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37. How to Rotate and Advance in a Complete Cleft

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37. How to Rotate and Advance in a Complete Cleft 37 HOW TO ROTATE AND ADVANCE IN COMPLETE CLEFT HAS BEEN SAID OFTEN THAT NATURALLOOKING RESULT FOLLOWING CLOSURE OF CONGENITAL CLEFT LIP IS WORK OF ART IN FACT IT IS THREEDIMENSIONAL WORK OF SCULPTURED ART PRINCIPLES MEASURE MARKS AND MENTS INCISIONS OF TECHNIQUE CAN BE STANDARDIZED AND BLUEPRINT OF THE TECHNIQUE MEMORIZED YET THE LAST FEW MILLIMETERS WHICH MAKE ALL THE DIFFERENCE MUST DEPEND UPON THE SCULPTOR AND HIS CLAY BEFORE AND MARKING CUTTING COMPARE THE NORMAL SIDE AND THE ABNORMAL CLEFT SIDE WITH YOUR EYES SWITCHING BACK ND FORTH AND IN HORIZONTAL AGAIN AGAIN NYSTAGMUS THEN BY TRANSPOSING THE IDEAL NORMAL OVER THIS ENTIRE COMPONENT IN YOUR MINDS EYE IT WILL BECOME APPARENT WHAT IS PRESENT ITS POSITION AND WHAT IS NEEDED NOW COMES THE SURGICAL SCRAMBLE TO MAKE UP THE DIFFERENCE WITHOUT COMPROMISING THE NORMAL 449 SKIN MARKING AND SCORING FIRST DOTMARK THE KEY LANDMARKS ON THE NONCLEFT ELEMENT AS DESCRIBED IN PART INCOMPLETE CLEFTS TO TO OF THE CUPIDS BOW ALL OF WHICH ARE USUALLY TO MM APART AN IMPORTANT MEASUREMENT ON THE NORMAL SIDE IS THE DISTANCE FROM POINT SIDE TO THE ALAR BASE AT THE HEIGHT OF THE BOW ON THE NONCLEFT WHICH MEASURES FROM TO 12 MM THIS IS THE DISTANCE THAT WILL HAVE TO BE MATCHED ON THE CLEFT SIDE AND IS ROUGHLY THE LENGTH THAT MUST BE ACHIEVED EVENTUALLY ALONG THE ROTATION EDGE INCI AS WELL AS ALONG THE ADVANCEMENT EDGE MARK THE ROTATION CLEFT SIDE OF THE COLUMELLA SION WHICH RISES VERTICALLY UP TO THE BASE AND THEN CURVES ACROSS THE MIDLINE HUGGING THE COLUMELLA OF THE COLUMN OF THE BASE BUT STOPPING JUST SHORT PHILTRUM NORMAL SIDE THE BACKCUT MARKING IS POSTPONED TEMPORARILY THE ROTATION INCISION MARK IS SCORED WITH 67 BEAVER BLADE THE DISTANCE FROM THE COMMISSURE TO THE HEIGHT OF THE CUPIDS BOW ON THE NONCLEFT SIDE IS MEASURED AND IS USUALLY CLEFT SIDE ABOUT 20 MM THE SAME DISTANCE IS MARKED ON THE FROM THE COMMISSURE TO POINT ALONG THE MUCOCUTANEOUS POINT INDICATES THE JUNCTION LINE OF THE LATERAL LIP ELEMENT MEDIAL LIMIT OF LATERAL PARING THE HIGHEST AND MOST POINT MARKED THE OF OF USABLE LATERAL LIP ELEMENT IS AS PROBABLE TIP THE ADVANCEMENT FLAP 450 11 DOTTING THE BOW MARKING THE TOTATION ENSURING NORMAL VERTICAL AND FLAP BY BENDING STRAIGHTENING 451 BE TO IF THE LATERAL ELEMENT IS