Cleft Lip and Palate repair

Question 1

Considerations for technique used

Answer 1

Cheiloplasty technique depends on whether the cleft is unilateral or bilateral

Question 2

Goal of cleft lip repair

Answer 2

bring the muscles (orbicularis oris) and the mucus membrane together
to achieve symmetry of the nostrils and cupid’s bow
achieve a natural border between the vermillion and the skin of the upper lip
minimize appearance of scars

Question 3

Risk of scar tissue

Answer 3

can have detrimental effect on maxillary growth

Question 4

Presurgical management

Answer 4

often done to align lip and maxillary segments before the formal lip repair resulting in less tension on the lip post repair (especially important for bilateral clefts)
Simplest procedure uses tape to pull segments together for 4-6 weeks
Also can use palatal appliance (active or passive) like the Latham Appliance, screw is slowly turned
Surgical Lip Adhesion: straight line repair to apply pressure on segments to pull them together. Done at 6 weeks, followed by formal repair 3-4 months later.

Question 5

Unilateral Cleft Lip repair techniques

Answer 5

Millard

Tennison-Randall

Question 6

Millard Technique

Answer 6

Rotation Advancement Flap
Used in 80% of cases
Most anatomical, most difficult
“Cut as you go” constant adjustments made during procedure to bring lip into balance
Initial incision made along philtral ridge on cleft side and carried up along ridge and beneath nose in curvilinear manner allowing the lip to open up and rotate down into cupid’s bow level

Question 7

Tennison-Randall Technique

Answer 7

Triangular Flap Procedure
20% of cases, older technique
“cookie cutter” precise and measured incisions
Incision is placed about halfway up the philtral ridge on the cleft side creating a triangular opening in the inferior portion of the lip and causes the point of cupid’s bow to drop into position
Nasal appearance not as good as Millard

Question 8

Bilateral Cleft Lip repair techniques

Answer 8

-usually less successful than unilateral repairs

Broadbent-Manchester
Millard

Question 9

Broadbent Manchester Repair

Answer 9

White roll from the prolabium (central part of upper lip which would have formed the philtrum if there was no cleft) is preserved. Because of the discontinuity of the orbicularis oris in a bilateral cleft lip, the prolabium has no muscle in it. Looks like two lines running parallel along philtrum and continuing down through both sides of the lip.

Question 10

Millard Repair (bilateral)

Answer 10

White roll from the area used rather than the prolabium. Looks like two lines running parallel along the philtrum with another line in the center of the lip.

Question 11

Cleft Palate repair goals

Answer 11

Palatoplasty
Goal is to close off the oral cavity from the nasal cavity for the benefit of feeding, middle ear function, but most of all for speech

Question 12

Cleft Palate repair techniques

Answer 12

Von Langenbeck
Wardill-Kilner V-Y Pushback
Intravelar Veloplasty
Furlow Z-Palatoplasty
Two Flap Palatoplasty

Question 13

Von Langenbeck Repair

Answer 13

-one of the oldest, most successful palatal closures, still popular today
Incision made just inside the gum line, starting behind the area of the molars and extending up to the area of the canine tooth. The mucoperiosteum is carefully raised off the bone and, in conjunction with the velum, separated in one large layer. Cleft margin is incised and the raw edges are brought together and sewn down in middle.
High incidence of VPI

Question 14

Wardhill-Kilner V-Y Pushback

Answer 14

Used for lengthening the palate
Initial incisions are similar to Von Langenbeck except instead of leaving the mucoperiosteum attached in the front of the mouth, it is cut across as a “V”. The resulting area is “Y” shaped. This frees up the mucoperiosteum of the whole palate and allows it to be pushed back in an attempt to lengthen it.
High incidence of anterior fistulas reported

Question 15

Intravelar Veloplasty

Answer 15

Can be done to normalize the construction of the velopharyngeal sling and can be done in conjunction with any type of palatal repair
Not as successful as initially hoped and some authors have found no difference in VP function between palatoplasty with and without Intravelar Veloplasty

Question 16

Furlow Z-Palatoplasty

Answer 16

Involves reconstruction of the levator sling and lengthening the velum by closing it with opposing Z-plasties. Used to lengthen tissue.
Borrows tissue from the width of the velum to add length. Resulting scar looks like a “Z”.
Levator muscles are carried on the Zs, one on each side so that when they are moved into position they automatically overlap and form a intravelar veloplasty.

Question 17

Two-Flap Palatoplasty

Answer 17

Very popular technique that involves mobilizing the palatal shelves on the greater palatine arteries and incorporating an intravelar veloplasty. It is very effective and allows a single stage closure of even the widest clefts.

Question 18

Potential Complications of cleft repair

Answer 18

Technically more demanding than lip repair
Greater risk of postoperative problems like dehiscence (breakdown of surgical repair) causing fistulae or excessive scarring
Difficult to correct these surgical problems
Potential for airway compromise or excessive bleeding
Not enough to close palate, must function dynamically for normal speech
In some cases, palatal repair is not enough to create normal VP function.