Functional primary closure of cleft lip

Three-dimensional Analysis of Maxillary Morphology in Infants with Unilateral Cleft Lip and Palate

OBJECTIVE

To three-dimensionally (3D) analyze the maxillary morphology of infants with unilateral cleft lip and palate (UCLP) and preliminarily classify the alveolar arch to assist in personalization of sequence therapy.

DESIGN

Retrospective study.

SETTING

Patients with UCLP referred to outpatients' clinic.

PARTICIPANTS

84 nonsyndromic infants with complete UCLP were recruited (58 boys, 26 girls, mean age 29.48 days).

MAIN OUTCOME MEASURE

Morphometric analysis was conducted on 3D maxillary models. Principal component analysis (PCA) and cluster analysis were combined to classify maxillary phenotypes preliminarily. The Wilcoxon Signed Rank test and the Kruskal-Wallis test were used to compare differences between variables. A P value less than .05 was considered statistically significant.

RESULTS

The maxilla was divided into three types: narrow, homogenous and broad, accounting for 9.52%, 23.81% and 66.67% respectively. The alveolar cleft site (median value) was located in 61% of the total length of the alveolar arch. In the comparison of anterior and total alveolar lengths, the non-cleft side had longer alveolar bone than the affected side, a difference of approximately 2 mm. Pairwise comparisons of variables describing alveolar symmetry revealed significant differences in all subjects; whereas type C had poorer arch symmetry than types A and B, mainly in terms of anterior and overall symmetry.

CONCLUSIONS

In infants with UCLP, the maxillary alveolar arch was inherently asymmetrical with partially bone missing (about 2 mm). Significant differences in alveolar bone morphology and symmetry exist between different types of infants, with individuals with broad clefts (type C, the largest proportion) having the worst maxillary development.

Treatment Modalities to Achieve Nasal Symmetry in Unilateral Cleft Lip/Nasal Deformity: An Objective and Comparative Evaluation

Introduction

Primary cleft lip repair techniques do not address the nasal deformity adequately resulting in nasal asymmetry. Maneuvers employed to minimize this have varying degrees of success.

Aim

To assess the outcome of different treatment modalities employed to establish nasal symmetry in unilateral cleft lip.

Methods

100 patients with complete unilateral cleft lip/ palate operated for primary cheiloplasty with modified Millard's rotation advancement technique were divided into five groups. Group 1: lip repair alone, Group 2: NAM followed by lip repair, Group 3: lip repair followed by placement of conformers, Group 4: NAM followed by lip repair and placement of conformers, Group 5: lip repair with semi-open rhinoplasty. Objective assessment was done using measurable parameters after 12 months post-operatively on a 1:1 standard photograph.

Results

Group 5 showed statistical significance in all parameters assessed. Progressive improvement in nasal symmetry was noted from Group 1 to Group V.

Conclusion

In our study, group V, i.e., modified Millard's repair with semi-open rhinoplasty improved the results in terms of all the objective parameters assessed. The results of the other groups showed improvement though not consistent in all parameters. Naso-alveolar molding is an effective adjunct. Additionally, nasal conformers proved to be of great value in retaining the results obtained post-surgery.

Correction of a prominent premaxilla in a juvenile with a bilateral cleft lip and palate using a novel, hybrid function regulator, the FR-BCPPm, followed by preadjusted fixed appliances: A 20-year follow-up

A seven-year-old boy with a repaired bilateral cleft lip and palate, presented with a severe skeletal II base and an extremely prominent premaxilla. He had grossly incompetent lips with lower lip trapping, an 18.5-mm overjet, a deep overbite, markedly retroclined lower incisors, bilateral crossbites and 12-mm-wide alveolar gaps together with 6-mm vertical steps between the extruded premaxillary incisors and the posterior teeth. Before the eruption of the permanent canines, there was an urgency to approximate the opposing cleft alveolar margins and to level the split maxillary occlusal plane, in order to facilitate the successful insertion and subsequent consolidation of secondary alveolar bone grafts.A new functional appliance was therefore designed to achieve this objective, which drew components from Fränkel's FR I and FR III function regulators. Together with a couple of novel components, it created a hybrid appliance, namely the function regulator for juveniles with a bilateral cleft and a prominent premaxilla: the FR-BCPPm.The patient was treated with this appliance and a nocturnal headgear at 7-13 years, together with a concomitant quad helix appliance followed by a transpalatal arch and bilateral bone grafts. He was then treated non-extraction up to the age of 17 years with preadjusted fixed appliances to correct his residual, crowded Class II malocclusion.The marked improvement in his occlusion, dentofacial appearance and his perioral function after a decade of treatment was then followed up over 20 years, during which time mild relapse of the incisor overjet and moderate recurrence of the lower anterior misalignment was noted two years after treatment.While no further relapse was observed at the four-year post-treatment review, by 20 years after treatment, a little further misalignment of the lower anterior teeth was noted, half of which was deemed to be attributable to age-related maturation.

Morphological Correlations in Nasolabial Formation After Primary Lip Repair for Unilateral Cleft Lip

PURPOSE

We aim to reveal postoperative morphological correlations between the nasolabial components in patients with unilateral cleft lip (UCL). The hypothetical correlations are first, a correlation between the vertical height of the cleft-side alar base and the length of the cleft-side red lip, and second, a correlation between the length of the cleft-side red lip and the vertical position of the cleft-side oral commissure. We explain how these morphological balances are controlled by surgery.

METHODS

Three-dimensional bilateral measurements of the length of the red lip, vertical height of the nasal alar base, and vertical height of the oral commissure were conducted retrospectively on 31 patients with UCL and palate (complete UCL: 26; incomplete UCL: 5) who underwent primary lip plasty at Osaka Women's and Children's Hospital from 2017 to 2019.

RESULTS

We found a statistically significant correlation between the vertical height of the cleft-side alar base and cleft-side red lip length (P = .012, r = 0.45); thus, the longer the red lip, the lower was the nasal alar base. The correlation between the cleft-side red lip length and the vertical height of the cleft-side oral commissure also showed a statistical significance (P = .00074, r = 0.57); thus, the shorter the red lip, the higher was the oral commissure.

CONCLUSIONS

The present results provided objective evidence showing basic morphological relationships between the postoperative nasolabial features of patients with UCL. The results lead to a reasonable approach to define the proposed peak of the Cupid's bow, an unsettled major controversy in cleft lip surgery.

