Bilateral cleft lip repair: "putting it all together"

Utility of J-Shaped Scar Tissue-Based Flap for Secondary Bilateral Cleft Lip Repair: A One-Stage Procedure with Successful Outcomes on Correction of Vermilion Border, Volume Deficiency of Lip, and Muscular Function

This study aimed to evaluate the utility of J: -shaped scar-tissue-based flap as a new technique in secondary bilateral cleft lip reconstruction in patients with challenging secondary deformities. A total of 52 patients, comprising 38 males and 14 females with a mean age of 21.0 years (range: 16-42 years), who underwent secondary bilateral cleft lip repair operation via the J: -shaped scar tissue flap technique in our clinic between 2014 and 2019 were included. Postoperatively, patients were followed up for an average of 2 years (range, 6 months to 5 years) to assess the outcomes regarding vermilion border, philtrum symmetry, function of the orbicularis muscle, and lip volumetric symmetry, based on the Global Aesthetic Improvement Scale (GAIS), patient-reported outcomes, and independent plastic surgeons' examinations. After an average follow-up of 2 years, outcomes regarding vermilion border, philtrum symmetry, function of the orbicularis muscle, and lip volumetric symmetry were successful, and none of the patients experienced new notch formation, muscular functional loss, lip volume loss, or asymmetry. Owing to good muscular function preventing the stretching, the postoperative scars become more acceptable to the patients. The technique has proven to be safe and successful through the GAIS objective assessment, as also confirmed by the examinations of the three independent surgeons, while the majority of patients reported an exceptional improvement in the appearance alongside a more than 95% satisfaction rate with the operation. In conclusion, our findings revealed successful functional and aesthetic outcome of using J: -shaped scar tissue flaps in secondary repair of cleft lips. The technique was associated not only with the correction of significant secondary deformities yielding an improved and symmetrical lip volume, correction of vermilion notch, and prevention of notch re-formation but also with the restoration of orbicularis oris muscle function and thus integrity of the lip with minimal scarring.

One-Stage versus Two-Stage Repair of Asymmetric Bilateral Cleft Lip: A 20-Year Retrospective Study of Clinical Outcome

BACKGROUND

Both one- and two-stage approaches have been widely used for patients with asymmetric bilateral cleft lip. There are insufficient long-term outcome data for comparison of these two methods. The purpose of this retrospective study was to compare the clinical outcome over the past 20 years.

METHODS

The senior author's (L.J.L.) database was searched for patients with asymmetric bilateral cleft lip from 1995 to 2015. Qualified patients were divided into two groups: one-stage and two-stage. The postoperative photographs of patients were evaluated subjectively by surgical professionals and laypersons. Ratios of the nasolabial region were calculated for objective analysis. Finally, the revision procedures in the nasolabial area were reviewed. Statistical analyses were performed.

RESULTS

A total of 95 consecutive patients were qualified for evaluation. Average follow-up was 13.1 years. A two-stage method was used in 35 percent of the patients, and a one-stage approach was used in 65 percent. All underwent primary nasal reconstruction. Among the satisfaction rating scores, the one-stage repair was rated significantly higher than two-stage reconstruction (p = 0.0001). Long-term outcomes of the two-stage patients and the unrepaired mini-microform deformities were unsatisfactory according to both professional and nonprofessional evaluators. The revision rate was higher in patients with a greater-side complete cleft lip and palate as compared with those without palatal involvement.

CONCLUSIONS

The results suggested that one-stage repair provided better results with regard to achieving a more symmetric and smooth lip and nose after primary reconstruction. The revision rate was slightly higher in the two-stage patient group.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Anthropometric study of the upper lip and the nose of infants less than a year of age

