Cleft lip.pptx introduction and management

PES Institute of Medical Sciences & Research
CLEFT LIP MANAGEMENT
Presenter : Dr DEEPANRAJ
Moderator: Dr PRAMOD

INTRODUCTION
• Cleft lip and/or palate is the most common congenital abnormality
afecting the orofacial region.
• commonly occur as isolated deformities but can also be
associated with other medical conditions, e.g. congenital heart
disease
• All children born with a cleft are screened for other congenital
abnormalities.

• The incidence of cleft lip and/or palate is around 1:600 live births
• There are geographical and ethnic variations, with a higher incidence among the
South East Asian and Native Americans.
• The typical distribution of cleft types is:
• cleft lip alone: 15%
• cleft lip and palate: 45% more common in boys
• isolated cleft palate: 40% more common in girls

embryology and pathogenesis
• Embryologically, the lip and palate are derived from facial
prominences/processes which begins around the 9th week of
embryonic development.
• Prominences: During early development, three prominences
(frontonasal, medial nasal, and maxillary) form on the child's face.
• These prominences grow towards the center of the face and fuse
together during the 6th to 13th weeks of pregnancy.

• The fusion of the medial nasal and maxillary prominences forms the
upper lip and primary palate.
• cleft lip occurs when these prominences fail to fuse properly, resulting
in a gap or split in the upper lip.

Aetiology
• Familial—(Risk is 1:25 live births).
• Protein and vitamin deficiency.
• Rubella infection.
• Radiation.
• Chromosomal abnormalities.
(Klippel-Feil syndrome, Down’s syndrome, Treacher-Collin’s syndrome)
• Maternal epilepsy and drug intake during pregnancy
(steroids/eptoin/diazepam).

Family relation
Affected relatives. predicted recurrence CL/P
• 1 sibling 4.4%
1 parent. 3.2%
• 1 sibling, 1 parent. 15.8%

• Central—rare. In upper lip. Between two median nasal processes.
• Lateral—commonest; can be unilateral or bilateral
• Incomplete cleft lip does not extend into nose
• Complete cleft lip extends into nasal floor
• Simple cleft lip is only cleft in the lip
• Compound cleft lip is cleft lip with cleft of alveolu
Classification

Central cleft lip (Hare lip, Type I
cleft lip-It is rare)
Lateral type of cleft lip it is
commonest. It is due to imperfect fusion of
maxillary processand median nasal process.

LAHS classification of cleft disorders
• ‘L’ for lip, ‘A’ for alveolus, ‘H’ for hard palate, ‘S’ for soft palate
• Capital ‘LAHS’ for ‘complete’ type
• Small letters ‘lahs’ for ‘incomplete type’
• Asterisks ‘lahs’ for microclefts
• ‘LAHSHAL’ for bilateral clefts

LAHSHAL *
Abbreviated notation. Phenotypic description
[LAHS•••]. right unilateral complete CL, complete alveolus
and complete "unilateral" CP
[laHS•••] right unilateral incomplete CL and alveolus, complete
"unilateral" CP
[•••SHal] left unilateral incomplete CL and alveolus, with
complete "unilateral" CP
[LAHSHAL]. bilateral symmetric complete CL, complete CA, and complete
"bilateral" CP
[l*HSH*L] bilateral symmetric incomplete CL, notched CA, and
complete "bilateral" CP
[••HSH••] complete "midline" cleft of hard and soft palate
[•••S•••]. complete "midline" cleft of soft palate

Veau (1931): divides cleft palates
into four groups.
• Group I - Cleft of soft palate
only.
• Group II - Cleft of hard and soft
palate
• Group III - Complete unilateral
cleft
• Group IV - Complete bilateral
cleft,

Problems in Cleft Disorders
• Difficulty in sucking and swallowing.
• Speech is defective especially in cleft palate, mainly
to phonate B, D, K, P, T and G.
• Altered dentition or supernumerary teeth.
• Recurrent upper respiratory tract infection.
• Respiratory obstruction ( in Pierre Robin syndrome)
• Cosmetic problems.
• Hypoplasia of the maxilla.

Prenatal diagnosis
• Ultrasound is the primary method used for prenatal detection of cleft lip
and palate.
• 2D ultrasound between 18 -24 weeks (18 complete clefts, 24 incomplete
clefts)

SROP - surface-rendered oropalatal view
• Technique that uses ultrasound to create a 3D image of the fetal mouth
and palate, allowing for better visualization of the lips and palate.
• SROP view combines ultrasound insonation with surface rendering,
creating a 3D image that allows for better visualization of the soft tissues
and underlying structures of the fetal mouth and palate.
• SROP allows for the detection of cleft lip and/or palate as early as 16 weeks
of pregnancy.