DIMINUTIVE IT MAY NECESSARY VESTIBULE TO THE EXTRA CLEFT EXTEND POINT UP INTO THE NASAL GET MATCH THE ROTATION THIS EXTENSION EDGE LENGTH REQUIRED TO EDGE WILL ENABLE ONE TO HOLD THE LINE AT POINT IN THE LATERAL PARING CURVED WIRE AN ESTIMATE OF THESC DISTANCES IS BEST CHECKED BY THE HAS BEEN INTO TECHNIQUE WHEN ALL AVAILABLE TISSUE INCORPORATED AND THE IS STILL SHORT CON THE TIP OF THE ADVANCEMENT FLAP FLAP SERVATIVE PARING OF THE CLEFT EDGE LATERALLY EVEN BEYOND POINT FOR MILLIMETER TWO AT MOST MAY BE NECESSARY OR OF THE ALAR BASE THE NEXT POINT 10 IS SET AT THE MIDPOINT CLEFTS THIS BE THE LATERAL JOIN WITH THE LIP IN INCOMPLETE MAY INCISION YET IN EXTENT OF THE UPPER CURVED HORIZONTAL COMPLETE OF CLEFTS THAT INCISION MUST BE CONTINUED TO THE LATERAL EXTENT ON THE THE ALAR BASE JOIN WITH THE LIP 11 AND DEPENDING PARTLY AMOUNT OF ALAR BASE FLARE MAY HAVE TO BE EXTENDED FARTHER IN CIRCUMALAR DIRECTION AROUND TO POINT 12 THE ALAR BASE AT 10 TO THE IF THE LENGTH OF THE LIP FROM SHORTER THAN THE DISTANCE FROM MUCOCUTANEOUSRIDGE AT IS MUCH THE NORMAL TO THEN THE INCISION FROM TO 10 TO 11 AND MILLIMETER EVEN TO 12 MAY HAVE TO BE RAISED TO INCLUDE OR BIT OF MORE OF ALAR BASE IN THE LATERAL LIP FLAP INCLUDING OF THE LATERAL ADVANCEMENT WILL ALAR BASE IN THE UPPER PART FLAP THIS INTO CONVENIENTLY SHIFT THIS PROMINENCE AS FLAP ADVANCES 10 FOR VERTICAL THE BASE FOR NEEDED EDGE LENGTH TIP OF REQUIRED HEIGHT THE OF THE ALA CAN BE INCLUDED IN THE LIP FLAP CAN BE EXTENDED INTO VESTIBULE FLAP 452 NOSTRIL SILL POSITION IN INCOMPLETE CLEFTS OR COLUMELLA BASE IN COMPLETE CLEFTS THE STRETCHED ALA CAN WELL WITHSTAND SUCH MINOR SHORTENING LINE IS MARKED TO THESE JOIN POINTS 891011 AND POSSIBLY 12 AND THE LINE IS THEN SCORED TO DEFINE THE ADVANCEMENT FLAP NOW THE ROTATION AND ADVANCEMENT FLAPS HAVE BEEN MARKED FINALLY SAVE THE PARINGS THE NEXT IS CONCERNED WITH THE STEP SALVAGING OF THE CLEFT EDGE MUCOSA AS THE CLEFT MUST BE IN ORDER EDGES PARED TO APPROX IMATE THEM FLAP OF VERMILION BASED ABOVE ON THE MUCOSA OF THE ALVEOLUS IN THE UPPER LABIAL SULCUS IS STABBED OFF EACH SIDE OF THE CLEFT WITH 11 BARDPARKER BLADE AND LEFT DANGLING FOR LATER USE 453 OFFER THEMSELVES THE MEDIAL OF COURSE VARIOUS POSSIBILITIES BASED ABOVE ON THE ALVEOLUS CAN BE USED MUCOSAL PARING FLAP THE CLOSURE OF THE ALVEOLUS AND ANTERIOR AS THE SECOND ORAL LAYER IN HARD PALATE MEDIAL CLEFT EDGE MUCOSA PRESERVED AS FLAP WITH ITS BASE ABOVE BE CLOSED THE SOFT PALATE CAN ADHESION EARLY