Nasolabial appearance of bilateral cleft lip repair at five years of age. Comparing techniques of modified advancement-rotation (Delaire) with Manchester repair: a retrospective cohort study

The techniques used to repair bilateral cleft lip have evolved over time, yet little data exist to compare outcomes using the various techniques. The aim of this study was to retrospectively evaluate and compare the aesthetic outcomes of two types of complete bilateral cleft repair: advancement rotation and a historic cohort repaired with the Manchester technique. A total of 32 consecutive patients who had complete repair of bilateral cleft lips were identified retrospectively from our centre using inpatient records. The first 16 (born between 1994 and 2005) underwent the Manchester repair, the second 16 (born between 2006 and 2010) a Delaire modified advancement rotation technique. Standardised photographs were taken at five years post repair and cropped to isolate the nasolabial component. Appearance outcomes were assessed by 20 members of the cleft and plastic surgery team, who were each asked to rate all 32 images using the Asher-McDade five-point scale. A chi squared test was used to determine whether there was a statistically significant difference in cleft scores between the two approaches. There was a mean (SD) of 2.8 (1.02) in the advancement rotation group and a mean (SD) of 3.1 (1.07) in the Manchester group. There was a statistically significant difference in the distribution of scores in the advancement rotation group compared with the Manchester group, with lower scores (better results) in the advancement rotation group (p=0.003). This study demonstrates that the advancement rotation technique for the repair of bilateral cleft lip defects resulted in a superior nasolabial appearance when directly compared with the Manchester repair at 5 years of age.

Force balance reconstruction of the orbicularis oris in unilateral incomplete cleft lip

PURPOSE

To demonstrate a maneuver for achieving optimal force balance of reconstructed orbicularis oris during primary unilateral incomplete cleft lip reconstruction.

METHODS

The surgical maneuver was performed as follows: the length of the orbicularis oris on the noncleft side is first isolated and adjusted to be equal to the length of the muscle on the cleft side. The remaining muscle from the noncleft side near the midline is used to fill in the vermilion tubercle, and finally, the two orbicularis oris muscles are sutured at the midline. Finite element analysis was utilized to model the biomechanics of our novel surgical method.

RESULTS

Finite element analysis showed that when the lengths of two orbicularis oris muscles were the same after primary cleft lip repair, the stress on this muscle system was minimized under different lip conformations. Seventeen cleft lip patients were enrolled to receive reconstruction with this new maneuver. Significant differences were found in (1) noncleft/cleft alar base width, nasal dorsum angle, columella length relationship between two sides, and columella angle under the comparison between preoperative and postoperative; (2) noncleft/cleft alar base width, nasal dorsum angle, and columella angle under the comparison between preoperative and follow-up; and (3) columella length relationship between two sides under the comparison between postoperative and follow-up.

CONCLUSION

Force balance of the orbicularis oris muscles is important during unilateral incomplete cleft lip repair. This surgical maneuver for achieving force balance of the orbicularis oris and the muscle system of the lips is easy to perform and can help avoid relapses.

Application of a Layered Muscle Flap Technique for the Reconstruction of the Cupid's Bow and Vermilion in the Repair of Secondary Cleft Lip Deformities

In the repair of unilateral cleft lip, the Cupid's bow, and vermilion on the affected side are sometimes lowered excessively. Methods involving skin and mucosa flaps have been used to correct this issue, but they pose some risk of scarring. The authors here describe a layered muscle flap technique that was based on the anatomical research of nasal-labial muscles, especially the levator labii superioris alaeque nasi muscle. This technique can be used to suspend the Cupid's bow and vermilion in secondary unilateral cleft lip repair. Forty-five patients with secondary unilateral cleft lip with excessively lowered Cupid's bows and vermilion on the affected side were included in this study, which lasted 3 years. These patients were treated using the layered muscle flap surgical technique. The heights of specific bilateral landmarks were measured on patient photos and used to define the symmetry of bilateral Cupid's bow and vermilion. The comparison between post-operative and pre-operative symmetries was used to evaluate the post-operative results, and most of them were satisfactory. The results were also mostly well retained in follow-up investigations. This layered muscle flap technique could be effective in selected cases.

Efficacy of morpho-functional repair in management of different morphological variants of unilateral complete cleft lip

BACKGROUND

To study the surgical outcome in various morphological variants of unilateral complete cleft lip in our high volume centre over a period of 4 years, using Morpho-Functional technique in all cases by indirect two dimensional photographic analysis.

METHODS

In this prospective cohort study, 749 patients with Unilateral Cleft Lip with palate were included over a period of 4 years from January 2010 to December 2014. All Subjects underwent surgery before the age of 1 year with the follow-up two dimensional photographs taken at 4 years post-operatively. Eight measurements were performed on the photographs. All parameters were measured on both Cleft & Non cleft sides and the ratio was considered with the normal side as the base line. Shapiro-Wilk and Kolmogrov-Smirnoff tests were used to confirm that the data was normally distributed. One way ANOVA was done to find out if there were any significant differences amongst the different groups along various parameters, respectively. Further Tukey post hoc analysis was done to confirm where the differences occurred between groups.

RESULTS

None of the groups showed any statistical differences on any parameters. There were minor variations between the different groups due to the ranging morphology of the defect but overall satisfactory to good results were seen on all measured parameters evaluated.

CONCLUSION

This shows that the Morphofunctional technique, with its combinations & modifications of various school of thought, is versatile enough to achieve good surgical outcomes despite the wide variations seen in size and type of defects in unilateral cleft lip. This comes about because of the comprehensive nature of the technique & the balance that it creates among the affected structures.

Symmetric Philtral Column Repair for Unilateral Cleft Lip

BACKGROUND

When treating a patient with a unilateral cleft lip, the goal is to try and achieve a result that is the least perceivable at conversational distance. The result should be a balanced and symmetric lip with scars that are hidden or are placed in natural anatomical lines. Several methods have been described to repair the lip. The most popular repairs at present are the rotation-advancement or its modifications and the various versions of the straight-line repair.

METHODS

In the author's unit, a method has evolved entitled the symmetric philtral column repair. In this method, the author attempts to achieve a philtral column that mirrors the philtral column on the normal side, producing a balanced appearing lip. This method has been used for the past 14 years in over 500 patients.

RESULTS

The results have been satisfying, with a lip revision rate of 6 percent.

CONCLUSIONS

The symmetric philtral column repair of a unilateral cleft lip is an effective and safe repair. The repair is easy to understand and produces results that minimize the stigmata of a cleft lip deformity.

