Comparison of the Fisher Anatomical Subunit and Modified Millard Rotation-Advancement Cleft Lip Repairs:

Cleft lip re-repair: How does it affect the nasolabial appearance?

Cleft lip re-repair is a procedure frequently endorsed to enhance a compromised nasolabial appearance. However, the actual effect of such revision surgery on the nasolabial appearance has scarcely been studied. Therefore, the aim of this study was to critically review surgical outcomes of patients that underwent surgical re-do of their cleft lip, using well-validated objective and subjective methods and standardised outcome measures. 20 patients with at least 6 months follow-up after cleft lip re-repair were assessed. Standardised pre- and postoperative photographs were analysed. The objective assessment was carried out using the SymNose-software. Furthermore, a subjective evaluation of the nasolabial area was conducted by ten examiners who rated seven parameters using a Likert-scale ranging from 1to5. The objective evaluation showed substantial improvement regarding symmetry values. Significant postoperative decrease in labial asymmetry from 26.42% (±8.13) to 18.77% (±6.28) (p < 0.001) and upper lip asymmetry in relation to the facial midline (26.91% (±8.03) vs. 18.27% (±5.17) (p < 0.001)) was observed. Similar results were corroborated in the subjective analysis. Differences regarding the ratings were detected considering the examiners' professional background and level of expertise. Cleft re-repair was found to significantly improve upper lip symmetry and lead to a more harmonious nasolabial appearance.

"Strategic Application of Anatomical Subunit Approximation Technique for Correction of Complete Unilateral Cleft lip"

OBJECTIVE

To discuss advantages, disadvantages and strategical application of anatomical subunit approximation technique in complete unilateral cleft lip repair.

DESIGN

Analysis of consecutive 28 cases.

SETTING

A single surgeon experience at a university hospital.

PATIENTS

Among 77 patients who underwent cleft lip repair between May 5, 2019 and June 30, 2021, 28 patients with complete unilateral cleft lip who received cheiloplasty by author's technique.

MAIN OUTCOME MEASURES

Surgical outcomes were assessed by frontal view medical photographs obtained postoperatively at follow-up visits.

RESULTS

The average length difference between cleft and noncleft sides was <10% for transverse lip length and philtral height. Nostril sill height demonstrated about twenty percent of difference with much variable results. Although the one sample t-test revealed that differences exist between the cleft and noncleft side, they were within an acceptable range.

CONCLUSIONS

Understanding the strengths and limitations of anatomical subunit approximation technique enabled strategic application in complete unilateral cleft lip repair. Satisfactory outcomes were achieved not only regarding the scar placement but also regarding the symmetry of the lips and augmentation of nasal sill.

Scar Outcome in Unilateral Complete Cleft Lip Repair: A Comparative Analysis of Vertical Lip Lengthening Strategies Using the Rotation-Advancement Concept

OBJECTIVE

To assess the differences in scar outcomes between modified rotation-advancement techniques proposed by Drs. Mohler and Noordhoff, designed to address issues such as inadequate vertical lip length and scarring on the upper third of the lip in the original rotation-advancement technique.

DESIGN

Retrospective single-surgeon (RD) study.

PATIENTS

Consecutive non-syndromic children (n = 68) with unilateral complete cleft lip and palate.

INTERVENTIONS

Modified Mohler (columellar backcut reconstructed with C flap; n = 34) and modified Noordhoff (lower, medially-created backcut reconstructed with laterally-based triangular skin flap; n = 34) repairs.

MEAN OUTCOME MEASURES

Using 12-month postoperative frontal photographs, scar evaluations (overall and superior, middle, and inferior portions of the lip) were appraised by an assessment panel composed by independent professional and nonprofessional raters employing four validated qualitative scar assessment scales: Manchester Scar Scale, modified Scar-Rating Scale, Stony Brook Scar Evaluation Scale, and Visual Analog Scale. Quantitative computerized photogrammetric scar widths of the superior, middle, and inferior portions of the upper lip were also measured.

RESULTS

The modified Noordhoff method showed significantly (all P < .001) better scar quality for the overall scar and superior portion of the scar in all four scales compared to the modified Mohler method, with no significant (all P > .05) difference for the middle and lower portions. No significant difference (all P > .05) was observed for photogrammetric scar width measurements.

