Treatment of Complete Bilateral Cleft Lip-Nasal Deformity Philip Kuo-Ting Chen, M.D.,1 M. Samuel Noordhoff, M.D., F.A.C.S.,2 and Eric J.W. Liou, M.S., D.D.S.3 ABSTRACT The modern technique of presurgical orthopedics and nasoalveolar molding produces a better skeletal foundation and nasal shape for the repair of the bilateral cleft lip-nasal deformity. The general principles are as follows: (1) preserve the presurgical columellar length; (2) keep the width of the central lip segment narrow without compromising the blood supply; (3) advance the columella prolabium complex superiorly to allow reconstruction of the orbicularis oris muscle behind the prolabium; (4) release the alar cartilage attachment from the pyriform rim and provide additional coverage of this soft tissue deficiency with the use of inferior turbinate flaps; (5) release and reposition the lower lateral cartilage; (6) adequately dissect above the maxillary periosteum; (7) reconstruct the nasal floor by local mucosal flaps; (8) reconstruct the prolabial buccal sulcus with tissue from the prolabium; (9) reconstruct the orbicularis muscle sphincter and attach it to the anterior nasal spine; (10) reconstruct a new Cupid’s bow, central vermilion, and lip tubercle with tissue from the lateral lips; (11) balance the height of both lateral lips without any incision around the ala; and (12) maintain the presurgical nasolabial angle. The residual nasal deformity remains a problem that needs further improvement. The long-term result in Chang Gung Craniofacial Center suggests overcorrection of columella height before, during, and after lip repair. KEYWORDS: Bilateral cleft lip, nasoalveolar molding, long-term result The objective for surgical correction of the bi- trimmed the forked flap and reconstructed the nose with lateral cleft lip is to reconstruct a symmetrically balanced intranasal and nasal tip incisions that allowed approx- lip and nose with good columellar length. The most imation of the splayed lower lateral cartilages for accen- common approach is a two-stage correction with col- tuation of the columella. Trott and Mohan14 advocated umella elongation as a secondary procedure at the age of an open rhinoplasty approach raising the nasal tip with 1 to 5 years.1–10 Noordhoff,11 in 1989, reported a one- the prolabial flap for approximation of the alar domes. stage reconstruction with microscopic dissection of the Cutting et al15 used presurgical nasoalveolar molding to prolabium as an island pedicle flap and interdigitation of stretch the columella to achieve a more satisfactory one- the two-forked flap between the columella and pro- stage repair. Millard et al5 advocated aggressive, active labium for primary elongation. It was abandoned be- presurgical orthopedics, gingivoperiosteoplasty, and lip cause it was technically too complicated. Mulliken12,13 adhesion along with a forked flap elongation of the Cleft Lip Repair: Trends and Techniques; Editor in Chief, Saleh M. Shenaq, M.D.; Guest Editor, Joseph K. Williams, M.D., F.A.C.S., F.A.A.P.; Seminars in Plastic Surgery, Volume 19, Number 4, 2005. Address for correspondence and reprint requests: Philip Kuo-Ting Chen, M.D., Craniofacial Center, Chang Gung Memorial Hospital, 5, Fu-Hsin Street, Kwei-Shan, Taoyuan, Taiwan. 1Department of Plastic & Reconstructive Surgery, 2Superintendent Emeritus, 3Department of Orthodontic and Craniofacial Dentistry, Chang Gung Memorial Hospital, Taipei, Taiwan. Copyright # 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 1535-2188, p;2005,19,04,329,342,ftx,en;sps00184x. 329 330 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005 side and incomplete on the other. Kernahan’s ‘‘striped Y’’ method16 cannot fully illustrate the range and diversity of the asymmetric cleft. The double-Y numbered classi- fication, reported by Noordhoff in 1990,17 is a more accurate method for recording as well as a more suitable system for computer database documentation (Fig. 1). For patients with a complete cleft of primary and secondary palate on one side and a complete cleft of the secondary palate on the other side, this classification can record the pathology in a more accurate way than the single striped Y classification. EVALUATION OF PATHOLOGY There is a wide variation in the quality and amount of tissue in the prolabium, premaxilla, nasal cartilages, vomer, and lateral lip elements.18–22 All bilateral clefts have some amount of asymmetry in their horizontal or vertical dimensions.23 All cleft patients have a certain amount of tissue deficiencies. These deficits are most severe in bilateral medial facial dysplasia patients24 Figure 1 The double-Y numbered classification. The numbers 1 (Fig. 2), who, therefore, have a less than optimal out- to 9 represent the right side of the cleft and the numbers 11 to 19 come after lip and nose repair. They always have a represent the left side of the cleft. The number 10 represents a submucous cleft palate. It more accurately