Pilot Study of Visual and Quantitative Image Analysis of Facial Surface Asymmetry in Unilateral Complete Cleft Lip and Palate

Objective:

To visualize and quantitatively analyze facial surface asymmetry following primary cleft lip repair in patients with unilateral cleft lip and palate (UCLP) and to compare this with noncleft controls.

Design:

Retrospective comparative study.

Patients:

Twenty-two patients with complete UCLP who underwent primary lip repair from 2009 to 2013 were enrolled in this study. The preserved 3-dimensional (3D) data of 23 healthy Japanese participants with the same age were used as controls.

Interventions:

All patients had received primary labioplasty in accordance with Cronin triangular flap method with orbicular oris muscle reconstruction.

Main Outcome Measures:

Shadow and zebra images established from moiré images, which were reconstructed from 3D facial data using stereophotogrammetry, were bisected and reversed by the symmetry axes (the middle line of the face). The discrepancies of the gravity and density between cleft and noncleft sides in 2 regions of interest, facial and lip areas, were then calculated and compared with those of healthy participants.

Results:

In the UCLP group, the mean discrepancies of gravity on shadow and zebra images were 1.76 ± 0.70 and 2.63 ± 1.72 pixels, respectively, in the facial area and 1.31 ± 0.36 and 3.83 ± 2.08 pixels, respectively, in the lip area. There was a significant difference in the mean discrepancies of gravity and density on zebra images in the lip area between the UCLP and control groups.

Conclusions:

Our image analysis of digital facial surface asymmetry in patients with UCLP provides visual and quantitative information, and it may contribute to improvements in muscle reconstruction on cleft lip repair.

Quality of life and nasal splints after primary cleft lip and nose repair: Prospective assessment of information and tolerance

Splints are commonly used after primary cleft surgery in order to secure the position of the nasal cartilages. Although the importance of splints is more and more stressed in the literature, many questions remain unanswered relative to the psychological impact of this device on children and families. Two questionnaires, Information and Tolerance, were used in order to measure the quality of life (QoL) associated with the use of nasal splints after primary cleft surgery. Information assessed the understanding of the parents the day before the procedure. Tolerance assessed their experience 3 months after splint placement. We prospectively included 41 consecutive patients from a Paris cleft center, 21 consecutive patients from a Russian center (Moscow) and 10 consecutive patients form a another French center (Nantes). In Paris and Nantes, an initial fixed splint was placed during the procedure until day 10, and then replaced by a removable splint for a period of 4 months. In the Moscow group, removable splints were used primarily for a total period of 4 months. Three types of removable splints were considered: commercial anatomical self-retentive splints (Nose-Fit™, Moscow, Russian Federation), in-house anatomical self-retentive splints and commercial Talmant-type splints requiring taping (Sebbin, Boissy-l'Aillerie, France). The data was analyzed as Likert scales and internal consistency was assessed using the Cronbach coefficient. Age at surgery, uni- or bilateral cleft, type of splint, number of splint changes and complications were tested against the scores of the questionnaires using multivariate models. We did not find correlations between the factors assessed by the multivariate analysis and the splint type. Information and Tolerance scores were high and showed satisfactory QoL associated with the use of splints. The internal consistency of the combination of the two forms was good. While the effects of splints on nasal morphology still need to be confirmed based on a controlled prospective study, we show here that this device is well tolerated by families and is not associated with specific complications.

Facial and Nasolabial Aesthetics of Complete UCLP Submitted to 2-Stage Palate Repair With Vomer Flap

OBJECTIVE

To evaluate the aesthetics of nasolabial appearance and facial profile of children with unilateral cleft lip and palate (UCLP) submitted to 2-stage palate repair with vomerine flap.

DESIGN

Retrospective.

SETTING

Single center.

PATIENTS

Forty patients with UCLP, mean age of 7.81 years of both sexes, rehabilitated at a single center by 1 plastic surgeon.

INTERVENTIONS

Lip and anterior palate repair with nasal alar repositioning was performed at 3 to 6 months of age by Millard technique and vomer flap, respectively. Posterior palate was repaired at 18 months by Von Langenbeck technique.

MAIN OUTCOME MEASURE(S)

Four cropped digital facial photographs of each patient were evaluated by 3 orthodontists to score the nasolabial aesthetics and profile. Frequencies of each score as well means and medians were calculated. Kappa test was used for evaluating inter- and intrarater reproducibility.

RESULTS

The nasal form and deviation was scored as good/very good in 70%, fair in 22.5%, and poor in 7.5% of the sample. The nasal-subnasal aesthetic was considered good/very good in 55%, fair in 30%, and poor in 15% of the sample. The lip vermilion border and the white part of surgical scar aesthetics were good/very good in 77.5% and 80%, fair in 17.5% for both categories, and poor in 5% and 2.5% of the cases, respectively. In all, 67.5% showed convex facial profile, 20% was straight, and 12.5% was concave profile.

CONCLUSIONS

Two-stage palatoplasty presented an adequate aesthetical results for the majority of patients with UCLP in the mixed dentition.

Quantitative assessment of the learning curve for cleft lip repair using LC-CUSUM

The first step in cleft lip repair is the precise positioning of anatomical landmarks and tracing of the incisions on the patient's lip at the beginning of the procedure. The aim of this study was to evaluate progress made in learning cleft lip repair tracing using a quantitative assessment of learning curves: LC-CUSUM (learning curve - cumulative sum). Eight surgical residents were enrolled and asked to trace lip repair incisions on five cases of unilateral left cleft lip over 5 consecutive weeks. Results were compared to a reference tracing based on the positioning of nine anatomical landmarks and assessed using LC-CUSUM. Competence was defined as the accurate positioning of the nine landmarks (less than 1.4mm deviation from the reference positions, with an accepted 15% failure rate). After five tracing sessions, competence was not achieved evenly for all trainees, or for all landmarks, underlining differences in inter-individual learning ability even with similar training. However, despite an initial marked lack of theoretical and practical training in lip repair techniques, repeated drawings of cleft lip incisions allowed a satisfactory level of competence to be reached for most landmarks and most trainees. Nevertheless it was found that not all landmarks are understood by students with similar ease, and that landmark positioning reveals significant inter-individual differences. This approach allowed a global assessment of the teaching of cleft repair and will help to focus training on specific problematic points for which competence was not obtained according to the LC-CUSUM test.