CONCLUSION

The modified Noordhoff technique provided better qualitative results for unilateral complete cleft lip-related scars compared to the modified Mohler technique.

Advances in Cleft Lip and Palate Surgery

Cleft lip with or without cleft palate is one of the most common congenital malformations, with an average prevalence of 1 in 1000 live births. Cleft lip and/or palate is incredibly phenotypically diverse, with constant advancements and refinements in how we care for patients. This article presents an in-depth review of the latest advances and current evidence in cleft lip and palate surgery. This includes presurgical infant orthopedics, perioperative practice patterns including use of enhanced recovery after surgery (ERAS) protocols, patient-reported outcome measures, and the latest adjuncts in cheiloplasty and palatoplasty.

Modified Placement of C-flap in Unilateral Cleft Lip Repair to Avoid Alar Base Scar - A Retrospective Study

Introduction

In spite of several techniques, Millard's approach for the correction of cleft lip still is widely used. Although versatile, it has certain drawbacks including scar contraction, short lip and notching. A modification of the 'C' arm helps to address this drawback. The purpose of this study was to describe the qualitative and quantitative outcomes of the author's modification of Millard's C flap.

Materials and Methods

Archival photographic records of cleft lip repairs and post-operative photos of cases treated by author were screened. Anthropometric measurements of the height and width of the lip, the height of the vermilion and the width of the alar base were considered. The outcome was quantified by comparing the ratio of each feature between the cleft and normal sides. The quality of cleft lip repair was assessed using the Steffensen criteria. Appropriate statistical tests were performed.

Results

In all, 233 cases with a mean age of 4.46 ± 0.91 years and 106 (45.5%) males formed the study group. The mean lip height ratio was 0.936 ± 0.04, the mean lip width ratio was 0.938 ± 0.037, the mean vermillion height ratio was 0.9433 ± 0.35 while the mean alar base width ratio was 0.932 ± 0.35. The physical parameter ratios' mean difference between the normal side and the cleft side was below 0.06 mm.

Discussion

The mechanism behind the drawback of the classical Millard's technique is discussed and compared with present modification. The authors' modification shows that modified Millard's technique produces better aesthetic outcomes.

The role of primary surgery in the management of orofacial clefting

Primary cleft surgery refers to the planned surgical procedure(s) necessary to reconstruct an orofacial defect according to a specified protocol; in the context of a unilateral cleft lip and palate, this would include lip repair (with vomer flap closure of the hard palate), subsequent repair of the residual soft palate cleft and finally, the alveolar bone graft. This paper will provide an overview of the goals of primary surgical reconstruction, including the utility of pre-surgical orthopaedic techniques, including nasoalveolar moulding. The surgical methods of primary lip repair in both unilateral and bilateral clefts will be outlined and the concept of a primary rhinoplasty will be introduced. The principal techniques of cleft palate reconstruction will be delineated for a variety of cleft phenotypes. The final element of the primary reconstructive sequence is the alveolar bone graft using cancellous bone harvested from the iliac crest at approximately 8-10 years of age. The role of optimising oral hygiene prior to bone grafting cannot be over-emphasised and the utility of pre-surgical orthodontic arch expansion is also discussed. In the UK, bone graft outcomes are audited using the Kindelan score, which is evaluated from the six-month postoperative upper standard occlusal radiograph.

Six-year Burden of Care for Nonsyndromic Unilateral Cleft Lip and Palate Patients: A Comparison Between Cleft Centers and Noncleft Centers

OBJECTIVE

To determine differences in burden of care between nonsyndromic patients with unilateral cleft lip and palate undergoing treatment at American Cleft Palate-Craniofacial Association (ACPA)-accredited centers and nonaccredited centers in New York State.

DESIGN

A retrospective review of the New York Statewide Planning and Research Cooperative System database from January 2001 to December 2014 was performed using ICD-9 and CPT coding.

PATIENTS, PARTICIPANTS

This study included patients with unilateral cleft lip and palate who underwent both lip and palate repairs during their first  6 years of life. Exclusion criteria included orofacial cleft syndromes, follow-up under  6 years, and one-stage combined cleft lip and palate repairs.

