Unilateral cleft lip repair

Current Surgical Practice for Children Born with a Cleft lip and/or Palate in the United Kingdom

OBJECTIVE

This study describes primary surgical reconstructions performed for children born with a cleft lip and/or palate (CL ± P) in the United Kingdom (UK).

DESIGN

Data forms completed at the time of surgery included details on timing, technique, and adjuncts used during the operative period. Demographic data on participants were validated via parental questionnaires.

SETTING

Data were obtained from the Cleft Collective, a national longitudinal cohort study.

PATIENTS

Between 2015 and 2021, 1782 Cleft Collective surgical forms were included, relating to the primary reconstructions of 1514 individual children.

RESULTS

The median age at primary cheiloplasty was 4.3 months. Unilateral cleft lips (UCL) were reconstructed with an anatomical subunit approximation technique in 53%, whereas bilateral cleft lips (BCL) were reconstructed with a broader range of eponymous techniques. Clefts of the soft palate were reconstructed at a median age of 10.3 months with an intravelar veloplasty in 94% cases. Clefts of the hard palate were reconstructed with a vomer flap in 84% cases in a bimodal age distribution, relating to reconstruction carried out simultaneously with either lip or soft palate reconstruction. Antibiotics were used in 96% of cases, with an at-induction-only regimen used more commonly for cheiloplasties (P < .001) and a 5 to 7-day postoperative regime used more commonly for soft palatoplasties (P < .001). Perioperative steroids were used more commonly in palatoplasties than cheiloplasties (P < .001) but tranexamic acid use was equivalent (P = .73).

CONCLUSIONS

This study contributes to our understanding of current cleft surgical pathways in the UK and will provide a baseline for analysis of the effectiveness of utilized protocols.

The nasal cantilever technique in children undergoing primary cleft lip surgery: novel concepts and review

Background

Nasal deformity associated with cleft lip deformity is a challenging issue, encompassing controversies, theories, and a diversity of techniques. Historically, esthetic outcomes have ranged from being below expectations to barely acceptable.

Method

Based on the concept that the nasal cartilaginous framework in clefts is similar to that of a collapsing pyramid, a novel suspension technique has been described. The entire cartilaginous structure is lifted from the infratip segment with a loop suture and is secured in a cantilever fashion onto the periosteum overlying the nasal bone. This part of the operation is performed in a semiclosed manner. The technique is applied during primary surgery in bilateral and unilateral nasal cleft lip deformities, with changes in the orientation of the cantilever loop suture. Studies conducted by Masters S. Tajima, H. McComb, H. Thomson, D. Fisher, and J. Mulliken, which are most relevant to this article, have been reviewed and discussed throughout.

Results

The technique was first applied over 10 years ago. A case series of nine children whose parents consented to the developing technique is presented with follow-up ranging from months to years, along with technical descriptions and illustrative drawings. None of these cases had preoperative orthopedic correction, molding, or postoperative nostril splints. The esthetic outcome was optimal enough; none of the cases requested a secondary correction.

Conclusion

The nasal cantilever technique is a novel concept in cleft nasal deformity, which can be used in conjunction with an appropriate lip technique, per the surgeon’s discretion. Other than a learning curve, we believe that it provides a solid correction by securing the cartilaginous structures after they have been mobilized to a stable base, the nasion.

Anatomical Reconstruction of the Nasal Floor in Complete Unilateral Cleft Lip Repair

BACKGROUND

Numerous methods exist for repairing unilateral cleft lips and mainly focus on cutaneous design to achieve sufficient rotation of the medial (M) cleft lip and produce a natural Cupid's bow and philtrum. However, precise nasal floor reconstruction has not been described in detail. This is the first study to introduce a technique for repairing complete unilateral cleft lips with a focus on nasal floor reconstruction.

