Postoperative deformities of the upper lip and palate: etiology, pathogenesis, clinical features,...

Postoperative deformities of the upper lip and palate: etiology,

pathogenesis, clinical features, surgical treatment of deformities.

Voles of the maxillofacial area, salivary glands, etiology,

symptoms, diagnosis, surgical treatment.

Cleft VariantsCleft Variants

Great anatomic variation in types of clefts!Great anatomic variation in types of clefts!

Anatomic Classification based on:Anatomic Classification based on:

1) Location 1) Location

2) Completeness (Incomplete/Complete)2) Completeness (Incomplete/Complete)

3) Extent3) Extent

Since lip, alveolus, and hard palate differ in embryologic origin, Since lip, alveolus, and hard palate differ in embryologic origin, any combination can occurany combination can occur

Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction

Iowa ClassificationIowa Classification

Group IGroup I

Clefts of lip onlyClefts of lip only

Group IIGroup II

Clefts of palate only (Clefts of palate only (22oo))

Group IIIGroup III

Clefts of lip, Clefts of lip, alveolus, palatealveolus, palate

Group IVGroup IV

Clefts of lip and Clefts of lip and alveolus alveolus (primary (primary cleft palate and lip)cleft palate and lip)

Group VGroup V

MiscellaneousMiscellaneous

Cleft VariantsCleft Variants

1) Isolated Incomplete1) Isolated Incomplete

Intact skin/muscle between the lip and noseIntact skin/muscle between the lip and nose

Less distortion brought on by abnormal muscle pullLess distortion brought on by abnormal muscle pull

Bilateral/UnilateralBilateral/Unilateral

Cleft LipCleft LipExpressed in structures anterior to incisive foramenExpressed in structures anterior to incisive foramen

- prepalatal alveolus, maxilla, lip, nasal structures- prepalatal alveolus, maxilla, lip, nasal structures

Gaping cleft of alveolus/lip structures to mere ‘scar’ Gaping cleft of alveolus/lip structures to mere ‘scar’ ((forme frusteforme fruste))

Deficiency in skin, muscles, mucous membranes, Deficiency in skin, muscles, mucous membranes, maxillary/nasal bones, nasal cartilagesmaxillary/nasal bones, nasal cartilages

2) Isolated Complete *2) Isolated Complete *

Bilateral/UnilateralBilateral/Unilateral

Cleft runs entire length of lip to floor of noseCleft runs entire length of lip to floor of nose

Abnormal muscle pull distorts nose extensively and creates wide clefts Abnormal muscle pull distorts nose extensively and creates wide clefts between the lip segmentsbetween the lip segments

Cleft VariantsCleft VariantsIsolated Cleft PalateIsolated Cleft Palate

Complete/IncompleteComplete/Incomplete

Soft PalateSoft Palate

-cleft can extend into the hard palate to any -cleft can extend into the hard palate to any extentextent

Hard PalateHard Palate

Primary Palate (CL)Primary Palate (CL)

Secondary PalateSecondary Palate

Cleft VariantsCleft VariantsCombined CleftsCombined Clefts

Complete lip/palateComplete lip/palate

Incomplete lip/palateIncomplete lip/palateClinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction

Surgical ManagementSurgical Management

Multidisciplinary approachMultidisciplinary approach

Beyond lip repair are other issues:Beyond lip repair are other issues:

Hearing (otolaryngologists)Hearing (otolaryngologists)

Speech (speech pathologists)Speech (speech pathologists)

Dental (oromaxillofacial surgeons)Dental (oromaxillofacial surgeons)

PsychosocialPsychosocial

Integration with team-based approachIntegration with team-based approach

Each case is assessed independently by those involved and a global treatment plan is Each case is assessed independently by those involved and a global treatment plan is instituted based on present need in his/her developmentinstituted based on present need in his/her development

Cleft Lip and PalateCleft Lip and Palate

NutritionNutrition

Surgical ManagementSurgical ManagementStaging and Timing of SurgeryStaging and Timing of Surgery