DURING THE LIP ADHESION IS PROCEDURE OR IF THE IT BE CLOSED NOT USED CAN NASAL CLOSURE OF AN ANESTHESIA DURING THE SAME TENOR CLEFT IS REI TO THE FINAL RA LIP JUST PRIOR FORCED WITH FLAP PROCEDURE THE ORAL LAYER ON SIDE 454 II OR THIS MEDIAL VERMILION PARING FLAP CAN SERVE AS THE SECOND LAYER BUT ON THE NASAL SIDE THEN FLAP CAN SERVE AS SECOND LAYER CLOSURE ON THE NASAL SIDE FREEING THE MEDIAL LIP ELEMENT OFF THE MAXILLA WITH CARE TO AVOID THE BASE OF THIS FLAP THE MEDIAL LIP ELEMENT IS FREED BY SHARP DISSECTION FROM THE MAXILLA 45 OF THE LATERAL SIMILAR PARING OF THE VERMILION EDGE LIP THE OF THE ELEMENT CAN PRODUCE FLAP BASED ABOVE ON MUCOSA VALUABLE FILLER FOR THE DEFECT MAXILLA THIS FLAP IS EXTREMELY AS WHEN PRODUCED DURING THE INCISING OF THE LATERAL VESTIBULAR LINING MAXILLA FREEING THE ALAR BASE FROM THE AND THE OF ITS THE STRATEGIC POSITION OF THIS FLAP EASE DEFECT HAVE CAUSED IT TO BECOME TRANSPOSITION INTO THE VESTIBULAR STANDARD IN THIS MANEUVER WHEN ONE CONSIDERS THAT THIS TISSUE HAS BEEN DISCARDED FOR CENTURIES ITS PRESENT SALVAGE IS AN IMPOR ALAR RELEASE WITHOUT CONTRAC TANT STEP MAKING POSSIBLE SECONDARY TURE VESTIBULAR DEFECT AND MAINTAINS NASAL ALA ADVANCEMENT CONTRACTURE LATERAL EDGE MUCOSAL FLAP FITS INTO THIS LATERAL AGAINST ADHESION USED IN ALMOST ALL PRELIMINARY PROCEDURE IS BEING COMPLETE UNILATERAL CLEFTS AT ABOUT WEEKS OF AGE IT IS NOW STANDARD AT THE TIME OF THIS ADHESION TO INSERT FLAP OF THE CLEFT THE LATERAL ELEMENT INTO THE LATERAL EDGE VERMILION FROM LIP VESTIBULAR DEFECT AFTER RELEASE OF THE ALAR BASE FROM THE MAXILLA AND LETS THE THIS FRESHENS ONE LIP EDGE FOR THE ADHESION NOSE BACK AND ALAR BASE COME FORWARD EARLY WITHOUT THREAT OF CON TRACTURE 456 LATERAL LIP AND ALAR BASE UNDERMINED LATERAL EDGE MUCOSA PRESERVED FLAP BASED ABOVE 457 PRESENT APPROACH IN COMPLETE CLEFTS IN THE IN MOST COMPLETE CLEFTS TODAY AN ADHESION IS CREATED EARLY WEEKS AS SHOWN HERE PREFERABLY USING FLAP ALL LANDMARKS MUST BE PRESERVED LATERAL MUCOSAL UNDER FLAP SLID MEDIAL ELEMENT OR PREFERABLY FLAP SHIFTED INTO NASAL LINING MUCOSAL DISSECTED FROM LATERAL FREED FROM THE MAXILLA BUT LATERAL ELEMENT LEFT ATTACHED WHEN POSSIBLE FLAP MEDIAL LIP ELEMENT ELEMENT AND USED TO ADVANTAGE ADHESION SUTURED IN THREE LAYERS THEN AT SIX TO EIGHT MONTHS OF AGE THE ROTATIONADVANCEMENT FIRST THE ROTATION AND THEN THE ADVANCE OPERATION IS CARRIED OUT MENT INCISIONS ARE MARKED THUS THE INBETWEEN MUCOSA AND AND SCAR TISSUE OF THE ADHESION