Postoperative alar base symmetry in complete unilateral cleft lip and palate:A prospective study

In the evolution of cleft lip repair, there have been continuous attempts to minimize local trauma and to improve lip and nasal appearances. In order to obtain an aesthetically balanced development of midface, the primary surgical correction of the nasolabial area is of paramount importance. In this study, the importance of a back-cut extending cephalically above the inferior turbinate at the mucocutaneous junction which elevates the nostril floor on the cleft side for the purpose of achieving symmetry of the alar bases are analyzed by pre and postoperative photographic anthropometry. This study comprised of fifty cases of the unilateral complete cleft lip. At the time of surgery, the patient age ranged from 3-9 months. The surgeries, performed by a single surgeon, employed the standard Millard technique, incorporating Mohler modifications of lip repair. Anthropometric analysis revealed that the preoperative mean difference between the normal side and the cleft side was 0.2056 with a standard deviation of 0.133. In the postoperative analysis, the mean difference was reduced to 0.0174 with a standard deviation of 0.141. The paired t-test showed that the p-value is <0.001, indicating high statistical significance. To conclude, in complete unilateral cleft lip and palate, the geometrically placed nasal back-cut incision has a definite role in the correction of the alar base symmetry during primary surgery.

Quantitative assessment of healthy and reconstructed cleft lip using ultrasonography

Purpose:

This study is conducted to investigate the feasibility of echographic imaging of tissue thickness of healthy and reconstructed cleft lip.

Design:

Prospective study.

Materials and Methods:

The study was conducted in SDM Craniofacial Unit, Dharwad and was approved by Local Institutional Review Board. A total of 30 patients, age group ranging from 4 to 25 years, of which 15 postoperative unilateral cleft lip constituted the test group. The remaining 15 with no cleft deformities, no gross facial asymmetry, constituted the control group. The thickness of the mucosa, submucosa, muscle and full thickness of the upper lip were measured with the transversal images using ultrasonography at midpoint of philtrum, right and left side philtral ridges and vermillion border, at 1, 3, 6 months interval.

Results:

There was an increase in muscle thickness at the vermillion border (mean = 6.9 mm) and philtral ridge (5.9 mm). Equal muscle thickness were found between the normal and test group at 6 months follow-up in a relaxed position, which was statistically significant (P = 0.0404).

Conclusion:

Quantitative assessment of thickness and echo levels of various lip tissues are done with proper echographic calibration. Diagnostic potentials of this method for noninvasive evaluation of cleft lip reconstructions were achieved by this study.

Muscle tension line concept in nasolabial muscle complex--based on 3-dimensional reconstruction of nasolabial muscle fibers

BACKGROUND

Plastic surgeons have attempted various ways to rebuild the aesthetic subunits of the upper lip in patients with cleft lip with less than perfect results in most cases. We propose that repairing the 3 muscle tension line groups in the nasolabial complex will have improved aesthetic results.

METHODS

Micro-computed tomographic scans were performed on the nasolabial tissues of 5 normal aborted fetuses and used to construct a 3-dimensional model to study the nasolabial muscle complex structure.

RESULTS

The micro-computed tomographic (CT) scans showed the close relationship and interaction between the muscle fibers of nasalis, pars peripheralis, levator labii superioris, and pars marginalis.

CONCLUSIONS

Based on the 2-dimensional images obtained from the micro-computed tomographic scans, we suggest the concept of nasolabial muscle complex and muscle tension line group theory: there is a close relationship among the alar part of the nasalis, depressor septi muscle, orbicularis oris muscle, and levator labii superioris alaeque nasi. The tension line groups are 3 tension line structures in the nasolabial muscle complex that interlock with each other at the intersections and maintain the specific shape and aesthetics of the lip and nose.

Comparison of Outcome of Modified Millard's Incision and Delaire's Functional Method in Primary Repair of Unilateral Cleft Lip: A Prospective Study

BACKGROUND

Certain preoperative anatomical features may lead the surgeon to choose one particular incision pattern in preference to another. No one technique of cleft lip repair consistently produces ideal aesthetic and functional results.

OBJECTIVES

This study was conducted to compare the outcomes attained using two different designs of skin incision used for surgical correction of unilateral cleft lip.

MATERIALS AND METHODS

Modified Millard's incision and Delaire's functional method techniques were performed and evaluated on 18 patients who received primary unilateral cleft lip repair. Soft-tissue measurements of the lip and nose were recorded preoperatively. Analysis was based on postoperative assessment of the white roll, vermilion border, scar, Cupid's bow, lip length, and nostril symmetry and appearance of the alar dome and base. Chi-square and Fisher exact test, Student t test (two tailed, independent) and Student t test (two tailed, dependent) were used for statistical analysis of study parameters at 5 % level of significance.

RESULTS

Preconceptions that one particular technique was better suited to certain preoperative cleft anatomical forms were not proven statistically. The outcome of our surgical methods was good and suggested quantitative changes with progressive diminution of asymmetry of the cleft and non cleft sides.

CONCLUSION

Lip length improvement was better in case of modified Millard's incision. The Delaire's functional method of cleft lip repair results in improved nasal symmetry due to correction of the abnormal insertions of the underlying musculature.

Upward Advancement of the Nasolabial Components at Unilateral Cleft Lip Repair Prevents Postoperative Long Lip

OBJECTIVE

To prevent the occurrence of postoperative long lip, longitudinal postoperative changes in nasolabial forms of patients with unilateral cleft lip who underwent primary lip repair with or without upward advancement of the nasolabial components were compared.

PATIENTS

Forty-three subjects (24 unilateral cleft lip and palate [UCLP] and 19 unilateral cleft lip solely, and cleft lip and alveolus [UCL/UCLA]) who underwent primary lip repair with upward advancement of the nasolabial components (NA group) and 30 subjects (16 UCLP and 14 UCL/UCLA) without upward advancement (LA group) were enrolled.

OUTCOME MEASURES

Postoperative photos taken at 1 and 6 months and at 1, 2, and 3 years were used for measuring the heights of the nasal alar base (NBH), the columellar base (CBH), Cupid's peak (CPH), and the upper lip (ULH). The ratios of these measurements between the affected and unaffected sides were calculated in both groups.

RESULTS

In the LA group, the 3-year postoperative all-items ratios of UCLP were significantly larger than those at 1 month postoperatively, demonstrating drooping of the nasolabial tissues in the affected side (all P < .01). Furthermore, the 3-year postoperative CPH and ULH ratio of UCL/UCLA was significantly larger than that at 1 month postoperatively, demonstrating the long lip (P < .01). In the NA group, the NBH, CBH, and CPH ratios of both UCLP and UCL/UCLA did not show significant differences between 1 month and 3 years postoperatively.

CONCLUSION

Upward advancement of the nasolabial components prevents postoperative long lip.