• The SROP view can be used to explain the nature of the defect to
parents
• Parents councelling begins from here it self

Sequence in management
1. Immediately after birth
A) pediatric consultation and complete head and neck
examination
B) parent councelling - special concerns, expected
devlopment , treatment and expected outcome should be
explained to the parents.

Sequence in management
C) genetic evaluation - first step taken, before initiation of any
treatment. E.g. If a b/l clp is associated with trisomy 13, lip repair
should not be done as child is not expected to live beyond early
infancy
D) feeding
E) pre-surgical orthopedics
F. Surgical repair

Feeding
• Unilateral cleft lip alone - seldom present with feeding problems.
• Cleft lip and palate or isolated cleft palate - major feeding problems
• Easier to breast feed a child with Cleft palate than Cleft lip.

Feeding precautions
. Minimise nasal regurgitation and aspiration
-hold the child at an angle of 45-60°
to the horizontal during feeding.

Feeding precautions
2. Do not flood the pharynx - provoke aspiration.
3. Infant with a major cleft tends to swallow air while feeding - feed more
frequently than a normal child.
4. Breast feeding is only sufficient for two weeks. After this, expressing milk
and supplement is necessary.
•

Feeders:
. Soft bottles, modified teats -
slightly enlarged hole/cruciform
design.
• Spoon-feeding is an alternative to
bottle feeding.
• Squeeze Haberman feeder
• Pigeon feeder

Presurgical orthopedic appliances
• custom-made acrylic base plate that provides improved anchorage in the
molding of lip, nasal and alveolar structures during presurgical phase.
Duration - 2-3 months
• • The use of infant orthopaedic plate before CL repair may favour correct
arch form establishment in infants with unilateral complete cleft lip and
palate

Goals of Pre surgical orthopedic (pso)
• Reduce the width of the cleft gap.
• Achieve optimal alignment of the cleft segments before
surgery.
• Allow surgical repair with minimal tension.
• Improve the aesthetics of the nasolabial complex.

Nasoalveolar Molding (NAM):
• A custom-made appliance that brings together the two
sides of a cleft lip or palate, narrows the cleft, and shapes
the nose and facial structures.

Orthopaedic taping:
• Also known as lip taping or lip tape therapy.
• technique used to approximate the tissues of a cleft lip before surgical
repair, helping to narrow the gap and improve the outcome of the surgery.
•

Treatment for Cleft Lip
Millard criteria is used to undertake surgery for cleft lip.
Millard criteria (Rule of ‘10’)
• 10 pound in weight
• 10 weeks old
• 10 gm % haemoglobin

Principles of cleft lip repair
• “Rule of 10’ should be fulfilled
• Before 6 months it should be operated
• Incision should be over full thickness lip
• Three layer lip repair should be done (mucosa,muscle and skin)
• Cupid’s bow should be horizontal
• Continuity of white line should be maintained
• Vermilion notching should not be there

Normal anatomy - upper lip

• Vermillion: The lower margin of the upper lip, characterized by its rosy colour.
• Vermillion border: The line or ridge between the skin of the upper lip and the
vermilion
• White roll: thin raised white line just above vermillion border
• Cupid's bow: the concave or dipped portion of the vermilion border in the
centre of the upper lip.

Philtral dimple: Above the center of the upper lip
• Philtral columns/lines: the raised ridges on either side of this dimple
• Prolabium: In unilateral clefts, the philtrum remain attached to the larger
portion of the lip. In bilateral clefts, the philtrum is isolated from the lateral lip
segments.
• • Length of the lip: length of the skin from the base of the nose to the lower
margin of the vermilion

Basic surgical preparation
• GA using oral RAE (Ring – Adair- Elwyn)
• tube taped to midline of lower lip - not to produce any lateral distortion
•
• After markings - 0.5% lignocaine with 1:2,00,000 epinephrine is injected
into the lip tissue.
• It also helps to grip lip firmly between thumb and index finger to avoid
bleeding while incising.
• Goal of surgery is to achieve a normal looking lip and a normal looking
nose, which will not be distorted by the effects of ageing and growth

Millard rotation-advancement technique
• widely used method for unilateral cleft lip repair and remains a popular
method for cleft lip repair worldwide.
• The technique aims to reconstruct the philtrum and Cupid's bow by
advancing the outer cleft segment inward and rotating the inner lip
segment downward.

