Unilateral cleft lip repair

Cleft Lip Repair and Primary and Intermediate Cleft Rhinoplasties

The cleft lip is one of the most common craniofacial abnormalities seen worldwide. The lip and primary rhinoplasty repairs are performed together in a single surgery for patients aged 3 to 6 months. The intermediate rhinoplasty has fallen out of favor due to more advanced approaches at primary rhinoplasty. However, it still plays a role in addressing severe nasal airway obstruction or correcting anatomic differences causing emotional distress from social ridicule. The article reviews the incidence of cleft lip, discusses its development and variant anatomy, and examines the approaches to surgical repair of the cleft clip, primary and intermediate rhinoplasties.

Clinical Application of a Resembling Rectangular Flap on Lateral Lip in Unilateral Cheiloplasty: A Modified Millard's Technique

PURPOSE

This clinical study aimed to design and utilize a modified rotation-advancement technique (MRAT) with a resembling rectangular flap on the lateral lip for primary unilateral cheiloplasty and evaluated its postoperative outcomes.

MATERIALS AND METHODS

A retrospective study was conducted on patients with a unilateral cleft lip who had undergone initial cheiloplasty with MRAT. The postoperative outcomes were assessed for nasolabial symmetry by photogrammetry. Repeated measures of ANOVA and two independent samples t tests were applied for statistical analysis.

RESULTS

Twenty patients with unilateral cleft lip met the inclusion criteria. Postoperatively, the patients had well-shaped nasal sill and centered nasal columella. In addition to, the bilateral symmetrical ratios noticeably improved ( P <0.001). Simultaneously, the postoperative outcomes were independent of the cleft type and height differences of the two peaks ( P >0.05).

CONCLUSIONS

Unilateral cheiloplasty using the present MRAT can better preserve the nasolabial structure and symmetry. The postoperative scar is concealed and simulates a normal philtral ridge.

Use of a Three-dimensional Smartphone Scanner in the Quantitative Analysis of Repaired Unilateral Cleft Lip during the Coronavirus Disease Pandemic

Cleft lip, a major craniofacial abnormality, is highly prevalent among people with low socioeconomic status in Indonesia. Direct two-dimensional measurement of the affected region is the gold standard for surgical preparation; however, its compliance and usability are limited in pediatric patients. Modern smartphones, including iPhones, are equipped with high-resolution cameras, which can record images and videos of a face. Here, we investigated whether a three-dimensional (3D) smartphone scanner can be used for the facial measurements of patients with unilateral cleft lip.

Harnessing the Power of Artificial Intelligence to Teach Cleft Lip Surgery

Artificial intelligence (AI) leverages today’s exceptional computational powers and algorithmic abilities to learn from large data sets and solve complex problems. The aim of this study was to construct an AI model that can intelligently and reliably recognize the anatomy of cleft lip and nasal deformity and automate placement of nasolabial markings that can guide surgical design.

The Evolution of Unilateral Cleft Lip Repair

ABSTRACT

The understanding of cleft lip etiology and approaches for surgical repair have evolved over time, allowing for improved ability to restore form and function. The variability of cleft lip presentations has necessitated a nuanced surgical approach with multidisciplinary cleft care. The earliest documentation of unilateral cleft lip repair predates the 19th century, with crude outcomes observed before the advent of curved incisions and advancement flaps. In the 20th century, straight line, quadrilateral flap, and triangular flap repairs were introduced to mitigate post-repair surgical scarring, increase lip length, and restore the symmetry of the Cupid's bow. Towards the latter part of the century, the development of rotation-advancement principles allowed for improved functional and aesthetic outcomes. Future technical improvements will continue to address the goals of lip and nasal symmetry, muscular continuity, precise scar concealment, and improved patient satisfaction in an increasing range of cleft phenotypes and during subsequent years of growth.

Correlation between alveolar cleft volume and alveolar bone quality in patients with unilateral cleft lip and palate: A cone-beam computed tomography study

OBJECTIVES

This study aimed to determine the correlation between alveolar cleft volume and fenestration and dehiscence in the adjacent alveolar bone in patients with unilateral cleft lip and palate (UCLP) using cone-beam computed tomography (CBCT) sections.