Effect of lip closure on early maxillary growth in patients with cleft lip and palate

IMPORTANCE

Debate continues about the cause of midfacial growth disturbance in patients with facial clefts.

OBJECTIVE

To evaluate the functional effect of surgical closure of the lip before palatal closure according to the technique by Delaire on early maxillary growth in patients with complete unilateral cleft lip and palate.

DESIGN, SETTING, AND PARTICIPANTS

Twenty-two patients with unilateral cleft lip and palate were studied using plaster casts obtained at the time of cheilorhinoplasty and 6 months later before palatal closure. The interrupted lateral muscles were anatomically repositioned using the surgical technique by Delaire. No patients had received preoperative orthodontic treatment or a passive palatal plate. Cast analyses were performed using a digital caliper.

MAIN OUTCOMES AND MEASURES

Landmark positioning was performed 3 times by 2 different examiners to define intraobserver and interobserver differences. The final maxilla dimensions were recorded as the distances between the mean landmark positions. Using the t test, dimensions obtained before palatal closure were compared with dimensions obtained before lip closure.

RESULTS

The method allowed good reproducibility. Functional closure of the lip significantly narrowed the transverse anterior cleft areas by -2.36 mm (P < .05). Sagittal variables were increased by 1.68 mm on the nonaffected side and by 1.48 mm on the affected side (P < .05 for both).

CONCLUSIONS AND RELEVANCE

Functional closure according to the technique by Delaire narrows the transverse dimensions of the maxilla, while simultaneously preserving initial sagittal growth.

LEVEL OF EVIDENCE

4.

"Three-unit" muscle reconstruction in secondary cleft lip repair

Background :  Secondary deformities are common in people born with unilateral cleft lip and palate. In recent years, more and more attempts and efforts have been directed toward muscle reconstruction. The authors present a new method of orbicularis oris repair in correction of secondary cleft lip deformities. Methods :  From April 2009 to April 2013, a total of 28 patients underwent this procedure in the authors' department and had a follow-up with a minimum length of 1 year. Muscle reconstruction was divided into three units that deal with the nasal floor, white lip, and red lip. Common anatomical pathologies including a deviated columella, blunted alar-facial groove, lack of philtral column, "free border" deficiency, and unapparent vermilion tubercle can be corrected in a single operation. Results :  The average follow-up period was 14.6 months (range, 12 to 24 months). Contractubex gel (Merz Pharma, Frankfurt, Germany) was used to treat prominent or reddish scars in 16 patients. No major complications occurred. All the patients were satisfied with their nasolabial appearance. Conclusions :  "Three-unit" muscle repair was found to be effective and practical in secondary repair. Improved aesthetic and functional results can be achieved with this comprehensive procedure.

Short-term molding effects on the upper alveolar arch following unilateral cleft lip repair with/without nasal vestibular expansion

Objective : To elucidate the various effects on maxillary growth following different procedures for vestibular expansion at the time of primary lip repair for unilateral cleft lip and palate (UCLP). Participants : Thirty patients with complete UCLP who underwent primary lip repair using a triangular-flap technique with nasal vestibular expansion (NVE; the NVE group) and 30 patients who underwent the same lip repair with closure of the nasal floor (non-NVE group) were enrolled in this study. Interventions : Serial dental casts on lip and palatal repair were scanned with a laser scanner. The three-dimensional coordinates of seven anatomical landmarks and their growth changes, the curvature radius rate between major/minor segments, and the collapse rates were compared between the two groups. Results : At the time of lip repair, the incisal point was located slightly anteriorly in the non-NVE group. At the time of palatal repair, the cleft edge of the alveolar process in the minor segment was located significantly anteriorly and laterally in the NVE group, showing the significantly forward change of the minor segment. The minor segment collapsed in the non-NVE group. The collapse rate of the NVE group (3.3%) was significantly lower than that of the non-NVE group (40.0%). Conclusions : NVE following simultaneous advancement of nasolabial components on the affected side at the time of primary lip repair for UCLP facilitates the forward molding of the maxilla, resulting in a more symmetrical alveolar arch form.

Assessment of deformities of the lip and nose in cleft lip alveolus and palate patients by a rating scale

INTRODUCTION

Labial and nasal deformities have always been a fundamental problem in the treatment of cleft lip, alveolus and palate patients. The primary surgical treatment of nasolabial area is of paramount importance in order to obtain both an esthetical correction of the deformity and a progressive and a balanced development of mid-face. In this study the nasal deformities in patients with cleft lip, alveolus and palate (CLAP) were analyzed and the relevant role of the perinasal, perioral muscular balance and the inborn dislocation of the alar cartilages are presented.

PATIENTS AND METHODS

50 CLAP patients were analyzed, 40 UCLP and 10BCLP. The lip repair was done by modification of Millard's technique. The severity of the cleft appearance was evaluated pre and post operatively, according to a pre-agreed visual rating scale. There are 4° of severity of the deformity pre operatively (mild, moderate, severe and very severe) and post operatively 5 categories of outcome (excellent,very good, good, satisfactory and poor), depending on the scores obtained by summing up the points corresponding to different types of deformity. This scale is closely related to the American Cleft Palate classification of clefts.

RESULTS

In the 40 UCLP patients, 8 excellent, 10 very good, 16 good and 6 satisfactory results were obtained following primary cheiloplasty. In 10 BCLP patients 1 very good, 7 good, 1 satisfactory and 1 poor result were obtained.

CONCLUSIONS

During the primary repair, it is important to correct the abnormal position of ala nasi, the nasal floor and the base of the columella. Abnormalities in the insertion of the nasolabial muscles with their abnormal function contribute to the cleft nose deformities. Therefore the reconstruction not only the orbicularis muscle but also of the paranasal muscles is therefore important for a symmetrical growth of the nose. Separate suture of intrinsic orbicularis oris provide a better shape to the vermillion. The position of the alar cartilage plays an important role for the symmetry of the nose. It is necessary to place the alar base symmetrically in three dimensions.

Seven fundamental procedures for definitive correction of unilateral secondary cleft lip nasal deformity in soft tissue aspects

PURPOSE

It is accepted that patients who undergo appropriate primary repair for cleft lip will have secondary deformities. Because these deformities are caused by complex and diverse patterns, the deformities were categorized to provide a standardized treatment for each category.

