3 Unilateral Cleft Lip H. S. Adenwalla, P. V. Narayanan, and Karoon Agrawal ¾ Introduction ¾ Lip Adhesion ¾ Anatomical Landmarks of the Lip and Nose • Advantages • Lip • Disadvantages • Nose ¾ Lip Repair Techniques ¾ Embryology of the Lip and Nose • Millard’s Rotation Advancement Technique ¾ Surgical Anatomy of the Lip and Nose ◊ Markings • Lip ◊ Infiltrations • Nose ◊ Incisions ¾ Evaluation of the Cleft and the Nature of the ◊ The Millard “M” and “L” Flaps Deformity ◊ C Flap ¾ History and Evolution ◊ Turbinate Flap (T Flap) • Early Techniques ◊ Rotation Flap • Straight Repair ◊ Advancement Flap • Mirault Technique ◊ Lateral Mobilization • Le Mesurier Procedure • Primary Nasal Correction • Millard’s Rotation Advancement Procedure ◊ Primary Alar Cartilage Dissection ◊ Principles ◊ Primary Septal Repositioning ◊ Advantages ◊ Columella ◊ C Flap ◊ Closure of the Anterior (Hard) Palate at the Time of • Triangular Flap Repair of Tennison Cleft Lip Repair ◊ Principle ◊ Closure of Lip ◊ Advantages ◊ Postoperative Care ◊ Disadvantages ¾ Randall-Tennison-Sawhney Triangular Flap Technique • Triple Wedge Technique of Unilateral Cleft Lip Repair ◊ Advantage • Marking ¾ Principles of Cleft Lip Repair ◊ Markings on the Medial Element of Lip ¾ Goals of Treatment ◊ Markings on the Lateral Element of the Lip • Goals of Unilateral Cleft Lip Surgery • Incisions ¾ Timing and Protocol • Anterior Palate Repair 38 Cleft • Approximation and Suturing of Lip ¾ Mohler’s Modification of Millard’s Procedure • Ancillary Procedures ¾ Noordhoff-Chen Technique ¾ Role of Nasal Conformers ¾ Fisher’s Anatomic Subunit Repair ¾ Primary Gingivoperiosteoplasty Technique ¾ The Pfeiffer and Afroze Incisions ¾ Partial Cleft Lip ¾ Secondary Deformities ¾ Microform Cleft Lip • Secondary Deformities of the Lip ¾ Late Presentations • Nasal Deformities ¾ Prevention of Deformities • Timing of Secondary Repair ¾ Unsolved Problems ¾ Conclusion Introduction Type III shows convergence anywhere below the base of the columella.1 •• It was Werner Hagedorn who said, “Great things are done Cupid’s bow is the most striking aspect of the upper when art and science meet.” What better example than lip. Located at its center, it is a V­shaped bow, with an apex at the midline and high points (peaks) on the repair of a cleft lip where art meets science to forge a either side. formidable weapon for the benefit of mankind. This half art, ••White roll is a rolled­up area of skin 1 to 2 mm in half science stimulates the mind, challenges the dexterity of height, and it extends from one oral commissure to the the hand and at the same time pulls at your heartstrings. other in normal persons. The unilateral cleft lip in its many varying manifestations ••Vermillion is the portion of the lip below the white of shape, size and asymmetry is a complex deformity. To roll. It is made up of a superior dry area and inferior obtain consistent results, one requires a sound basic training wet area of mucosa. There is a red line at the junction in soft tissue handling, a proper understanding of the bony of these two areas. foundation of the face, a knowledge of the muscles of the lip, followed by experience and a fair amount of dexterity and craftsmanship. A cleft surgeon must build his house on M rock. Many of us forget in our enthusiasm that behind the complex play of muscles and soft tissues, there lies the bony K structure of the face. Great artists like Leonardo da Vinci N L realized this before we surgeons did and it was Kazanjian A B D C who told us that the so­called pretty face without a good E F bony structure disappears like the mist with the first flush of G H youth. This chapter deals with the reconstruction of the soft tissues of the lip and therefore, the readers must realize that I in itself it is incomplete. J A — Philtral column right side Anatomical Landmarks of the Lip B — Philtral column left side C — Philtral dimple and Nose D — Apex E — Peak right side Cupid’s bow Lip F — Peak left side G — Dry vermillion H — Central vermilion tubercle ••Philtral ridges or columns are raised areas ascending I — Red line of noordhoff from the height of the peak of the Cupid’s bow point J — Wet mucosa on each side toward the base of the columella. Their K — Columella configuration varies in different people (Fig. 3.1). L — Alar base M — Nasal ala Type I shows divergence of the column at the base of N — Nasal sill the columella. Type II shows convergence at the base of the columella. Fig. 3.1 Anatomical landmarks of the lip and nose. Unilateral Cleft Lip 39 Nose Surgical Anatomy of the Lip and Nose ••Columella is the central column extending from the base to the nasal tip in the midline. Lip ••Nasal sill is the raised fold on either side extending The