RESULTS

Eighty-eight patients were treated at cleft centers, and 29 patients at nonaccredited centers (  n = 117). Age at primary palatoplasty (13.0 months vs 18.1 months;   p = .019), total number of cleft operations (2.3 vs 2.7;   p = .012), and total number of primary cleft-specific procedures (2.2 vs 2.5;   p = .0049) were significantly lower for patients treated in cleft centers. Age at primary cheiloplasty (4.8 months vs 4.6 months;   p = .865), post-cheiloplasty length of stay (1.2 days vs 1.2 days;   p = .673), post-palatoplasty length of stay (1.5 days vs 1.9 days;   p = .211), average hospital admissions (2.2 vs 2.3; p = 0.161), and total complication rates (34.1% vs 21.1%; p = 0.517) did not differ significantly between cleft centers and noncenters.

CONCLUSIONS

This data demonstrates some significant differences in overall 6 year burden of care for nonsyndromic patients with unilateral cleft lip and palate treated at ACPA-accredited cleft centers versus nonaccredited centers.

Trends of cleft surgeries and predictors of late primary surgery among children with cleft lip and palate at the University College Hospital, Nigeria: A retrospective cohort study

BACKGROUND

Cleft of the lip and palate is the most common craniofacial birth defect with a worldwide incidence of one in 700 live births. Early surgical repairs are aimed at improving appearance, speech, hearing, psychosocial development and avoiding impediments to social integration. Many interventions including the Smile Train partner model have been introduced to identify and perform prompt surgical procedures for the affected babies. However, little is known about the trends of the incidence and surgical procedures performed at our hospital. Nothing is also known about the relationship between the clinical characteristics of the patients and the timing of primary repairs.

OBJECTIVE

To determine the trends in cleft surgeries, patterns of cleft surgeries and identify factors related to late primary repair at the University College Hospital, UCH, Ibadan, Nigeria.

METHODS

A retrospective cohort study and trends analysis of babies managed for cleft lip and palate from January 2007 to January 2019 at the UCH, Ibadan was conducted. The demographic and clinical characteristics were extracted from the Smile Train enabled cleft database of the hospital. The annual trends in rate of cleft surgeries (number of cleft surgeries per 100,000 live births) was represented graphically. Chi square test, Student's t-test and Mann Whitney U were utilised to assess the association between categorical and continuous variables and delay in cleft surgery (≥12 months for lip repair, ≥18months for palatal repair). Kaplan-Meier graphs with log-rank test was used to examine the association between sociodemographic variables and the outcome (late surgery). Univariable and multivariable Cox proportional hazard regression was conducted to obtain the hazard or predictors of delayed cleft lip surgery. Stata version 17 (Statacorp, USA) statistical software was utilised for analysis.

RESULTS

There were 314 cleft surgeries performed over the thirteen-year period of study. The male to female ratio was 1.2:1. The mean age of the patients was 58.08 ± 99.65 months. The median age and weight of the patients were 11 (IQR:5-65) months and 8 (IQR: 5.5-16) kg respectively. Over half (n = 184, 58.6%) of the cleft surgeries were for primary repairs of the lip and a third (n = 94, 29.9%) were surgeries for primary repairs of the palate. Millard's rotation advancement flap was the commonest lip repair technique with Fishers repair introduced within two years into the end of the study. Bardachs two flap palatoplasty has replaced Von Langenbeck palatoplasty as the commonest method of palatal repair. The prevalence of late primary cleft lip repair was about a third of the patients having primary cleft lip surgery while the prevalence of late palatal repair was more than two thirds of those who received primary palatoplasty. Compared with children who had bilateral cleft lip, children with unilateral cleft lip had a significantly increased risk of late primary repair (Adj HR: 22.4, 955 CI: 2.59-193.70, P-value = 0.005).

CONCLUSION

There has been a change from Von Langenbeck palatoplasty to Bardachs two-flap palatoplasty. Intra-velar veloplasty and Fisher's method of lip repair were introduced in later years. There was a higher risk of late primary repair in children with unilateral cleft lip.

Current Concepts and Challenges in the Treatment of Cleft Lip and Palate Patients-A Comprehensive Review

Cleft lip and cleft palate has one of the highest incidences in the malformations of the oral cavity, that varies between populations. The background underlying the issue of cleft lip and palate is multifactorial and greatly depends on the genetic factors and environmental factors. The aim of this nonsystematic narrative review is to present the cleft palate and or lip pediatric population as target for interdisciplinary treatment. The purpose of this narrative review is to sum up the modern knowledge on the treatment of patients with clefts, as well as to highlight the importance of the great need for cooperation between different dental specialists along with medical professionals such as oral surgeons, prosthodontists, orthodontists along with medical professions such as pediatricians, speech therapists and phoniatrics, and laryngologist.