Different institutions = different practiceDifferent institutions = different practice

Rule of 10’sRule of 10’sHgb = 10gHgb = 10g

Weight of 10lbsWeight of 10lbs

Age 10wksAge 10wks

IWK - 6-8 weeksIWK - 6-8 weeks

Cleft LipCleft Lip Cleft PalateCleft PalateIWK - 9-12 months of ageIWK - 9-12 months of age

Surgical ManagementSurgical ManagementUnilateral Complete Cleft LipUnilateral Complete Cleft Lip

Goal: Symmetric shaped nostrils, nasal sill, and alar bases; well defined philtral Goal: Symmetric shaped nostrils, nasal sill, and alar bases; well defined philtral dimple and columns; natural appearing Cupid’s bow; functional muscle repairdimple and columns; natural appearing Cupid’s bow; functional muscle repair

Surgical Principle: Lengthen medial side of cleft so that it equals the Surgical Principle: Lengthen medial side of cleft so that it equals the vertical dimensions of non-cleft sidevertical dimensions of non-cleft side

Flap designs:Flap designs:

1) Triangular (Tennison-Randall)1) Triangular (Tennison-Randall)

2) Quadrangular 2) Quadrangular

3) Rotation-advancement (Millard*, Mohler)3) Rotation-advancement (Millard*, Mohler)

Millard TechniqueMillard Technique

Scar placed in more anatomically correct position along philtral column

““Cut as you go” techniqueCut as you go” technique

1) Medial flap rotates downward to achieve 1) Medial flap rotates downward to achieve necessary lengtheningnecessary lengthening

2) Lateral flap advances into the defect produced by 2) Lateral flap advances into the defect produced by downward displacement of medial flapdownward displacement of medial flap

3) Small pennant-shaped medial flap can be used to 3) Small pennant-shaped medial flap can be used to restore nostril sill or lengthen the columellarestore nostril sill or lengthen the columella

Preserves’ cupid’s bow and philtral dimplePreserves’ cupid’s bow and philtral dimple

Tension of closure under the alar base; reduces flair and promotes better molding of the Tension of closure under the alar base; reduces flair and promotes better molding of the underlying alveolar processesunderlying alveolar processes

In simple medical student terms:In simple medical student terms:

In Complex Resident/Staff Terms:In Complex Resident/Staff Terms:

Post-op ManagementPost-op Management

1) Feedings administered with catheter tip syringe fitted with 1) Feedings administered with catheter tip syringe fitted with small red rubber catheter for the first 10 days post-opsmall red rubber catheter for the first 10 days post-op

2) Nipples are avoided to minimize strain on the muscle/skin 2) Nipples are avoided to minimize strain on the muscle/skin suturessutures

3) Velcro arm restraints to protect repair from 3) Velcro arm restraints to protect repair from flailing hands/fingersflailing hands/fingers

4) Suture line care: PRN cleansing with half strength peroxide 4) Suture line care: PRN cleansing with half strength peroxide followed with polymixin B-bacitracin ointmentfollowed with polymixin B-bacitracin ointment

Cleft LipCleft Lip

Scar contractureScar contracture

ErythemaErythema

FirmnessFirmness

Inform the parents of:Inform the parents of:

Avoid placing in direct sunlight until the scar fully maturesAvoid placing in direct sunlight until the scar fully matures

ComplicationsComplicationsPost-op ManagementPost-op Management AestheticAesthetic

vermilion-cutaneous vermilion-cutaneous mismatchmismatch

vermilion notchingvermilion notching tight appearing lateral tight appearing lateral

lip segementlip segement lateral muscle buldgelateral muscle buldge laterally displaced alalaterally displaced ala constricted appearing constricted appearing

nostrilnostril

OtherOther dehiscencedehiscence excessive scar excessive scar

formationformation

Surgical ManagementSurgical ManagementCleft PalateCleft Palate

Goal: Production of a competent velopharyngeal sphincterGoal: Production of a competent velopharyngeal sphincter