METHODS

In our technique, "Straight-Line Advanced Release Technique (StART)," the nasal floor is considered a 3-dimensional cuboid structure; the M mucosal and lateral (L) mucosal flaps constituted the posterior surface. The M flap became the roof of the orbicularis oris muscle sling and the posterior side of the nasal lining. The B flap met the L lip flap at the superior border of the M flap, and together they formed the roof and anterior surface. The B flap also formed a transitional zone connecting the columella and nasal floor.

RESULTS

Seventy-two patients with complete unilateral cleft lip were treated from 2003 to 2015. The difference in the height of the nostril sills between the cleft and non-cleft sides was not significantly different from that in control patients (P = 0.472) 1 year postoperatively. Twenty operations for secondary deformities were performed: 8 for nose deformities not involving the nasal floor. The transverse scar at the alar base was concealed within the nostril.

CONCLUSIONS

Nasal floor reconstruction is important in complete unilateral cleft lip repair. Our technique provides a naturally shaped, symmetrical nasal floor without conspicuous scarring.

The Essential Anatomical Subunit Approximation Unilateral Cleft Lip Repair

The anatomical subunit approximation cleft lip repair advantageously achieves a balanced lip contour, with the line of repair hidden along seams of aesthetic subunits. Dr. David Fisher's original description of the repair reflects the considerable thought that went into the evolution of his design. As his technique has gained acceptance in the intervening 10 years, the authors note several key principles embodied in it that represent a shift in the cleft lip repair paradigm. The authors believe understanding these principles is important to mastery of the anatomical subunit technique, and facilitate its teaching. First, design a plan that adheres to anatomical subunits and perform measurements precisely. Second, identify and adequately release each cleft tissue layer from the lip and nose to enable restoration of balance. Third, drive surgical approximation through inset of the lateral muscle into the superiorly backcut medial orbicularis muscle, followed by skin closure with inferior triangle interposition above the white roll. In this article, the authors present essential components of the technique, and identify several principles that enable its successful execution.

Unilateral cleft lip repair: an anatomical subunit approximation technique

BACKGROUND

A technique of unilateral cleft lip repair is described. The repair draws from a variety of previously described repairs and adheres to a concept of anatomical subunits of the lip. Cases from within the spectrum of the deformity have been chosen from a series of 144 consecutive cases to demonstrate the applicability of the technique in all forms of unilateral cleft lip.

METHODS

Incisions cross the lip perpendicular to the cutaneous roll at the cleft side peak of Cupid's bow of the medial lip and at the base of the philtral column of the lateral lip. Above this level, incisions ascend the lip to allow for approximation along a line symmetrical with the non-cleft-side philtral column. Incisions then ascend superolaterally bordering the lip columellar crease to the point of closure in the nostril sill. A Rose-Thompson lengthening effect occurs just above the level of the cutaneous roll. If necessary, a small triangle positioned just above the cutaneous roll is often used. Any central vermilion deficiency is augmented by a laterally based triangular vermilion flap from the lateral lip element.

RESULTS

Since January of 2000, this technique has been used in 144 consecutive unilateral cleft lip repairs. The inferior triangle is small (average, 1.24 mm; range, 0 to 2 mm). The technique can be applied to all degrees of unilateral cleft lip.

CONCLUSIONS

A technique of unilateral cleft lip repair is described. The repair allows for a repair line that ascends the lip at the seams of anatomical subunits.

Unilateral cleft lip repair--state of the art

OBJECTIVE

A number of surgical techniques are utilized to correct the unilateral cleft lip, including variations of the rotation-advancement technique. This attests to the variability of the original deformity and the esthetic and functional results from any one technique, especially those based on traditional geometric rearrangement of the skin and associated tissues.

RESULTS

Most recent advances in cleft lip repair have occurred in two main areas. The morphological result has been improved by functional muscular reconstruction of the lip with or without orthopedic molding. Early correction of the nasal deformity has also been readvocated based on newer principles with excellent results demonstrated.

CONCLUSION

Further work continues in these areas and improved outcomes will continue to be seen along with a clearer understanding of surgical affects on growth and development.