We divided healthy newborns (aged between 2 weeks and 6 months) into four groups, less than 2 weeks old, 60 +/- 7 days, 120 +/- 7 days, and 180 +/- 7 days, between June 2001 and February 2002, and each group had 40 infants. The lineal distances included 13 items related to the nose, mouth, and lips. The average width of the columella at the midpoint was 3.2, 3.5, 3.7, and 3.8 mm for the 2-week-old group, the 2-month-old group, the 4-month-old group, and the 6-month-old group, respectively. The average height of the columella was 4.7, 4.9, 5.2, and 5.3 mm. The average length between the medial alar bases was 13.7, 14.4, 17.4, and 17.6 mm. The average length from the base to the tip of Cupid's bow was 9.5, 10.0, 10.5, and 10.6 mm. The average length from the columella lateral base to the tip of Cupid's bow was 8.4, 9.9, 10.2, and 10.5 mm. The average length from the columella central base to the center of Cupid's bow was 8.3, 9.5, 9.8, and 9.9 mm. The average width of one limb of Cupid's bow was 2.7, 3.1, 3.4, and 3.5 mm. The average length from the tip of Cupid's bow to the commissure was 13.4, 14.7, 16.4, and 16.9 mm. The average intercommissural distance was 26.8, 30.3, 30.8, and 32.7 mm. The average width of the philtral column at the columella base was 3.1, 3.6, 3.7, and 4.0 mm. The average width of the philtral columns at the mid-portion was 3.7, 4.6, 4.6, and 4.6 mm. The average height of the nasal tip protrusion was 8.7, 11.0, 11.7, and 12.1 mm. The average width of the nose was 20.7, 23.7, 25.3, and 25.9 mm. In conclusion, these data are expected to be useful for patients with a bilateral cleft lip.

Long-term outcome of simultaneous repair of bilateral cleft lip and nose (a 15 year experience)

We have performed primary repair of bilateral cleft lip and nose on 169 patients in the past 15 years. During the first eight years, we used a small triangular flap skin design for the lip and for the nose correction, we used a corrective nasal cartilage lifting suture through rim incisions in order to bring the nasal dome cartilage toward the center and create the columella. The small triangular flap at the columella base was rotated 90 degrees posteriorly to emphasize the contour of the nasolabial angle. In the subsequent 7-year period, the lip design was changed to the straight line method, and an inverted trapezoid suture was placed between the alar and nasal dorsum at four points. By this procedure displaced cartilages are moved into correct position and the alar groove became more distinct.Long-term observations showed a favorable configuration of the nose, and eliminated the bilateral cleft nose stigma with only minimum degree of growth disturbance. The remaining problem is the somewhat superior faced nasal tip. To leave the bilateral cleft lip nasal deformity uncorrected for a long period places great psychosocial burden on the patient and the family. We believe that it is desirable to conduct early lip and nose repair synchronously in a minimally invasive manner, as a collaborative effort between plastic surgeons with specialized training in cleft lip repair and an interdisciplinary team.

Primary repair of bilateral cleft lip and nasal deformity

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. List five principles that guide synchronous repair of bilateral complete cleft lip and nasal deformity. 2. Explain how different growth rates for the principal nasolabial features are applied during primary repair. 3. Describe two approaches for positioning the alar cartilages to form the columella. 4. Discuss the influences on referral patterns for a newborn with bilateral cleft lip. --Traditional repair of bilateral cleft lip focused on labial closure but accentuated the nasal deformities, which were addressed later. By the end of the past century, single-staged labial closure had replaced the old multistaged procedures and the technical emphasis had begun to shift from secondary to primary nasal correction. Now, presurgical maxillary orthopedics sets the bony foundation for synchronous nasolabial repair and for closure of the alveolar clefts. The study of normal nasolabial growth and the typical stigmata of the conventional methods provides the necessary foreknowledge to guide surgical sculpture in three dimensions and to anticipate the fourth dimension. The convergence of several forces are changing referral lines for children born with bilateral cleft lip. These include affirmation of centers of excellence, surgeons' self-regulation, prenatal diagnosis, economics of health-care delivery, and increasing parental sophistication. These pressures are not necessarily in conflict. Care by a subspecialized plastic surgeon and experienced team is in the best interests of the child and the third-party payer.

Correction of the bilateral complete cleft lip: transformation to a unilateral incomplete cleft lip closure

The complete lip alveolus and cleft palate is the most difficult of all bilateral clefts to treat because of the deformity of and tissue insufficiency in the prolabium. A bilateral concomitant procedure is impractical for treatment of this condition because of the problems that have to be resolved postoperatively, including a short columella, a lack of philtrum, labial horizontal and vertical insufficiency, and vermilion and alveolar vestibulum insufficiency. A two-stage procedure called the transformation method has been developed to circumvent these problems, and the authors present it here. With this method one side is closed completely using the maximum amount of tissue available. Concomitantly, incomplete closure is performed on the other side. The result at the end of the first stage of the procedure is a condition approximating unilateral incomplete closure. The results were obtained from 6 patients who underwent complete bilateral closure and were followed for at least 2 years with satisfactory results.