MATERIALS AND METHODS

In this descriptive, cross-sectional study, CBCT scans of 68 non-syndromic patients with UCLP aged between 6 and14 years were selected. All patients were treated in Iran and had undergone lip and palate repair surgery within the first 3 to 18 months after birth. CBCT scans had been taken after orthodontic expansion and prior to alveolar bone grafting surgery. Cleft volume, fenestration and dehiscence were assessed using Mimics software. Data were analyzed using independent t-test, Kruskal-Wallis test, Spearman's correlation coefficient and logistic regression model.

RESULTS

The mean alveolar cleft volume was 628.66±172.84 mm³. There was a significant negative correlation between cleft volume and fenestration (P<0.001). Also, there was a significant positive correlation between cleft volume and dehiscence (P<0.001) in the adjacent bone.

CONCLUSION

The Mimics software can be successfully used to estimate the cleft volume prior to surgical procedures in UCLP patients. The results suggest that the alveolar cleft volume can be used as an aid to assess the periodontal condition of adjacent teeth. The cleft volume has a negative and positive correlation with fenestration and dehiscence respectively.

Anthropometric Changes in the Upper Lip Between the Standing Position in the Clinic and Supine Position on the Operative Table in Secondary Cleft Lip Nasal Deformities

BACKGROUND

We evaluated changes in lip height and length by position in cleft lip nasal deformity patients who underwent treatment with Millard technique.

METHODS

A retrospective review of the medical records and an anthropometric analysis of photographs were performed in 209 cases of cleft lip nasal deformity. In the photogrammetric analysis, the lip height and length were calculated with respect to the intercanthal width. To evaluate the change in the difference between the cleft- and noncleft-side measurements between the standing and supine positions, the difference between the cleft- and noncleft-side measurements (Δnc-c) was calculated. We identified which patients and surgical factors affected the difference between the cleft- and noncleft-side measurements between the standing and supine positions (Δst-sp).

RESULTS

From a total of 120 cases, cases with missing medical charts and clinical photographs were excluded, and 89 cases were included in this study. The discrepancy between the cleft-side lip height and noncleft-side lip height was significantly different between the standing and supine positions (P = 0.007). According to the univariate regression analysis, Δst-sp (sbal-cphi) had a significant positive correlation with body mass index (P = 0.044). In the final multiple linear regression analysis, body mass index had a significant positive correlation with Δst-sp (sbal-cphi, P = 0.044).

CONCLUSION

In our results, the difference in vertical lip height is easy to underestimate in the supine position during surgery. Therefore, surgeons should verify lip height with the patient in the sitting or standing position during the operation to avoid undercorrecting lips with short heights.

Interdisciplinary Considerations for Nasolabial Repair During a Global Pandemic

BACKGROUND

At the declaration of the global pandemic on March 11, 2020, many hospitals and institutions developed a tiered framework for the stratification and prioritization of elective surgery. Cleft lip and palate repair was classified as low acuity, and nasoalveolar molding (NAM) clinics were closed. Anticipating the consequences of delayed cleft care and the additional burden this would cause families, we reassessed our risk-stratification and perioperative algorithms. We hypothesized we could safely optimize nasolabial repair without burdening our care systems and without increasing COVID-19-related morbidity/mortality.

METHODS

Our multidisciplinary cleft team reevaluated patient selection to maximize surgical impact. Perioperative protocols were adjusted, and COVID-19 preoperative testing was utilized before nasolabial repair and prior to suture removal under anesthesia.

RESULTS

Early in the pandemic, unilateral cleft repair was prioritized and successfully completed on 9 patients. There were no complications related to COVID-19. Nasoalveolar molding clinic was reopened after total patient volume was significantly decreased.

CONCLUSIONS

We offer an approach for surgical management of nasolabial clefts during a global pandemic. Although guidelines have suggested postponing all cleft care, we found that at our dedicated pediatric hospital with low burden of COVID-19 and adequate resources, we could follow a strategy to safely resume cleft care while decreasing burden on our patients' families and care delivery systems.

Using Virtual Augmented Reality to Remotely Proctor Overseas Surgical Outreach: Building Long-Term International Capacity and Sustainability

BACKGROUND

Cleft lip affects one in 700 children globally, and the prevalence far surpasses capacity to deliver cleft care in underresourced and endemic regions. A hands-on educational presence is needed to promote overseas surgical autonomy, build overseas capacity, and ensure a sustained clinical and educational infrastructure. The goal of this study was to build and assess an augmented reality educational platform that allows a remote yet virtual interactive presence to transfer cleft surgery knowledge/skills to overseas colleagues.

