variety of manipulations
including radiofrequency ablation of anomalous vessels in
case of TTTS and TRAPS and placement of vesico-amniotic
shunts to decompress the urinary tract in case of posterior
urethral valves.

159. Complications:
Preterm labor:
This risk varies in magnitude depending upon the
invasiveness of the procedure. The risk of preterm
labor is more with open fetal surgery and least with
FIGS.
Bleeding:
Infection:
Puncture of membranes:
Anesthesia complications:

160. Complications of prematurity:
Studies has shown there is increased risk of
premature deliveries in mothers underwent fetal
surgery causing premature births and prematurity
associated problems.
Drugs related harm:
Various drugs are used post operatively to control
pain and preterm labor that may itself cause fetal
and maternal complications:
Abruption placenta:
Fetal death in utero and during procedure

161. Advantages
Fetal repairs may achieve result that more closely
approximate normality
Decresead need for extensive post op care, orthodontia and
speech therapy
Alleviate the psychologic trauma associated with the birth
of an infant with craniofacial malformations experienced
by parents and infant
Sullivan approximation of cleft lip edges without incision
underwent refusion and reorganization into lip architecture
nearly indistinguishable from noramal

162. Another advantage of fetal lip and palate repairing is
reduction of bony deformation
For example when post natal repair is limited to only
cleft lip in complete unilateral clefting of palate
,there is progressive bony deformation and mal
alignment of alveolar ridge.
Fetal repair may further limit the extent of bony
deformation at a point early during bone
development and render a more functional
anatomy ,decreasing subsequent surgical

163. Fetal diagnosis
Routine pre natal ultrasonographic examination
Better ultrasonic resolution has improve ability to
identify defect
Diagnosis are now being made even at gestation age
prior to 20 weeks
Bilateral cleft lip and palate is more elusive than
unilateral because premaxilla and primary palate
protrude beyond the coronal plane

165. How and when to intervene
Early intervene in gestation near 20 weeks or less
Skin immaturity would likely to provide better
wound healing than during late third trimester
repair.
[Skin development and diffrentiation with increasing
dermal complexity and maturation of extracellular
matrix may be a limiting feature of scarless wound
healing]

166. This stage uterus more ameanable to manipulation
and endoscopic intrusion reducing the risk of
inducing pre term labour

167. Procedure

168. Procedure
Use of endoscope diameter less than 1 mm allowed
to visualization
Limitations – suturing
suture placing
external knot tying with out excessive
tissue compression

169. Kirch and Zhu-
Microclips

170. Intra uterine fetal surgery is emerging as the next
frontier in advancement of cleft lip and palate
repair
Although the prospects for fetal cleft lip and palate
repair promising,extensive research comparing the
risk and benefits must be employed before this type
of surgery.

171. Rehabilitation of the patient with cleft lip
and palate is a challenging task to the
surgical team. The main aim should not be
just aesthetics but also anatomy,form &
function for betterment of an individual…
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172. REFERENCES
Mccarthy - vol 4
Peter Wardbooth – vol 1
Principles of oral and maxillofacial surgery –
Peterson vol.2
Surgery of mouth and jaw- J.R.MOORE
Clinics of plastic surgery- prospectives in cleft lip
and palate repair vol 20 no 4 october 1993
FETAL SURGERY -Muhammad Bilal Mirza peadiatric
surgery apr 2008

173. THANK YOU