PATIENTS AND METHODS

Pathologic characteristics of 1,170 patients were classified into 7 categories. Corrections were performed using 7 fundamental procedures corresponding to the surgical resolution of each deformity: 1) transposition of the caudal septum; 2) release of the septal-cartilaginous junction; 3) medial crus elevation; 4) lateral crus elevation; 5) release of the orbicularis oris muscle from the lip elevators; 6) anchoring of the orbicularis oris muscle to the anterior nasal spine; and 7) philtral column formation. A satisfaction survey was performed to evaluate the overall outcomes in 171 patients and an anthropometric analysis was performed in 38 patients.

RESULTS

Satisfactory scores obtained through postoperative follow-up were higher than preoperative scores, and there was no difference between postoperative scores obtained over the short and long term. All preoperative anthropometric measurements were different from the postoperative measurements, indicating that the fundamental procedure achieved effective outcomes.

CONCLUSIONS

These proposed 7 fundamental procedures can be used as guidelines that can always be applied for the correction of any secondary cleft lip nasal deformity to obtain ideal treatment outcomes.

Primary septoplasty in the repair of unilateral complete cleft lip and palate

BACKGROUND

The purpose of this study was to assess and compare nasal symmetry in patients who underwent correction of a complete unilateral cleft lip using the Afroze incision without and with primary septoplasty using a standardized two-dimensional photographic analysis.

METHODS

A prospective cohort study of 190 consecutive patients with complete unilateral cleft lip and alveolus with cleft palate treated with or without septoplasty using the Afroze incision technique was conducted at a high-volume center. Eighty-two patients operated on without primary septoplasty and 76 patients operated on with primary septoplasty were evaluated. Nasal symmetry was compared between patients using two-dimensional photographic analysis. Ratios between the cleft side and the non–cleft side for five parameters were used to assess symmetry: alar base–to–interpupillary line distance, columella-to–Cupid's bow distance, nostril gap area, nostril width, and nostril height. The Mann-Whitney U test was used to calculate differences between the two groups.

RESULTS

Patients operated on with primary septoplasty showed more nasal symmetry compared with patients operated on without septoplasty. This difference was statistically significant for columella-to–Cupid's bow distance, nostril gap area, and nostril height (p = 0.008, p < 0.001, and p < 0.001, respectively) and for the distance between alar base and the alar base–to–interpupillary line distance (p = 0.145) the difference was present but not statistically significant. For nostril width, no difference was found (p = 0.850).

CONCLUSION

Patients treated with primary septoplasty showed better results in terms of nasal symmetry when analyzed using two-dimensional photographic analyses.

[Sensibility changes of the infraorbital nerve after primary surgery on patients with unilateral cleft lip according to J. Delaire]

OBJECTIVE

The aim was to determine the overall sensibility changes in the area of the infraorbital nerve on patients with unilateral clefts lips and unilateral clefts lips and palate who had undergone primary surgical correction according to the principles of Delaire.

PATIENTS AND METHOD

Twenty patients (7-20years) with unilateral cleft lips (and palate) who had undergone surgery in infancy according to Delaire were included. Cutaneous sensibilities of the nasolabial fold and of the upper lip were tested using four cutaneous modalities. A tactil superficial sensibility light touch test, a two-point discrimination test (McKinnon-Dellon Disk-Criminator), and the determination of cold and warm detection thresholds (Quantitative Sensory Testing, Medoc Thermal Sensory Analyser). The possible difference of the sensibility between operated and controlateral sides of the face were compared. Results were finally compared to a control group of twenty healthy volunteers.

RESULTS

No significant difference could be found between the operated and non-operated side of the cleft group. There was also no difference between the cleft and the control group. Specific difference of perception between nasolabial fold and lip encountered in the literature were confirmed by the experiments.

CONCLUSION

The large subperiostal approach according to Delaire during the primary surgical procedure have not affected long term infraorbital sensibility of patients with unilateral complete cleft lip.

Bilateral cleft lip and nose repair

Over the last three decades bilateral cleft lip and nose repair has been characterised by a trend towards more detailed reconstruction of the nasolabial muscles together with simultaneous correction of the deformity. An understanding of the true nature of the nasal deformity in bilateral cleft lip and palate (BCLP) has gradually emerged, and has inspired new approaches to their repair. This article discusses recent trends and controversies in primary cheilorhinoplasty for BCLP.

Analysis and evolution of rotation principles in unilateral cleft lip repair

Unilateral cleft lip repair, over the last century, has seen both revolutionary changes and subtle technical refinements. Millard's rotation/advancement technique stands among the most striking of these innovations. We review the evolution of unilateral cleft lip repair including a look at straight-line, geometric and rotation/advancement type of repairs, while looking closely at the underlying theme of rotation and how common principles are evident in differing techniques. A review of how the medial cleft lip element is lengthened in these differing approaches illustrates common principles that, if learned and applied, will aid both the novice and experienced surgeon approach repair of the unilateral cleft lip in the lifelong quest of improved outcomes.

Cleft lip and palate surgery: an update of clinical outcomes for primary repair

The comprehensive management of cleft lip and palate has received significant attention in the surgical literature over the last half century. It is the most common congenital facial malformation and has a significant developmental, physical, and psychological impact on those with the deformity and their families. In the United States, current estimates place the prevalence of cleft lip and palate or isolated cleft lip at approximately 1 in 600. There is significant phenotypic variation in the specific presentation of facial clefts. Understanding outcome data is important when making clinical decisions for patients with clefts. This article provides an update on current primary cleft lip and palate outcome data.

Quantitative assessment of oral orbicular muscle deformation after cleft lip reconstruction: an ultrasound elastography study

Reconstruction of a cleft lip leads inevitably to scar tissue formation. Scar tissue within the restored oral orbicular muscle might be assessed by quantification of the local contractility of this muscle. Furthermore, information about the contraction capability of the oral orbicular muscle is crucial for planning the revision surgery of an individual patient. We used ultrasound elastography to determine the local deformation (strain) of the upper lip and to differentiate contracting muscle from passive scar tissue. Raw ultrasound data (radio-frequency format; rf-) were acquired, while the lips were brought from normal state into a pout condition and back in normal state, in three patients and three normal individuals. During this movement, the oral orbicular muscle contracts and, consequently, thickens in contrast to scar tissue that will not contract, or even expand. An iterative coarse-to-fine strain estimation method was used to calculate the local tissue strain. Analysis of the raw ultrasound data allows estimation of tissue strain with a high precision. The minimum strain that can be assessed reproducibly is 0.1%. In normal individuals, strain of the orbicular oral muscle was in the order of 20%. Also, a uniform strain distribution in the oral orbicular muscle was found. However, in patients deviating values were found in the region of the reconstruction and the muscle tissue surrounding that. In two patients with a successful reconstruction, strain was reduced by 6% in the reconstructed region with respect to the normal parts of the muscle (from 22% to 16% and from 25% to 19%). In a patient with severe aesthetical and functional disability, strain decreased from 30% in the normal region to 5% in the reconstructed region. With ultrasound elastography, the strain of the oral orbicular muscle can be quantified. In healthy subjects, the strain profiles and maximum strain values in all parts of the muscle were similar. The maximum strain of the muscle during pout was 20% +/- 1%. In surgically repaired cleft lips, decreased deformation was observed.