METHODS

A prospective study assessing a 13-month overseas augmented reality-based cleft surgery curriculum was conducted. Three semiannual site visits engaged two Peruvian surgeons in evidence-based didactics, on-site cleft surgery, and familiarization with the augmented reality platform. During 10 remote augmented reality visits, a surgeon stationed in United States guided the same Peruvian surgeons through cleft surgery. Quarterly assessments of the Peruvian surgeons were performed using visual analogue scale questionnaires.

RESULTS

Visual analogue scale scores by both the remote and overseas surgeons demonstrated significant, progressive improvement in all facets of cleft lip repair throughout the curriculum. Site visits preferentially built capacity for cleft diagnosis and preoperative counseling (p < 0.001), principles of repair (p < 0.001), repair technique (p < 0.02) and intraoperative decision-making (p < 0.001). Remote sessions preferentially developed understanding of cleft operative design/anthropometry (p < 0.04), cleft anatomy (p < 0.01), and operative efficiency (p < 0.001). At 30-month follow-up, no children with cleft lip required transfer to tertiary care centers.

CONCLUSION

A curriculum that combines on-site training and augmented reality-based hands-on remote teaching can build sustained capacity of comprehensive cleft care in underresourced areas.

Marked Variation Exists Among Surgeons and Hospitals in the Use of Secondary Cleft Lip Surgery

OBJECTIVE

To identify child-, surgeon-, and hospital-specific factors at the time of primary cleft lip repair that are associated with the use of secondary cleft lip surgery.

DESIGN

Retrospective cohort study.

SETTING

Forty-nine pediatric hospitals.

PARTICIPANTS

Children who underwent cleft lip repair between 1999 and 2015.

MAIN OUTCOME MEASURE

Time from primary cleft lip repair to secondary lip surgery.

RESULTS

By 5 years after primary lip repair, 24.0% of children had undergone a secondary lip surgery. In multivariable analysis, primary lip repair before 3 months had a 1.22-fold increased hazard of secondary surgery (95% confidence interval [CI]: 1.02-1.46) compared to repair at 7 to 12 months of age, and children with multiple congenital anomalies had a 0.77-fold decreased hazard of secondary surgery (95% CI: 0.68-0.87). After adjusting for cleft type, age at repair, presence of multiple congenital anomalies, and procedure volume, there remained substantial variation in secondary surgery use among surgeons and hospitals (P < .01). For children with unilateral cleft lip repaired at 3 to 6 months of age, the predicted proportion of children undergoing secondary surgery within 5 years of primary repair ranged from 4.9% to 21.8% across surgeons and from 4.5% to 24.7% across hospitals.

CONCLUSIONS

There are substantial differences among surgeons and hospitals in the rates of secondary lip surgery. Further work is needed to identify causes for this variation among providers.

Biomechanical analyses of common suspension sutures in primary cleft lip rhinoplasty

Background

For a better understanding of common suspension sutures during primary cleft lip nasal rhinoplasty, the biomechanical consequences of those sutures need to be demonstrated.

Methods

A finite element model of the infant specimen was established. The closure of cleft lip and four different specific suspension sutures were simulated by loading different forces on the model: 1. F1 to simulate the suture fastening both medial crura together; 2. F2 to simulate the suture which sewed both medial crura and the non-cleft-side upper lateral cartilage together; 3. F3 to simulate the suture elevating the alar cartilage cranially; 4. F4 to simulate the suture elevating the alar cartilage superiorly. The deformation and stress distribution consequent to each maneuver were analyzed in details.

Results

The deviation of columella was restored through the closure of cleft lip. Different suspension sutures had different biomechanical effects on the nasal structure. All suspension sutures had the function on elevating the alar cartilage. F2 had no function on restoring the collapse of the nasal tip. The suture which fastened both medial crura together leaded to the lowest stress on the skin envelope.

Conclusions

Each suspension suture had its characteristics respectively. The simulation suggested that F1, the suture which fastened both medial crura, could be the most potential maneuver for cleft lip rhinoplasty because it can symmetrically restore the shape of the nose without incurring a significant increase in stress.