Primary unilateral incomplete cleft lip repair by a modified rotational advancement technique

PURPOSE

This study aimed to describe a modified technique for primary unilateral incomplete cleft lip repair together with postoperative outcomes assessment.

STUDY DESIGN

A Retrospective study.

PARTICIPANTS AND SETTING

Photos of 64 consecutive patients with nonsyndromic primary unilateral incomplete cleft lip were reviewed. Of the 64 participants for the study sample, 32 patients had received Millard rotational advancement technique (RA), while the other 32 had modified rotational advancement technique (MRA) with preserving the nasal sill intact. It was conducted at a university-affiliated tertiary hospital between 2013 and 2021.

MAIN MEASURES

The lip measures were represented by lip height and width, vermillion height, midline-philtrum angle, and angle of Cupid's bow peaks. The nasal measures involved columella length and angle, nostril height and width, and ala width. Both descriptive and comparative data analyses were calculated.

RESULTS

Symmetrical lip height, lip width, philtrum angle, Cupid's bow, as well columellar length, and alar width were obtained following the MRA technique. No significant difference was found between the MRA and RA groups concerning the preoperative lip height, Cupid's bow angle, columellar length and angle. However, the postoperative lip height, width and columellar length were greater in MRA group than RA group (P= .001, 0.004 and 0.002, respectively). On the other hand, the MRA group had significantly smaller columellar and Cupid's bow peaks angles than RA group (0.53±0.36 vs 1.21±0.91 and 1.34±1.84 vs 3.14 ± 2.97, respectively).

CONCLUSIONS

The MRA technique has obtained satisfactory lip and nasal outcomes in terms of lip height, lip width, philtrum angle, Cupid's bow, columellar length, and alar width while keeping the nasal sill intact.

Can surgeons rely on growth-related changes to achieve lip height and width symmetry in unilateral complete cleft lip repair?

Surgeons face difficulties achieving simultaneous lip height and width symmetry while repairing unilateral complete cleft lip, so one is often sacrificed at the expense of the other. The aim of this study was to evaluate the effect of growth on lip height and width symmetry, to guide the surgeon to the best decision. The study patients (N = 105) were divided into two groups based on the treatment method: 42 were treated with the modified rotational advancement technique (MRA group) and 63 with the Millard rotation-advancement technique (RA group). Furthermore, based on lip height and width symmetry at 6 months postoperative, the patients were divided into three groups: 38 with symmetrical lip height and width (SL), 41 with horizontal lip width more symmetrical than lip height (RAW), and 26 with vertical lip height more symmetrical than lip width (RAH). Measurements were taken preoperatively (T0), 6 months (T1) and 5 years (T2) postoperatively. The MRA group had significantly more symmetrical lip height than the RA group at T1 (P = 0.003) and T2 (P = 0.002); however no statistically significant difference in lip width symmetry was observed between the two groups. In relation to the effects of growth, only lip width symmetry in the RAH group improved significantly between T1 and T2 (P = 0.023). In conclusion the improvement in lip width symmetry following 5 years of postoperative growth did not achieve the same symmetry as when lip width symmetry was achieved intraoperatively. Thus, the MRA technique could be used to obtain intraoperative symmetry of lip height and width.

Long-Term Evaluation of the Lip and Nose in Bilateral Complete Cleft Lip Patients following Lip Adhesion and Secondary Nose Correction

Background  Surgical correction of bilateral cleft lip deformities remains one of the most challenging areas in facial plastic surgery. Many surgical techniques and conservative devices have been offered for the early management of bilateral cleft lip in infants. The purpose of this study was to evaluate the effect of lip adhesion on the lip and nose of patients with bilateral cleft lip.

Methods  A retrospective review of 13 patients with bilateral cleft lip was performed and compared with age-matched noncleft children. Patients underwent lip adhesion at a mean age of 2.8 months, and cheiloplasty at 6.6 months of age using a modification the Mulliken method. Secondary rhinoplasty was performed at the age of 6 in 13 patients. The surgical results were analyzed using photographic records obtained at the age of 1 and 7 years. Twelve length measurements and one angle measurement were obtained.