The effect of Delaire cheilorhinoplasty on midfacial growth in patients with unilateral cleft lip and palate

The aim of this research was to evaluate the effect of the Delaire surgical technique on the midfacial morphology in a group of subjects with a congenital unilateral cleft of lip and palate (UCLP), prior to orthodontic treatment. Thirty-five UCLP (15 left and 20 right) patients (16 males and 19 females, mean age 7.03+/-0.9 years; age range 8.7-5.0 years), treated for the correction of congenital malformation, were retrospectively selected. Analysis of midfacial growth was undertaken on lateral cephalograms, and the data were compared with reference values (Ricketts analysis). A Mann-Whitney ranked sum test was used to detect significant differences between the findings and reference values. P <or= 0.05 was considered as significant. The results demonstrated a retropositioning of both the maxilla and mandible (SNA and SNB P<0.01) and increased mandibular development (Go-Me distance). Vertically, there was a trend to a posterior rotation of the mandible (P<0.01), resulting in a hyperdivergent profile. This trend was confirmed by the increase in SpA-SpP/Go-Me (P<0.05). In agreement with previous studies, the effects of surgical closure of a cleft lip might be responsible for excessive maxillary retropositioning with a downward rotation.

Current surgical practices in cleft care: unilateral cleft lip repair

BACKGROUND

The purpose of this study was to report objectively on practice trends in unilateral cleft lip repair in the United States and Canada. This study details current technique preferences, modifications, and adjunct procedure use.

METHODS

All surgeons in the American Cleft Palate-Craniofacial Association and the Canadian Society of Plastic Surgeons (n = 1138) were mailed a survey inquiring about their management of unilateral cleft lip.

RESULTS

Responses were received from 622 surgeons (55 percent response rate), of whom 269 currently perform cleft surgery. The results arise from this group of 269 active cleft surgeons. Eight-four percent of surgeons perform rotation advancement for complete unilateral cleft lip repair. Nine percent perform a variation of the triangular flap repair. Among those using rotation advancement, 45 percent use a modified technique. The most common modifications are the Noordhoff vermilion flap, the Mohler modification, and the Onizuka triangular advancement flap. Surgeons rarely use more than one technique in their practice, and 86 percent use the same repair for every unilateral cleft lip. Over half of surgeons routinely perform some form of primary nasal correction. Lip adhesion, presurgical orthopedics, nasoalveolar molding, and postoperative nasal stenting are performed by limited numbers of respondents, and the use of these surgical adjuncts is discussed.

CONCLUSIONS

Rotation advancement remains the most frequently used technique for unilateral cleft lip repair. However, almost half of those using rotation advancement perform a modification to the original technique. Surgeons should be familiar with both the rotation advancement repair and its common modifications. Among adjunct procedures, only primary nasal correction currently garners widespread use.

Choice of incision for primary repair of unilateral complete cleft lip: a comparative study of outcomes in 796 patients

BACKGROUND

No one technique of cleft lip repair consistently produces ideal aesthetic and functional results. This study was carried out in a developing, high-volume center. It compares outcomes attained using two different designs of skin incision used for primary closure of unilateral complete cleft lip and sought to identify the most appropriate technique for clefts of varying morphology.

METHODS

Seven hundred ninety-six patients were entered into the study. In each group of slightly less than 400 patients, either a modified Millard or Pfeifer wavy line incision was used, both in conjunction with functional repair of the underlying tissues as described by Delaire. Soft-tissue measurements of the lip and nose were recorded preoperatively. Analysis was based on postoperative assessment of the white roll, vermilion border, scar, Cupid's bow, lip length, and nostril symmetry and appearance of the alar dome and base.

RESULTS

Comparison of the two cohorts using Pearson chi-square testing for association and linear trend found a Millard incision gave significantly better results for vermilion match, whereas the Pfeifer method led to a better postoperative lip length. Preconceptions that one particular technique was better suited to certain preoperative cleft anatomical forms were not proven statistically.

CONCLUSIONS

Certain preoperative anatomical features may lead the surgeon to choose one particular incision pattern in preference to another, but in this study, it was found that one technique was essentially as good as the other. This suggests that the technique for closure of the underlying tissues is probably of more importance.

Delaire's cheilorhinoplasty: unilateral cleft aesthetic outcome scored according to the EUROCLEFT guidelines

OBJECTIVE

The aim of our study is to evaluate, in accordance with EUROCLEFT guidelines, the aesthetics of nasolabial area in a sample of complete unilateral cleft of lip and palate patients (UCLP), after surgical correction with Delaire' technique.

METHODS

Twenty-two UCLP patients (16 males and 6 females, 9 right and 13 left side clefts) were enrolled in this retrospective study. Patients were operated at 7 (mean value) months of age by a single surgeon. Frontal and sub-mental photos for each baby were recorded at 8.5 (mean value) years of age, and evaluated twice, by three independent maxillofacial surgeons. A five-point scale (EUROCLEFT guidelines) was used. Nonparametric analysis (Kruskal-Wallis test) was applied to detect differences in medians obtained in studied groups.

RESULTS

Kruskal-Wallis test showed no statistical significant differences among evaluations of three surgeons and between the first and the second evaluation of the same surgeon. The global appearance of the upper lip and nose was scored with a mean value of 2 (i.e. good). The sample was then divided into two subgroups, according with patient' age; the aesthetics and the symmetry of the nose resulted better in elder patients (i.e. subgroup A, mean period of observation=10.2 years), whereas upper lip achieved better results in younger patients (i.e. subgroup B, mean period of observation=4.9 years).

CONCLUSIONS

EUROCLEFT guidelines are a useful method to evaluate--aesthetically and over time--cleft lip and palate patients, treated with a single surgical procedure. We hypothesize that Delaire technique could progressively improve aesthetics and symmetry of the nose, throughout the growth of the patient.

A cephalometric evaluation of lower lip in patients with unilateral cleft lip and palate

OBJECTIVE

The aim of this study was to evaluate cephalometrically the lower lip position and area of patients with unilateral cleft lip and palate (UCLP) comparatively with Class I skeletodental normal subjects.