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.

Recapitulation of Unilateral Cleft Lip Nasal Deformity on Normal Nasal Structure: A Finite Element Model Analysis

Cleft lip nasal deformity has been challenging to plastic surgeons. A better understanding of the biomechanical aspect of the cleft nose would contribute to a better correction. In this study, finite element model of a normal nose was constructed and loaded with forces to recapitulate the unilateral cleft lip nasal deformity. Tether at the alar base was simulated by a laterally directed force at the lateral crus, and tether at the columella base by a posteriorly directed force at the medial crus. The equivalent von-Mises stress and the total deformation consequent to different patterns of loading were captured. In accordance with clinical observations, unilaterally loaded forces caused deformation on both sides of the nose. A correlation between the patterns of loading and different cleft lip nasal deformities was documented in detail. When set at the same force magnitude, tether at the columella base led to more extensive changes in the nasal morphology and higher level of stress than at the alar base. Clear identification of major pathological tethers in the nasolabial region might lead to more accurate and stable correction of cleft lip nasal deformities.

Biomechanical simulation of correcting primary unilateral cleft lip nasal deformity

For better outcomes of the primary correction of cleft lip nasal deformity, it is important to clarify the specific morphological and biomechanical consequences of major surgical maneuvers during cleft lip nose correction. In this study, a finite element model was established basing on the micro-MRI imaging of an infant specimen with unilateral complete cleft lip deformity. Alar base adduction was simulated as a medially-directed force on the lateral crus (F1); columella straightening was simulated as a laterally-directed force on the medial crus (F2); and nasal tip enhancement was simulated as an anteriorly-directed force on the intermediate crus (F3). The deformation and stress distribution consequent to each force vector or different force combinations were analyzed in details. Our biomechnical analyses suggested that W\when loaded alone, the three forces generated disparate morphological changes. The combination of different force loadings generated obviously different outcomes. F3 generated the most intensive stress when compared to F1 and F2. When F2 was loaded on top of F1-F3 combination, it further relieved nasal deviation without incurring significant increase in stress. Our simulation suggested that alar base adduction, columella straightening, and nasal tip elevation should all be included in a competent cleft lip nose correction.

Personal technique for definite repair of complete unilateral cleft lip: modified Millard technique

Background

Millard’s rotation-advancement repair, which is used by many surgeons, can make a natural philtral column, but most surgeons use a modification of the rotation-advancement flap. The purpose of this article is to introduce a modification utilized by the authors and to provide detailed surgical procedure.

Methods

We retrospectively reviewed 82 patients’ medical records and presented surgical technique and outcomes. The main features of the authors’ strategy are emphasizing horizontal length of the lip, orbicularis oris muscle duplication for improving the definition of the philtral column, overcorrection of domal portion than the non-cleft side in order to compensate for the recurrence during growth. Two judges rated two times the appearance of the patients’ nose and lip using Asher-McDade aesthetic index. Intra- and interobserver reliabilities were determined using Cohen’s kappa statistics.

Results

All patients recovered eventually after surgery; however, two patients have a minor complications (wound infection in one patient, wound disruption due to trauma in the other patient). The improvement of the aesthetic results can be achieved with this modified Millard technique. Total mean scores of the Asher-McDade index was 2.08, fair to good appearance. The intraobserver reliabilities were substantial to almost perfect agreement and the interobserver reliabilities were moderate to almost perfect agreement.

Conclusion

We modified Millard method for repair of complete unilateral cleft lip. The surgical outcomes were favorable in long-term follow-up. We hope our technique will serve as a guide for those new to the procedure.

Dental Arch Relationships and Reverse Headgear Effects in Southern Chinese Patients with Unilateral Cleft Lip and Palate: A Retrospective Study

OBJECTIVE

To evaluate the severity of the dental arch relationships and the treatment outcomes of reverse headgear (RHG) in southern Chinese patients with unilateral cleft lip and palate (UCLP).

DESIGN

A retrospective study.

SETTING

Faculty of Dentistry, The University of Hong Kong.

PATIENTS

Thirty-eight UCLP patients with complete records. Among them, 14 were later treated with RHG (RHG group) and 24 were under review (non-RHG group) before definitive orthodontic or in conjunction with orthognathic surgery.

