In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January...

In the name of God

Cleft Lip

Dr. Sasan DabiriOtorhinolaryngologist – Head & Neck Surgeon

January 2011Imam Hospital complex - Tehran

Cleft Palate

Introduction

Orofacial clefts are the most common craniofacial birth defects

Cleft lip ± cleft palate isepidemiologically & etiologically distinct

from isolated cleft palate

Cleft Lip Cleft Palate

Differences Cleft Lip Cleft Palate

Yes Ethnicity effect NoYes Socioeconomic status NoMale Gender preference Female25 % Syndromic rate 50 % 1 in 1000 Incidence 1 in 2000

Concordance of cleft in monozygotic twins is 50%

Differences

Classification

• Complete or Incomplete

• entire vertical thickness of upper lip• often associated with an alveolar cleft


Classification

Classification

• Complete or Incomplete

• Unilateral or Bilateral


Classification

Classification

•Complete or Incomplete

•( incisive foramen )Primary or Secondary

•Unilateral or bilateral


Classification

Team workCleft Lip Cleft Palate

Otolaryngologist

Maxillofacial surgeon

Orthodontist

Speech pathologist

Audiologist

Psychologist

Nurse

Plastic surgeon

Team work

airway management

otologic care

evaluation of velopharyngeal insufficiency

facial reconstructive surgeon


Otolaryngologist

Feeding

The most immediate concern in the care, other than the airway, is nutrition.

Early swallowing therapy is required in infant with complete cleft palate

to ensure near-normal feeding


Feeding

Feeding

– squeeze bottles with cross-cut nipples

– Aerophagia

– fail to gain weight – excessive aerophagia


Palatal obturator

• Frequent burping• Haberman feeder

Feeding

When to Treat

• Cleft lip : the rules of ten:

– weight at least 10 pounds– Hb at least 10 g– WBC count less than 10,000/mm3– age more than 10 weeks


When to Treat

When to Treat

• Cleft lip :

– wide complete clefts with marked premaxillary protrusion staged repair

• lip adhesion performed at age 3 months • definitive repair performed at age 5 to 6 months


When to Treat

When to Treat

•Cleft Palate

Speech outcome or Facial growthThis is a question?


Proposed time is roughly 1 year old

When to Treat

surgery

• freshening and approximation of cleft edges

• curved incisions to allow lengthening of lip – straight-line closure

• numerous geometric repairs – produced scars that violated the philtrum)

• Millard rotation-advancement technique


Surgery

surgery

• Millard method:


Surgery

surgery

• Millard Advantages:• scar along the natural philtral border• more flexible than geometric closures• complete muscular repair and primary cleft rhinoplasty• minimizes the discarding of normal tissue

• Millard Disadvantages: • extensive undermining• risk for nostril stenosis on the cleft side


Surgery

surgery

• Rhinoplasty– primary rhinoplasty (at the time of lip repair)– intermediate rhinoplasty

• correct any residual lower cartilaginous deformity– V-Y advancement flaps from upper lip lengthen columella – Y-V alar advancement to narrow alar base,

with fixation of base to nasal spine with permanent suture

– Delayed rhinoplasty (after puberty)• correct any bony dorsal deformity or nasal obstruction


Surgery

surgery

• Complications– Notch in the vermilion– Malalignment of Cupid’s bow (whistle deformity)– Absence of median tubercle and part of Cupid’s

bow

Rx : Z-plasty c


Surgery

surgery

•Goals

–Closure of oronasal communication

–(velum )Correct speech pathology

•mobility depends on six paired muscles

(normally insert on soft palate)


Surgery

surgeryCleft Lip Cleft Palate

Surgery

surgery

•primary veloplasty (Schweckendiek)


Surgery

surgery


•bipedicled flap palatoplasty (Von Langenbeck)


Surgery

surgery



•V-Y pushback palatoplasty (Oxford)

•unipedicled two-flap palatoplasty (Bardach)

•double-opposing Z-plasty (Furlow)


Surgery


Surgery

surgery







Surgery


Surgery

surgery







Surgery


Surgery

Surgery

•Complications–The most common : velopharyngeal insufficiency

–Oronasal fistula •Technical error•Severity of cleft

–airway obstruction•Pressure of mouth gag during surgery


Surgery

Postoperative care

Continuous pulse oximetry for first 24 to 48 hours

Intravenous hydration

Intr venous pain medications (+ acetaminophen supp)

Arm splints (first 2 wks)

Clear liquids by syringe or cup on first day (1 to 2 wks)

Discouraging nipple feeding


Postoperative Care

•Develops within the first months of life

•Frequency decreases with increasing age

•Due to abnormalities of cartilage and muscles

surrounding the eustachian tube


Otitis media

•Abnormalities of cartilage and muscles

–Hypoplasia of the lateral cartilage relative to the medial cartilage

–The curvature of the eustachian tube lumen

–width and angulation of skull base with respect to eustachian tube

–Abnormal insertions of TVP and levator veli palatini muscles


Otitis media

•Management

–Tympanostomy tube insertion

•Controversy : Type of VT

•Controversy : Time of VT


Otitis media

Thanks for your attention

In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January...

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