PATIENTS

Lateral cephalometric and hand-wrist radiographs obtained from 24 patients with UCLP (mean age 12.86 years), along with 20 normal individuals (mean age 12.33 years) used as a control group, were examined.

DESIGN

In addition to standard cephalometric dentofacial variables, lower lip area (superior, middle, inferior) was also measured using a digital planimeter on the lateral cephalograms.

RESULTS

The superior and middle part of the lower lip areas were significantly smaller (p < .05) in the UCLP group, compared to the control group. The inferior and total lower lip areas of patients with UCLP were found to be significantly smaller than controls. The labiomental angle was also smaller (38.79 degrees).

CONCLUSIONS

The results suggest that the lower lip of patients with UCLP is smaller, retruded, and curved, with a deep labiomental sulcus, compared with normal individuals during puberty. Therefore, practitioners should focus not only on the upper lip of patients with UCLP but also should consider the lower lip as it was found distinct from normal individuals during puberty.

Muscle reconstruction in cleft lip repair

This article presents a method of muscle reconstruction in the cleft lip patient that grossly reproduces the interlacing muscle anatomy in the central portion of the upper lip and thereby addresses both the static and the functional requirements of cleft lip repair. This lip repair procedure is combined with paranasal muscle reconstruction, preoperative nasoalveolar molding, and postoperative nasal stenting to constitute a comprehensive approach to cleft lip/nose repair.

The functional anatomy of the muscles of facial expression in humans with and without cleft lip and palate. A contribution to refine muscle reconstruction in primary cheilo- and rhinoplasties in patients with uni- and bilateral complete CLP

The great variation of primary cheiloplasty procedures in Cleft Lip and Palate (CLP) patients shows that there is disagreement regarding the embryonic development of this part of the face, the macroscopic and microscopic functional anatomy of the human muscles of facial expression and their role as a functional matrix for balanced and harmonious facial development. The purpose of this study is to present results of microsurgically dissected facial muscles, several parts of the nose and the human midface in specimens with and without cleft lip and palate. The results are compared with those of other investigations. Recommendations are presented for a standardized dissection technique of the facial muscles of expression for different types of primary cheilo- and rhinoplasty techniques.

Audit of a multidisciplinary approach to the care of children with unilateral and bilateral cleft lip and palate

Cleft lip and palate affects the child in many ways, particularly appearance, dental arch relationships, growth of the face, and speech development. The key to successful care is management in a multidisciplinary team adhering to a well-designed protocol, and careful audit of results. We present the intermediate outcome audit of 15 patients with complete bilateral and unilateral cleft lip and palate whose condition was managed in a multidisciplinary team according to a strict protocol. We give the results observations of operations of a single surgeon's functional primary surgery over a 6-year period in terms of dental arch relationships, cephalometric analyses, aesthetic assessments, and speech analysis. The results show good early facial growth, with dental arch relationships appropriate for the age and group; we found only minor speech discrepancies, with no patients requiring pharyngoplasty. The results show the importance of multidisciplinary management, the value of keeping to sound surgical protocols, and functional techniques in cleft lip and palate surgery. Our study includes the neglected group of children who have bilateral cleft lip and palate, and it conforms to the style of pan-European projects.

The influence of the muscles of facial expression on the development of the midface and the nose in cleft lip and palate patients. A reflection of functional anatomy, facial esthetics and physiology of the nose

The further improvement of well-established techniques in primary and secondary cleft surgery requires a detailed and interdisciplinary knowledge and observation of anatomical, functional and developmental problems. An investigation into the macroscopic and microscopic anatomy of the perinasal and perioral muscles and parts of the human nasal septum, as well as into the pathomorphology of ancient skulls with untreated clefts is presented. On this basis an interpretation of clinical findings in untreated newborns compared with surgically treated CLP-patients has been undertaken. The 3D-CT, superimposing photography and coloured experimental settings of nasal airflow complete the visualisation of the anatomical and functional findings.

Mid-facial growth following functional cleft surgery

The stigmata of lip and palate clefting are well recognized, but recently it has been thought that these may be exacerbated by the surgical repair. Functional repair, however, with re-establishment of muscle continuity may result in less disruption to normal facial growth. This study examines mid-facial growth in 10 consecutive children aged 6.5 years with complete unilateral cleft lip and palate who had undergone functional repair. Outcomes were compared with non-cleft children and children who had undergone non-functional surgery.

Nasal symmetry after primary cleft lip repair: comparison between Delaire cheilorhinoplasty and modified rotation-advancement

PURPOSE

Periosteal musculoaponeurotic (PMAS) reconstruction is a key objective in primary repair of the cleft lip. The reconstructed muscles provide a sound framework and stimulus for development of the nasolabial region. In this study two primary cleft lip repair techniques were retrospectively studied to determine if one [Delaire (Del)] which involves PMAS repair around the cleft results in more nasolabial symmetry than a technique that does not fully addressed the musculature [modified Rotation-Advancement, (mR-A)].

PATIENTS AND METHODS

Four-and 5-year-old children with complete unilateral cleft lip and palate were recalled for study (n = 33 children; Del group, 16; mR-A group, 17). Clinical and photographic records were obtained and anthropometric analyses determined for comparison between groups.

RESULTS

In the mR-A group, noses had more asymmetrical tips, were shorter, projected less, and tended to be flatter or wider. Nasal indices tended to support these findings. Nasal height was similar for the mR-A and Del groups. When comparing cleft versus noncleft sides, alar width and length and nostril length were significantly different for both cleft groups.

CONCLUSIONS

It appears from this study that reconstruction of the PMAS of the nasolabial region during primary cleft lip repair may positively influence growth and development of the nose in unilateral cleft lip and palate patients.

Primary closure of the cleft alveolus: a functional approach

The growth and development of the premaxilla in both normal and cleft lip and palate subjects is described and its relevance in surgery of the cleft alveolus discussed. Embryologically, the cleft alveolus results from failure of fusion of the median nasal and maxillary processes. Consequently, ossification centres in the premaxilla and maxilla cannot migrate and unite such that normal growth and development in the territory of the premaxillary-maxillary suture cannot occur. Functional repair of the cleft lip and soft palate encourages spontaneous alignment of the alveolar segments, facilitating the introduction of vascularized periosteum across the bony defect by gingivoperiosteoplasty. Early reconstruction in the region of the premaxillary-maxillary suture encourages a more normal development of the alveolus, particularly in the bilateral cleft subject.