Postoperative deformities of the upper lip and palate: etiology, pathogenesis, clinical features,...
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Transcript of 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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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)
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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:
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
In Complex Resident/Staff Terms:In Complex Resident/Staff Terms:
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
Post-op ManagementPost-op Management
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
Post-op ManagementPost-op Management
Airway obstructionAirway obstruction Intraoperative bleedingIntraoperative bleeding Palatal fistulaPalatal fistula Midface abnormalities (early Midface abnormalities (early
interventions)interventions)
ComplicationsComplications
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction
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