The effect of muscle repair on postoperative facial skeletal growth in children with bilateral cleft lip and palate

The effect of orbicularis muscle repair on postoperative facial skeletal growth in bilateral cleft lip and palate patients was studied by analysis of cephalometric radiographs and dental casts. Sixty-two patients operated on between 1961-1989 were selected for the study. They were divided into three groups, group 1a (muscle repair; n = 12), group 1b (failed attempt at muscle repair; n = 5), and group 2 (no attempt at muscle repair; n = 45). Comparison of the morphological measurements among these three groups showed that there was a trend towards crossbite in the muscle repair group, but this difference was not significant. Mechanisms by which muscle repair might influence maxillofacial skeletal growth include the possibility that the area around the nasal septum might be the growth centre. The choice of operative technique in bilateral cleft lip and palate should be important.

Effectiveness of two feeding methods in improving energy intake and growth of infants with cleft palate: a randomized study

OBJECTIVE

To compare two feeding methods advocated for infants with cleft palate: (a) a squeezable plastic container with a narrow, long crosscut nipple (squeezable cleft palate nurser); and (b) a standard nipple with a crosscut (crosscut nipple). The effectiveness of a nutrition intervention protocol for these infants was also documented.

DESIGN

Thirty-one infants (median age = 15 days) were randomized to one of two feeding methods (18 infants, squeezable cleft lip/palate nurser; 13 infants, crosscut nipple) within sex (21 boys, 10 girls) and palatal defect (22 cleft lip and palate, 9 isolated cleft palate) categories. The intervention included feeding technique instructions, nutrition counseling at each clinic visit, use of the same 20 kcal/oz standard formula for 12 months, and introduction of infant and soft table foods at 6 months. Four-day food records and growth data were obtained.

MAIN OUTCOME MEASURES

Mean energy and protein intakes at 3 and 6 months of age and growth measurements during the first 18 months of life were obtained.

STATISTICAL ANALYSES

A repeated measures analysis of variance for intakes was performed with time as the repeated measure and feeding method as the covariable. Similar analyses were completed for growth measures with sex and feeding method as covariates.

RESULTS

Mean energy intake at 3 and 6 months of age (P = .24) and growth measurements during the first 18 months of life (P values: weight gain [grams per day], .73; weight, .21; length, .07; head circumference, .18; triceps and subscapular skinfolds and mid-arm circumference, .47, .48, and .69, respectively) were not significantly different. Both feeding methods were effective in supporting normal growth.

APPLICATIONS

With adequate instruction related to the use of either feeding technique and close nutrition follow-up early in infancy, a dietitian or other health care practitioner may advise the use of either feeding method. These data support the need for feeding and nutrition education and early nutrition intervention.

Correction of the bilateral cleft lip nasal deformity: evolution of a surgical concept

The origin of the nasal deformity of a bilateral complete cleft lip is both primary (deformation/malformation) and secondary (postoperative distortion). This is an interim report of a personal evolution from staged correction of the bilateral cleft nasal deformity to synchronous repair of the nose and the lip and premaxillary-maxillary clefts. The anatomic concept is that, because of the malpositioned alar cartilages, the columella only appears to be short in an infant with bilateral cleft lip. The technical stratagems to model the nose are: (1) alignment of the premaxilla and (2) anatomic placement of the alar cartilages with sculpturing of the overlying soft tissue.

Comprehensive treatment of bilateral cleft lip by multidisciplinary team approach

Repair of bilateral cleft lip presents numerous problems, and in our opinion, it is better to begin treatment at the earliest age possible. At Fujita Health University Hospital, we utilise a multidisciplinary team approach to cleft lip. Nonsurgical correction of the nasal deformity using a nose retainer and preoperative orthodontics using a Kuwahara-modified Hotz's palatal plate begins soon after birth. Surgical repair of the lip is done within the first 2 months of life, by the time the nose, alveolus and projecting prolabium are adequately reformed. A one-stage surgical procedure, including restoration of muscle union, labial sulcus construction and nasal correction is performed. After lip repair, lip and tongue pressure are well balanced by the plate, and a good alignment of the alveolus can be achieved. A total of 27 cases of bilateral cleft lip were treated from August 1986 to October 1990. In all cases, the postoperative course was uneventful, and no complications due to early surgery were encountered.