Two most common repairs:Two most common repairs:

1) V-Y (Veau-Wardill-Kilner)*1) V-Y (Veau-Wardill-Kilner)*

2) von Langenbeck2) von Langenbeck

Main difference: V-Y repair involves Main difference: V-Y repair involves elongation of the palateelongation of the palate, while von , while von Langenbeck does notLangenbeck does not

Wardill-KilnerWardill-Kilner1) Incisions made along free margins of cleft and extend 1) Incisions made along free margins of cleft and extend anteriorly to apexanteriorly to apex

2) Dissection continued posteriorly along oral side of alveolar 2) Dissection continued posteriorly along oral side of alveolar ridge to retromolar trigoneridge to retromolar trigone

Wardill-KilnerWardill-Kilner3) Mucoperiosteal flaps are elevated from nasal/oral 3) Mucoperiosteal flaps are elevated from nasal/oral surfaces of bony palatesurfaces of bony palate

4) Dissection of the greater palatine vessels from the 4) Dissection of the greater palatine vessels from the foramen lengthens the pedicleforamen lengthens the pedicle

5) Tensor veli palatini muscle is elevated off the hamulus 5) Tensor veli palatini muscle is elevated off the hamulus to aid in relaxing the midline closureto aid in relaxing the midline closure

Wardill-KilnerWardill-Kilner6) Nasal mucosa freed from bony palate and 6) Nasal mucosa freed from bony palate and closed to either side, or if necessary closed closed to either side, or if necessary closed by using vomer flapsby using vomer flaps

7) Muscle and oral mucosa closed in a second 7) Muscle and oral mucosa closed in a second single layer in a horizontal fashionsingle layer in a horizontal fashion

Wardill-KilnerWardill-Kilner8) Anteriorly, the oral mucoperiosteal flaps are 8) Anteriorly, the oral mucoperiosteal flaps are attached to the third flap (mucosa overlying the attached to the third flap (mucosa overlying the primary palateprimary palate

9) Posteriorly, the palate is closed in 3 layers9) Posteriorly, the palate is closed in 3 layersNasal mucosaNasal mucosaLevator muscleLevator muscleOral mucosaOral mucosa

Post-op ManagementPost-op ManagementCleft PalateCleft Palate

Immediate concerns: Immediate concerns:

1) Airway management1) Airway management

2) Analgesia2) Analgesia

Risk of oversedation and subsequent airway comprimiseRisk of oversedation and subsequent airway comprimise

Acetominophen, Codeine sufficient: cont’d for 7-10 daysAcetominophen, Codeine sufficient: cont’d for 7-10 days

Arm restraints to prevent placing fingers in mouthArm restraints to prevent placing fingers in mouth

Diet restricted to liquids, soft foods (x3wks): bottles avoidedDiet restricted to liquids, soft foods (x3wks): bottles avoided

Change in nasal/oral airway dynamicsChange in nasal/oral airway dynamics

Airway obstructionAirway obstruction Intraoperative bleedingIntraoperative bleeding Palatal fistulaPalatal fistula Midface abnormalities (early Midface abnormalities (early

interventions)interventions)

ComplicationsComplications

NORMAL LIP MUSCULAR ANATOMY

CLEFT LIP ANATOMY

Problems in Cleft Lip and Cleft Palate

• Feeding• Frequent upper respiratuary tract infection• Frequent gas regurtation• Otitis media• Nasal regurtation of food• Aspiration pneumenia• Growing retardation• Other anomalies• Psycological problems (family)

Cleft lip and palate treatment team

Surgeon experienced in cleft management Pediatrist Orthodontist Pediatric Otorhinolaryngologist Pediatric dentist Geneticist Spech Terapist Social Worker Nurse experienced in cleft problems