INTERVENTIONS

Study models at T1 (aged 9.4 ± 0.4 years old), prebone grafting and before any orthodontic treatment started; T2 (aged 11.3 ± 0.6 years old), after bone grafting, and RHG treatment (RHG group) or under review (non-RHG group); and T3 (aged 15.3 ± 3.2 years old), pretreatment of definitive orthodontic or in conjunction with orthognathic surgery.

MAIN OUTCOME MEASURES

With satisfactory intra- and interexaminer agreement proven by the kappa value, the dental arch relationships of the study models at T1, T2, and T3 were assessed by a solo calibrated examiner using the GOSLON Yardstick.

RESULTS

The median GOSLON score for southern Chinese patients with UCLP at T1 was 4.0. Sixty percent of the patients were categorized as "poor" at T1. RHG significantly improved dental arch relationships from T1 to T2, and the improvement was maintained until T3 assessed by the GOSLON Yardstick.

CONCLUSIONS

The dental arch relationships in southern Chinese UCLP patients at 8 to 10 years old are unfavorable. RHG treatment shows positive effects in improving the dental arch relationships in UCLP patients, as assessed by the GOSLON Yardstick.

The Unilateral Cleft Lip Repair and Primary Cleft Rhinoplasty

Supplemental Digital Content is available in the text.

Difference in nasolabial features between awake and asleep infants with unilateral cleft lip: Anthropometric measurements using three-dimensional stereophotogrammetry

PURPOSE

Cleft lip repair is performed in the supine position, tilting the head back under general anesthesia. However, postoperative results are evaluated in the upright position while patients are awake. The purpose of this study was to anthropometrically assess whether nasolabial features of infants with unilateral cleft lip are influenced by posture and anesthesia.

MATERIAL AND METHODS

Three-dimensional facial images in a preoperative upright position and operating supine position under general anesthesia were captured from 51 consecutive infants with unilateral cleft lip. Twenty-four indirect anthropometric measurements (11 for the nose and 13 for the lip elements) were considered on each infant.

RESULTS

In the supine position under general anesthesia, alar surface distance was significantly shorter (p < 0.001). Regarding lip measurements, medial lip height of the cleft side and philtrum height were significantly smaller (p < 0.05 and p < 0.05, respectively), whereas vermilion height was greater (p < 0.01). In addition, the cleft width and lip width were significantly broader (p < 0.001 and p < 0.001, respectively) after general anesthesia.

CONCLUSIONS

Several nasolabial alteration patterns are found after general anesthesia that are presumably attributable to cessation of nasal breathing and the action of muscle relaxation. Surgeons should take these nasolabial changes into account during preoperative planning and postoperative assessment.

A modified Mohler technique for patients with unilateral cleft lip based on geometric principles--A primary report

OBJECTIVE

The Mohler technique is one of the most popular methods to repair unilateral cleft lip (UCL) among the modified Millard methods, but it is still imperfect. We successfully designed a modified Mohler method based on geometric principles and observed its clinical effect.

MATERIALS AND METHODS

Photogrammetry was performed in 56 patients who underwent UCL repair with the new technique. The symmetry ratios were assessed for sn-cphi, cphi-sbal, ch-sbal, ch-cphi, and vh preoperatively and 1 week after surgery, and were also compared with values in healthy control individuals.

RESULTS

Preoperatively, all distances on the cleft side were shorter to different degrees. One week after surgery, results showed well-healed wounds with full, symmetric, and continuous vermilion. On the cleft side, the sn-cphi was 6.13% longer than the non-cleft, and the others were shorter (cphi-sbal: 5.904%; ch-sbal: 1.760%; ch-cphi: 6.234%). The symmetry ratios had differences of significance between preoperative values and those 1 week after surgery (p = 0.000, respectively). Moreover, the vermilion height on the cleft side was 1.026% thicker. When compared with the matched control group, with the exception of SRcphi-sbal (p = 0.072) and SRch-sbal (p = 0.139), there were significant differences (p = 0.000, respectively). All distances in the matched control group were not absolutely symmetric.

CONCLUSIONS

The modified Mohler technique seems widely applicable, marking accurate, and less flexible.