Cleft lip Part- 2

Dr. Amit T. Suryawanshi

Oral and Maxillofacial Surgeon

Pune, India

Contact details :Email ID - amitsuryawanshi999@gmail.com

Mobile No - 9405622455

Treatment Plan(All patients do not undergo all treatment)

• 3 Months – Lip Repair

• 12 Months – Palate Repair

• After 12 Months – Speech Therapy

• 2-3 Years – Gingivo Periosteoplasty

• 7-8 Years – Alveolar Bone Grafting

• 14-15 Years – Orthognathic Surgery

• 18+Years – Rhinoplasty

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SURGICAL TECHNIQUESFOR CLEFT LIP

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Pare and Guillemeau technique(1564)

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Mirault technique (1844)• Initially given by Mirault• Lat .inf.triangle flap to be approximated to medial

paring,which provided increased length to the lip closure

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Rose and Thomson (1891)

• Described angled excision of short cleft edges to obtain length with closure, ---produced a more balanced result

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Inferior triangle plasty (1910)

• Put into practice by Jalaguier

• 1952 Tennison described this tech.

• There is no mathematical basis for this tech

• Relies on stencil of brass wire – stencil method

• Length of the wire represents the distance measured from upper reference point of nostril sill on inner border of cleft to the lateral peak of cupids bow on normal side.

• Bent into 3 equal segments to form an equi. triangle

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Principle techniques with critical evaluation

St line / curved incision Veau’s technique- 1938 Emphasized the importance of proper muscle

suturing Also emphasized the importance of inner mucosa

which he call as ‘’sterile’’ Advantages• scar orientation was good• Uncomplicated by small flaps • Easy method of repair for minor clefts

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• Blair (1930), brown(1945)

• Nearly a streight line closure without cupid’s bow

• Asymmetric vermilion tubercle

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Le Mesurier technique (1949)

• Lateral quadrilateral flap-----

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Tennison technique (1952)• To prevent contraction of straight line scar of Blair

and browns technique• Triangular flap was used• Designed z plasty aided with a bent wire

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Randall modified Tennison’s method

• Reduced the size of inferior flap and defined mathematics to the method

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Millard’s technique

• ‘’Cut as you go’’

• Method of rotation & advancement

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MOHLER’S MODIFICATION

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Delaire’s technique• Delaire’s philosophy of cleft lip repair

outcome of primary surgery for cleft lip repair is judged by its effect on quality of orofacialfunction and development

Suggested normal mid face growth is possible ifthere is formal restoration of disrupted anatomy,in particular reestablishment of continuity of allmuscles involved in deformity.

Except in Exceptional circumustances, there is notrue hypoplasia on either side of cleft. However there is displacement, deformation andunderdevelopment of muscles and skeletal tissues

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Surgical technique

Aim:

• skin of nose and lip in their respective position

• To correct height of lip in cleft as well as on non cleft side.

• Perfect continuity of white roll

• Vermilion matching

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REFERENCE POINTS

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INCISION

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Delaire’s technique

• Closure• 1) posterior part of anterior nasal floor

• 2)mucosal flaps of lateral stumps at level of alveolar incision laterally and together on midline

• 3)Muscle closure-

• a) transverse ms of nose- to vestibular periosteum about halfway up premaxilla

• b) Highest part of external orbicularis of both sides- to apex of nasal spine

• c) Muscle suturing continues in direction of vermillion until border of lip is reached

• 4)medial subcutaneous stitch to anchor point 2 to base of septum

• Anterior part of nasal floor and upper part of skin suture sompleted

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Why do we call it as a Functional closure ?

• Closure of nasal floor

• Transverse nasalis and myrtiformis- sutured to midline

• Superficial levator muscles separated from oblique head of orbicularis oris, sutured to base of nasal septum behind ANS

• Orbicularis muscle reconstruction in 2 layers > deep oblique part to just above and behind the labial frenum

• > horizontal head- firstly on its deep surface under the vermilion and then on its more superficial surface

• Skin suturing

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Thank You