CLEFT LIP DR VASANT RADHAKRISHNAN

SURGERIES CHARLES PINTO CENTRE FOR CLEFT LIP,PALATE AND

CRANIOFACIAL ANOMALIES

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OVERVIEW

Anatomy
History
Classification
Surgical techniques in cleft lip repair
Secondary Deformities

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ANATOMY

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 MUSCLES OF THE LIP

• LATHAM &DEATON (1976) suggested there are

basically only three muscles in the activity of the
upper lip

• ORBICULARIS ORIS
• LEVATOR LABAII SUPERIORIS
• NASALIS

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 MUSCLES OF LIP
• The principal muscle of the lip is orbicularis oris muscle.
• It generally is divided into two parts:
• Superficial layer(Pars Superficialis)
• Deep layer.(Pars Marginalis)
• In the upper lip these fibers decussate in the midline to
insert into the opposite filtral column.
• The orbicularis is joined with the muscles of the facial
expression.

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 Surface Anatomy
Philtral Ridge

White roll
Dry vermillion
Wet vermillion

Peak of cupids bow

Philtral dimple

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Complete bilateral cleft lip
Anatomy and its surgical implications

THE COMPLETE BILATERAL CLEFT LIP THE FRONTONASAL COMPONENTS

The complete separation of the frontonasal

components

Prolabium
Premaxilla

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 Bilateral cleft nose
Completely absent /minimal
columella of the nose

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Muscles in the blateral cleft lip

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Arterial
anatomy

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HISTORY:
EVIDENCE OF PRESENCE OF CLEFT LIP

In ancient Egyptian Mummies

Sculptors of Incas and Mayas

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First evidence of repair

In china during the Chin Dynasty (A.D 390)

Story of Wei Yang Chi

The Saxon surgeons of pre Norman Britain known as leeches

Sushruta samhita itself does not mention the repair of clefts

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 Franco and Pare

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 Von Graffe , Husson
WILLIAM ROSE AND JAMES
THOMSON

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 STRAIGHT LINE REPAIR
ANGLED INCISIONS
ABSENCE OF CUPIDS BOW

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Constructing the cupids bow
Werner Hagedorn and Le Mesurier

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THE QUADRILATERAL FLAP

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 Preserving the cupids bow
Triangular flap of TENNISON AND RANDALL

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 TRIPLE WEDGE TECHNIQUE
CK BALAKRISHNAN
C. SAWHNEY

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 Millard’s rotation and
advancement
Ralph Millard Jr.
Gilles commandments
Honor that is normal
Thou shall not throw away a living thing unless proven to be
absolutely useless
Though shall not steal from Peter to pay Paul unless Peter
can afford it
Though shall not commit Tension
Though shall not make a routine and treat each case
individually

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 Later picked up by his teacher Sir Harold Gilles

Presented at the first international conference of Plastic Surgery

Evolved since then in the hands of Millard and other surgeons

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 Brought to India by Sir Harold Gilles

Initial presentation of the procedure in Pune

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 CLASSIFICATIONS

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 CLASSIFICATIONS
 DAVIS & RITCHIE (1922)
 VEAU (1931)
 KERNAHAN AND STARK (1958)
 KERNAHAN (1971)
 HARKINS & ASSOSCIATES (1962)
 SPINA (1974)
 TESSIER (1976)
 AMERICAN ASSOCIATION OF CLEFT PALATE REHABILITATION CLASSIFICATION
 KARFIK CLASSIFICATION
 VAN DER MEULEN CLASSIFICATION OF CLEFTS

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 VEAU’S CLASSIFICATION (1931)
Veau 1 Cleft of the soft palate only

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Veau 2 Cleft of the hard and soft palate extending no further then the incisive foramen

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Veau 3 Complete unilateral cleft, extending from uvula to incisive foramen in the midline,
then deviating to one side

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 Veau 4 Complete bilateral cleft, both clefts involves the
alveolus and leaves a segment in between known as pre-
maxilla.

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 CLEFT LIP VARIANTS

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Microform cleft lip
MULLIKEN CLASSIFICATION

Mini Microform : Cleft confined to the

vermillion
Microform: Involves vermillion and up to 3mm
of the skin of the lip above the cupids bow.
Minor form: More than 3mm of the skin above
the cupids bow is affected

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 CLEFT LIP VARIANTS

PARTIAL UNILATERAL CLEFT LIP

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LIP&ALVEOLUS &ALVEOLUS
 CLEFT LIP VARIANTS

PARTIAL BILATERAL COMPLETE

CLEFT LIP AND COMPLETE UNILATERAL BILATERAL CLEFT LIP
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ALVEOLUS
PROMPT 2023
CLEFT LIP AND ALVEOLUS AND ALVEOLUS
 Treatment

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 Sequence of treatment for cleft
lip and palate
At birth, the cleft l/p team evaluates the child
At 6 months the cleft lip is repaired along with the anterior palate
At 12-18 months,the soft palate and remaining hard palate are repaired
Speech therapy initated after the child is 1and half years
At 7 years the speech is re-evaluated and corrective velopharygeal
surgery is done
At 5-8 years, interceptive orthodontics are employed
At 6 years a preschool rhinoplasty is done
At 7-8years, maxillary expansion is done,if needed

At 9-11years, alveolar cleft bone grafting is performed

At12-13years,comprehensive orthodontics are initiated

At 14-16years,orthognathic surgery and nasal surgery are done, if
needed
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 DIAGNOSIS AND PRENATAL
COUNSELLING

Often diagnosed prenatally during routine USG.