ARE LEFT TO BE MARKED AS IN IF USED IN ADHESION FLAPS BUT ARE NOT AS IMPORTANT FLAP ALREADY WI LANDMARKS THE BOW AND MEASURING WIREMEASURING ROTATION INCISION ADHESION PRESERVES MARLDNG THE HEIGHT 11 KAI RI AAA OF ALAR BASE IS INCLUDED ROTATION MARKED AND ADVANCE VERTICAL HEIGHT ON CLEFT SIDE IS SO PORTION IN THE MENTEDGEMEASURED SHORT LIP FLAP 458 THEN THE ADHESION IS DIVIDED DOWN ITS CENTER BETWEEN THE TO THE TWO FLAPS OPEN LIP FOR FULL EXPOSURE OF THE CLEFT THE TWO ADHESIONEDGE PARING FLAPS AND ARE DISSECTED FREE AND LEFT DANGLING TEMPORARILY MARK AND FLAPS BEFORE DIVIDING FLAPS AND ARE CUT THEY ARE LEFT DANGLING READY FOR USE LATER ROTATION MEDIAL SCORE THE ROTATION INCISION FIRST THEN PICK UP THE LIP AND LIFT IT ELEMENT WITH YOUR LEFT THUMB AND INDEX FINGER FREE SO THAT 11 PARKER BLADE CAN BE STABBED COMPLETELY THE SCORED ROTATION THROUGH THE FULL THICKNESS OF THE LIP ALONG SHOULD LINE IT IS USUALLY EASIER TO START AT POINT THE SCALPEL AND BE SLANTED ON THE BIAS TO RETAIN AS MUCH MUSCLE MUCOSA WILL THE CLEFT IN THE LIP AS POSSIBLE THIS MANEUVER JOIN PREVIOUS EDGE PARING ALREADY ACCOMPLISHED ROTATION INCISION SCORED HI II 11 FURTHER DEEP RELEASE AND MEDIAL LIP ELEMENT FREED FROM MAXILLA IIJ 460 4474 THE AMOUNT OF ROTATION REQUIRED DEPENDS DIRECTLY UPON THE DIFFERENCE IN VERTICAL HEIGHT OF THE CUPIDS BOW PEAKS ON THE NORMAL SIDE AT POINT AND THE CLEFT SIDE AT POINT OF THE MEDIAL ELEMENT AS LIP SOON AS THE ROTATION INCISION HAS BEEN CUT TO THE OF POINT POSITION SHOULD BE TESTED TO SEE IF THE DROP HAS BEEN LINE ADEQUATE TO UP THE PEAKS OF THE BOW ON AN EQUAL HORIZONTAL FURTHER WITH THE PLANE STABBING POINT OF THE SCALPEL THE IN SUBCUTANEOUS TISSUE AND MUSCLE ATTACHMENTS WILL INCREASE THE RELEASE THEN WITH CARE TO AVOID THE BASE OF THE MUCOSAL UNDERMINE THE EDGE FLAP IN MEDIAL LIP ELEMENT FREE FROM THE MAXILLA MODERATE AMOUNT TO FACILITATE THE ROTATION BACKCUT AFTER THE SIMPLE ROTATION TO POINT AND THE UNDERMINING THERE IS IN THE DOWNWARD USUALLY SLIGHT DISCREPANCY POSITIONING OF FLAP WITH ITS CUPIDS BOW AND PHILTRUM DIMPLE HERE THE BACKCUT MAKES ITS TRIUMPHANT ENTRY THE BACKCUT CHECKS THE TRANSVERSE DIRECTION OF THE INCISION AS IT IS DIRECTED OBLIQUELY DOWNWARDBEING PRICKED WITH THE 411 POINT MILLIMETER OR TWO TO THIS POINT APPROACH CAN MAKE UP FOR DISCREPANCY IN BOW PEAK HEIGHT OF OR OR MORE MILLIMETERS SO DO NOT PANIC WHEN THE DIFFERENCE IS MORE THAN THE FICTITIOUS
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