orbicularis oris muscle has a superficial part originating from the lateral part of the columella to the alar base. from bone (maxilla, mandible, and also the nasal septum) ••Alar bases are at the lateral most part of the nose. and a deep part arising from the facial muscles like the ••The two ala arch symmetrically on each side from the buccinator. In an incomplete unilateral cleft lip, the muscle nasal tip. fibers cross across the lip if there is at least half of the lip that is not cleft. In more severe cases, there is no crossover of the Embryology of the Lip and Nose muscle bundles. In complete cleft lips, the muscle ascends along the cleft margin to the base of the ala laterally.3 These abnormal Toward the end of the first week of gestation, facial pro­ attachments must be released during the lip repair. Medially, minences formed principally by the first pharyngeal the fibers ascend along the cleft margin to the base of the arches appear. Lateral to the stomodaeum, the maxillary columella (Fig. 3.2). These muscle fibers are arranged in a prominences appear and caudal to this the mandibular pro­ disorganized manner. For further detail, refer to Chapter 1 minences are formed. The frontonasal prominence forms on Cleft Lip and Palate: An Anatomical and Physiological on the upper border of the stomodaeum. Nasal placodes Overview in Volume III. are ectodermal thickenings formed on either side of the Release of these improper attachments of the muscle and frontonasal prominence. These placodes deepen into nasal the union of the muscle with its counterpart on the other pits with medial and lateral nasal prominences formed on side of the cleft forms an important aspect of cleft lip repair. either side of the pits by the fifth week on each side. The maxillary prominence fuses with the medial nasal pro­ minence of that side, forming the upper lip by the seventh Nose week. The lateral nasal prominences have no contribution The hemi columella is shorter on the cleft side as compared to the formation of upper lip. The medial nasal prominences to the noncleft side (Fig. 3.3). The ala on the cleft side is of the two sides form the philtrum and Cupid’s bow. Failure depressed and buckled. There is a flare of the ala which of fusion of the medial nasal prominence with the maxillary manifests as a wide nostril. The medial crura on the cleft prominence on one side results in a unilateral cleft lip2; and side is placed at a lower level. failure of fusion on both sides will end in a bilateral cleft lip. The anterior nasal spine is displaced toward the noncleft In the nose, the bridge is formed by the frontal promi­ side and the nasal septal cartilage is also deviated to nence, the tip is formed by the fused medial nasal pro­ the noncleft side anteriorly. Huffmann and Lierle4 have minences and the ala is formed on each side from the lateral extensively described the cleft lip nasal stigmata. For nasal prominence. further detail, refer to Chapter 1 on Cleft Lip and Palate: An For further details, please refer to Chapter 13 on Anatomical and Physiological Overview in Volume III. Development of the Craniofacial Complex, Anatomy, and Congenital Anomalies in Volume III. C E A B F D A — Medial crus placed at a higher levev on non cleft side. B — Lateral crus on the lower lateral cartilage depressed and buckled on the left side. C — Lateral crus on non­cleft side. D — Anterior nasal spine displaced to the non cleft side. E — Septum deviated to the non cleft side anteriorly. F — Flaring of the alar base. Fig. 3.2 Orbicularis oris. Fig. 3.3 Surgical anatomy of the lip and nose. 40 Cleft Evaluation of the Cleft and the Nature the soft tissue deformity is only a partial one, not involving the nasal sill or floor, the alveolus may be of the Deformity grooved. One has to decide on the need for mobilization of the lateral elements in these patients. There may ••The child is carefully evaluated to determine the nature be a bridge of skin between the two sides of the cleft of the cleft whether unilateral or bilateral (Box 3.1). lip. This is known as a Simonart’s band (Fig. 3.5). Its Some children with unilateral cleft may have a barely presence reduces the severity of the deformity and discernible microform cleft of the other side. These aids in better alignment of the bony segments, thus may become more pronounced after the repair of the acting like an orthodontic appliance5 and this band complete cleft. Hence, it is important to identify and was further used by Millard in the repair. also counsel the parents about this (Fig. 3.4a–c). ••In patients with gross disparity between the levels of The microform clefts are usually repaired at a separate the medial and lateral maxillary segments, there can be sitting.