defines the nature of significant growth disturbance and require orthognathic the clefts on either or both sides of the primary palate, 1 to 9 (or surgery when they reach skeletal maturity. It is impor- 11–19) as well as either or both sides of the secondary palate, 16 tant to document these deformities or any preexisting to 19 (6–9) or any combination. asymmetry, or both, prior to surgery to assess the post- operative results more accurately. columella. Most of the recent techniques that achieve a better result use the technique of presurgical orthopedics or nasoalveolar molding to stretch the columella pre- GENERAL PLAN OF MANAGEMENT surgically and try to maintain or further lengthen it Presurgical orthopedics, nasoalveolar molding, is started surgically. on the first visit. The aim of this molding process is to centralize the premaxilla, narrow the alveolar gaps, match the alar cartilages, and elongate the columella. RECORDING OF PATHOLOGY This process usually takes 3 to 4 months to achieve an There are many possible variations of the bilateral cleft optimal outcome. The initial surgery is usually per- lip. The morphology can vary from being complete on formed at 3 to 4 months of age, depending on the result both sides to asymmetric with a complete cleft on one of the molding process. The palate is repaired at about Figure 2 A patient with a diagnosis of bilateral median facial dysplasia. (A) The patient has a relatively small premaxilla and prolabium, very deficient columella, and septal cartilage along with wide alveolar clefts. The premaxilla usually has one central incisor and a weak premaxilla-vomerine suture. (B) There is no lip frenulum. TREATMENT OF COMPLETE BILATERAL CLEFT LIP-NASAL DEFORMITY/CHEN ET AL 331 12 months of age together with the insertion of grommet tubes. Speech assessment is started at 2.5 years. If the patient requires speech therapy, it starts at 3.5 years. Velopharyngeal insufficiency is diagnosed by nasoendo- scopy at 4 years old and corrective surgery for velophar- yngeal insufficiency is performed as soon as the diagnosis is made. Residual alveolar clefts are closed before the eruption of canine teeth, usually when the child is 9 to 11 years old. If the patient has any psychological prob- lems related to any residual lip or nasal deformity, a revision surgery is usually done before the child enters primary school.17 Figure 3 A method to increase the columellar height gradually by adding silicone sheets to the domes of the nasal stent. It can be used for presurgical elongation of the columella in incomplete PRESURGICAL ORTHOPEDICS/ clefts or postoperative maintenance of the nostril configuration in NASOALVEOLAR MOLDING an overcorrected position of the columella. The purpose of presurgical orthopedics or nasoalveolar molding is to restore a more normal nasal shape and a FIGUEROA’S TECHNIQUE balanced skeletal base. The following techniques have all Alveolar molding and nasal molding are performed been used in Chang Gung Craniofacial Center for the simultaneously using an acrylic plate with rigid acrylic past 20 years. nasal extension. Rubber bands are connected to the acrylic plate for gentle retraction of the premaxilla back- ward. A soft resin ball attaching to the acrylic plate Presurgical Orthopedics across the prolabium is sometimes used to maintain the The protruding premaxilla may be gradually pushed nasolabial angle29 (Fig. 4). back by applying micropore tapes across the lip with or without traction rubber bands.25 It is suggested that the LIOU’S TECHNIQUE patient sleep in either the prone or side-lying position The nasoalveolar molding device is composed of a dental to increase pressure on the cheeks. The movement of plate, two nasal components for nasal molding, and the alveolar segments is controlled by an acrylic plate. several micropore tapes for premaxillary retraction. Den- This simple technique is effective in expanding the ture adhesive (Poligrip, Australia) keeps the dental plate prolabial tissue and places the premaxilla in a better on the maxillary lateral segments. The nasal components position.26 are made up of 0.028-inch stainless steel wire projecting forward and upward bilaterally from the anterior part of the dental plate. The top portion contains a soft resin Nasoalveolar Molding molding bulb that fits underneath the nasal cartilages for nasal molding. Micropore tapes are placed across the SILICONE NASAL CONFORMER cleft lips and prolabium to minimize the alveolar cleft A silicone nasal conformer can be used as a tool for and retract the premaxilla. At the same time, they pull presurgical nasal molding when the patient has an both alar bases medially. Retraction of the premaxilla incomplete cleft lip.27 The height of the conformer can and lengthening of the columella are performed at the be adjusted by gradually adding some soft resin or flat same time. The columella is lengthened and stretched by silicone sheets on the domes (Fig.