Parents may want to terminate pregnancy.

If no other congenital deformity has been diagnosed pregnancy can be

continued.

The parents explained the treatment options available.

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 Presurgical orthopedics

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 Traditionally in India primary treatment of clefts involved surgery
alone

Presurgical orthopedics is a relatively new approach to treatment

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 Why Presurgical orthopedics?

Problems in cleft repair which affect stability of repair

Alveolar asymmetry
Nasal asymmetry
Nasal Cartilage malposition

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The latham appliance
ADVANTAGES DISADVANTAGES

Active appliance . Growth restriction in many of the cases

Can be used in patient who are older. Additional procedure under general
anesthesia for insertion and removal

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 Fixed appliance :Latham’s device

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 NASOALVEOLAR MOLDING (NAM)

NAM is a type of pre-surgical orthopedic appliance , described by Grayson and

coworkers in 1993

NAM uses an acrylic appliance to approximate and align the cleft alveolus and mold
the alar cartilages to a favorable presurgical position.

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 1 MONTH 20 DAYS

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 5 mm defect closed & nose molded in 2 months of time period

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NAM APPLIANCE IN SITU

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Lip repair
Dynamic repair
Functional repair
Delaire’s philosophy:
•Understand embryology
•Maintain vascular pedicles
•Identification and correction of pathologic muscular displacements and distortions
•Realignment of muscles
•Removal of abnormal vectors of force.

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 Primary nasal repair
Closed approach

Semi open approach

Open rhinoplasty approach

Post operative supports

• Bolsters

• Sling sutures

• Nasal stents

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 Surgical technique

Rotation and advancement technique with

modifications for UCLP

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INCISIONS Traditional / Mohler
modification

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Rotation and advancement incision,
Vermillion and mucosa ‘L’ flap

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VOMERINE FLAP

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FLAPS FOR CLOSURE OF NASAL FLOOR

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TURBINATE AND L
FLAP

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VERMILLION TRIANGULAR FLAP.

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Final closure

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Charles pinto centre protocol

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Fishers anatomic subunit approximation
technique

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Triangular flap technique

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 Triangular flap technique

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PATIENT 2 -NAM
AT TWO WEEKS

PREOP POST NAM

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POST OPERATIVE 7DAYS

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Bilateral cleft lip

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 EVOLUTION OF SURGICAL
TECHNIQUES
Principles of repair( Cronin)
The prolabium) used for
the entire length of the lip

Prolabial vermillion should

be turned down

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 EVOLUTION OF SURGICAL
TECHNIQUES Principles of repair
Central vermillion built by vermillion
muscle flaps from the lateral lip
elements

No lateral skin should be used under

the prolabium

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 John Mulliken
2001
Symmetry: Multi stage repair will not
give symmetry. Single stage repair is
best suited to this purpose

Primary muscular continuity

Proper philtral size and shape

Formation of the medial tubercle from

the lateral lip elements

Primary positioning of alar cartilages to

construct the nasal tip and the
collumella

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 Evolution of repair
The two stage repair

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 Two Stage
Repair
The second stage needs to be
done within 4to 6 weeks.
Causes rotation of the prolabium
and premaxilla to the repaired
side, if the repair is delayed
Difficult to attain symmetry

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 Manchester technique

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 The Manchester Technique
The projecting premaxilla

when retracts rotates the

prolabial vermillion inwards,

leaving a wide notch in the

middle
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 Modified Mulliken
technique
During the paring of the lateral cleft margin , the vermillion

muscle flap is turned down. The skin between the incision and the

vermillion is discarded but for the white roll

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 Orbicularis oris muscle

undermined & dissected from

both the skin of the lip and the

labial mucosa

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 The skin has been
removed from the
flaps leaving the white roll ridge,
vermillion mucosa and muscle

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 If the lateral lip is in excessive height a
full thickness wedge of tissue can be
removed from the area immediately
below the ala

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Primary Rhinoplasty

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Secondary deformities
Vermillion/ Mucosa
1. Vermillion notching
2. Vermillion excess

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Secondary deformities
Short lip

Long lip

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White roll discontinuity

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Cleft nose deformity Unilateral

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Cleft nose deformity Bilateral

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Thank You

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