Results  All measurements were not statistically different from those of the noncleft age-matched control group at the age of 1. At 7 years of age, upper lip height and vermilion mucosal height were shorter ( p  < 0.05) than in the control group. Nasal tip protrusion and the nasolabial angle were greater ( p  < 0.05) than in the control group.

Conclusion  Lip adhesion followed by secondary rhinoplasty resulted in an acceptable lip and nasal appearance. Although nasoalveolar molding is now widely used, lip adhesion can be an appropriate alternative if an orthodontist is not available due to geographical or economic constraints.

Nasolabial Appearance in 5-Year-Old Patients with Repaired Complete Unilateral Cleft Lip and Palate: A Comparison of Two Different Techniques of Lip Repair

Different surgical techniques are available to adequately correct the primary cleft lip deformity; however, when compared, none of these techniques have proven superior with regard to achieving optimal aesthetic results. Thus, the aim of this retrospective study was to assess the nasolabial appearance in patients with unilateral cleft lip and palate (UCLP) at age five with reference to two techniques for primary cleft lip repair used in our service: Pfeifer’s wave-line procedure and Randall’s technique. A modified Asher–McDade Aesthetic Index was applied to appraise the nasolabial area by means of 2D photographs of non-syndromic five-year-old patients with a UCLP. In this context, three parameters were assessed: 1. nasal frontal view; 2. shape of the vermilion border and philtrum length; and 3. the nasolabial profile. Five professionals experienced in cleft care were asked to rate the photographs on two occasions. Overall, 53 patients were included in the final analysis, 28 of whom underwent lip repair according to Pfeifer; 25 were treated employing Randall’s technique. Statistically significant differences between the two techniques regarding philtrum length and vermilion border were found (p = 0.046). With reference to the other parameters assessed, no significant differences were determined. The results suggest that Randall’s cleft lip repair may allow for more accurate alignment of the vermilion border and more adequate correction of the cleft lip length discrepancy in comparison to Pfeifer’s wave-line technique.

Results of Lip Adhesion in Wide Unilateral Complete Cleft Lip Patients

ABSTRACT

Long-term follow-up results of many surgical techniques for lip adhesion are unavailable. Thus, we report the surgical results of patients who underwent lip adhesions performed by a single surgeon. We retrospectively analyzed two-dimensional photographs of 29 patients aged 1 year who underwent lip adhesion and definite lip repair. Among these patients, we analyzed the photographs of 20 patients aged 6 years who underwent secondary rhinoplasty. The ratio of the cleft side length to the noncleft side length was calculated. Only the upper lip length in the photographs of 1-year-olds was measured; both the upper lip and nose lengths were measured in the photographs of 6-year-olds. Lip width, vermilion height, and medial lip height on the cleft and non-cleft sides of 1-year-olds were not significantly different; the alar base width ratio was 1.17 ± 0.15, and the lateral lip height ratio was 0.91 ± 0.09 (P < 0.001). No significant differences were observed in lip width and vermilion height between the cleft and non-cleft sides of the upper lip of 6-year-olds; the alar base width ratio was 1.22 ± 0.16, medial lip height ratio was 1.11 ± 0.11, and lateral lip height ratio was 0.89 ± 0.09 (P < 0.05). There were no significant differences in the alar projection and nasal dome height on the cleft side of the nose; the nostril height and width ratios were 0.82 ± 0.11 and 1.31 ± 0.21 (P < 0.001), respectively. These consecutively performed lip adhesions for patients with wide unilateral complete cleft lip resulted in excellent long-term results. Therefore, lip adhesion for wide unilateral complete cleft lip is a reasonable alternative to presurgical molding.

A Need for Updating the Research Agenda for Cleft Lip and Palate and Extending the Cleft Team Model to Dental Medicine

Care for individuals born with cleft lip and palate is done by a team approach, including dental medicine. However, oral health is not integrated in other situations that affect overall health. This perspective essay makes the case for a universal team approach, having dental medicine integrated regardless of the overall health issue, much like how cleft lip and palate is managed. Furthermore, future research agenda on the etiology of cleft lip and palate in particular will need to be adjusted for a major roadblock: the lack of more sophisticated clinical descriptions for the cases ascertained at birth.

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.