Millard rotation-advancement technique

• Benefits:
• Minimizes tissue removal and maximizes tissue usage
for cleft correction.
•
• Tension from suturing is aligned along the vermilion
border, preventing scar spreading.
•
• It is a versatile technique that can be adapted for various
types of cleft lip deformities.

Advantages
• The flaps can be modified after initial cutting to bring down the cleft side
to the level of the non cleft side. This technique scarifies little tissue from
the margin of the cleft.
• Dissection of muscle as a separate layer is relative straightforward and a
three layer closure can be achieved.
• This scar is excellent for later revision. It stimulates a normal philtral
column and this technique produces a best possible nasal philtrum.

Disadvantages:
• The scar is almost always a little short and even when
the static length of the new philtral column is satisfactory,
dynamic motion will not be natural.
• In a wide cleft the closure can be difficult to achieve and
it an be a very radical procedure where cleft is minimal.

Mohler modification
• He extended the rotation into the base of columella and made a
back cut and sutures it to the lateral flap

• Tennison - Z plasty
•
• Tennison -Z plasty technique which preserves the cupid's bow and places
it in normal position
• He inserted a wedge from the lateral lip into the lower portion of the
medial lip, and achieved good results - and called it 'stencil method' -
came to be known as the Tennison triangular flap technique.

Randall's modification
• Randall's modification of the Tennison technique for unilateral cleft lip
repair
• using a triangular flap from the outer lip segment to address the
insufficient length of the inner lip segment, which is then inserted into a
back-cut on the inner lip's vermilion border.

Disadvantages:
• Violation of philtrum on the cleft side
• Difficult in modifying the repair during Secondary revision
. mathematical precision in measurement is necessary in the
pre-operative assessment and during the surgery

Bilateral cleft lip repair
A lip that is completely cleft on both sides -
usually associated with a cleft of primary or
whole palate.
PRE-TREATMENT EVALUATION:
1. Whether the cleft is complete or incomplete
2. The size and position of the premaxilla and the prolabium
3. The length of the columella
4. Whether the inter-alveolar space is sufficient to accommodate the
premaxilla
5. The presence or absence of associated anomalies, like lip pits.

The Veau III operation
• Also known as a straight-line closure, is a surgical
approach for repairing bilateral cleft lip.
• It involves directly closing the cleft without elevating
or moving the prolabial skin (the tissue between the
nostrils and the lip).

• Millard repair
Millard technique for bilateral cleft lip repair is designed to
correct the deformity to the greatest extent possible.
•
• It aims to provide a philtrum of proper width
• A prime requisite of this technique is a fairly large
prolabium (if the prolabium is too narrow, a straight-line
repair is more preferable).

Manchester method
2 stage repair of B/L lip and palate
• 1st-5 months PSO - straight line closure preserving
prolabium, anterior palate repair
• 2nd - push back palate repair at 9 months of age
• Drawback - whistle deformity

Columella lengthening
• A shortened columella is almost always associated with a complete
bilateral cleft lip. Columellar lengthening is usually not attempted at the
time of initial lip repair.
• It has been found that early repair results in downward slippage of the
columella and lip over the premaxilla.
• Lengthening of columella may be done any time after the patient is 2-3
years of age.

Post op care:
• Dressing to be in place for 24 hrs
• Logan's bow may be used
• Feed with bulb syring - 10-14 days
All skin sutures were removed on 4th post op day
• Steri-strips for 10 days
•

Complications of lip repair
1. Wound infection
2. Wound disruption / spreading of scar - only supporting tapes should be
used in the initial phase. No definitive repair should be attempted until all
the induration has subsided.
3. Lip scars
4. Long lip (vertical excess) - Tennison-Randall or excessive rotation in
Millard flap.
5. Short lip (vertical defeciency) - notching - vertical scar along suture line,
inadequate rotation of medial flap.

6. Tight Lip (Horizontal defeciency): sacrifice of
excessive tissue during primary repair
7. Orbicularis oris abnormalities: defeciency,
discontinuity, diastasis.
8. Vermillion deformity: corrected by Z plasty.V-Y
plasty, transposition flap,crosslip flaps

THANK YOU

Cleft lip.pptx introduction and management

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