Feeding Rules

Swallowing is not impaired, oral feeding is possible

Bottle feed with additional cross cut in the end Elastic plastic bottle Bulb syringe with a nipple Feeding with a spoon The child should be held in a head-up position at

about 45 º during and after feeding Lateral position during sleeping

When to Operate

Generally (Rules of 10’s)

Weight > 10 pound (4500 gr) Hb > 10 gr Age > 10 weeks

Cleft lips between 3-6 months Cleft palate between 12-18 months (preferred before

speech devolops)

Cleft Lip Treatment Cleft lip

Mikroform cleft lip Unilateral cleft lip Bilateral cleft lip

Associated nasal deformity is classified as mild, moderate or severe

Alveolar arc position evaluated. If necessary “presurgical maksiller orthodontics” applied

Operation technique in Microform cleft (Straight line closure)

Surgical technique for unilateral cleft lip(Millard Rotation-Advancement)

Surgical technique for unilateral cleft lip(Tennison Triangular Flap)

Surgical technique for unilateral cleft lip and palate

Millard techniques provides primary lip and nasal repair . It is possible “gingivoperiostoplasy” after “Presurgical maksiller ortopedics”

Pre -Orthodontic treatment After 3 months of Grayson molding plate application

A.M.Kul, right unilateral primary and secondary cleft palate

Pre -Orthodontic therapy After 3 months of Grayson molding plate application

Postoperative 6 months

Postoperative 1,5 years

Bilateral Cleft Lip

More complex and difficult to treat Projectil premaksilla Broad and flared nasal tip Prolabium Short columella or absent columella

Incomplet or complet It is important to retropositon the premaksilla

with presurgical orthopedic treatment Surgical techniques used for unilateral cleft

lip repair are used for bilateral cleft lip repair in one or two stage operation (Millard, Tennison...)

Treatment of Premaksilla

Lip repair or “Lip-adeshion”

Elastic traction ( with a Head Bonnett)

Premaksillary retantion (Latham)

Nazoalveoler molding (Grayson)

Surgical premaksilla excision or set-back (severe maxillary retrusion)

Bilateral Incomplet Cleft lip Operation Technique

Millard (Two stage)

Bilateral Incomplet Cleft lip Operation Technique

Straight Line Closure (One stage)

Cleft PalatePalate and palatal muscles close the

velopharengeal valveVelofarengial closure can not be done in

cleft palate patient.Patient can not create intraoral pressure Feeding and speach are effected

Problems with cleft palate

FeedingSpeechHearing and middle ear problemsAdditional anomalies (% 30)Psychological problems

Goal of Palatal Repair

Understanble speechNo maxillary retrusionNo hearing problemGood occlusion

Palatoplasty Technique

“Double opposing Z Plasty”

Von Langenback Method

Surgical treatment of isolated cleft palate

Pierre Robin Sequence Micrognathy

Glossoptosis

Airway obstruction

Cleft palate( % 50 )

Breathing and feeding problem

Treatment of Velopharyngeal Insufficency

Patient should evaluate by speech terapist before any treatment

Nasendoscopic evaluation and Multiview videofluoroscopy is importany diagnostic tests

Goal is to provide normal velopharyngeal anatomy

Surgical Treatment of Velopharyngeal Insufficency

Pharyngeal Flaps (Superior, inferior pedicled)

Pharyngoplasty (Hynes, Orticochea)

Soft palate lengtening and levator muscle repair

Posterior wall augmentation (teflon, proplast)

Other Operations Fistula Repair Velopharyngeal Insufficency correction (5 yeras)

Secondary Onarımlar (preschool age)

Alveolar bone grafting (before canine theth eruption)

Orthodontic Surgery (12-14 years) (Le-Fort I Maksillary osteotomy, Mandibular split ramus osteotomy)

Rhinoplasty (16-18 years)

Thank you for your Attention

Postoperative deformities of the upper lip and palate: etiology, pathogenesis, clinical features,...

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