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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 1  |  Page : 107-113

Different modalities for the management of bilateral cleft lip


1 Department of Plastic and Reconstructive Surgery, Menoufia University Hospital, Menoufia, Egypt
2 Department of General Surgery, Menoufia University Hospital, Menoufia, Egypt

Date of Submission11-Oct-2014
Date of Acceptance28-Nov-2014
Date of Web Publication29-Apr-2015

Correspondence Address:
Mohammed S AboShaban
Shebin Elkoom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.155962

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  Abstract 

Objectives
The aim of this randomized prospective trial was to evaluate the different modalities for the management of bilateral cleft lip including primary and secondary deformities.
Background
Cleft lip repair will remain the aim of cleft surgeons. The complexity of deformity and the delicate interrelation between muscular arrangement and external lip features require a comprehensive approach for proper management. This study describes technical refinements in the skin design and modifications in the muscle repair in bilateral cleft lip.
Materials and methods
From January 2012 to April 2014, 16 patients with bilateral cleft lip deformities received surgical treatment in the form of either (group A, n = 10 patients) closure of the primary cleft according to the type and amount of protrusion of the premaxilla or (group B, n = 6 patients) repair of secondary deformities according the presentation. Demographic data, operative time, post, hospital stay, duration of incapacity for work, postoperative complications (infection, wound dehiscence, hypertrophic scar), symmetry, vermillion red alignment, quality of the scar, and patient satisfaction were recorded.
Results
The overall results were very satisfactory in function and appearance, without major complications. The lip adhesion procedure was performed at the age of 2-8 weeks postnatally, definitive lip closure at the age of 3-6 months (primary repair 10 cases), and secondary repair at the age of 2 years until adulthood (secondary repair six cases). Wound dehiscence occurred in two cases that healed spontaneously without intervention.
Conclusion
This method of comprehensive primary muscle, soft tissue, and skin reconstruction in bilateral cleft lip addresses the major sites of distortion in the lip, sulcus, and nasal floor, producing a full central segment, prominent philtral ridges, adequate white roll, and thick vermilion with a seam-like median tubercle in addition to a deep gingivo-labial sulcus and alar base symmetry. Nasal deformity postponed with secondary repair.

Keywords: Bilateral, cleft lip, deformities, modalities


How to cite this article:
Keshk TF, Omar AA, Elsaka DM, Elsheikh YM, AboShaban MS. Different modalities for the management of bilateral cleft lip. Menoufia Med J 2015;28:107-13

How to cite this URL:
Keshk TF, Omar AA, Elsaka DM, Elsheikh YM, AboShaban MS. Different modalities for the management of bilateral cleft lip. Menoufia Med J [serial online] 2015 [cited 2019 Sep 20];28:107-13. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/107/155962


  Introduction Top


Cleft lip and cleft palate together are the most common congenital facial defects that manifest in about one in every 800 live births, and the majority occur in males. Combined lip and palatal defects represent 86% of cases, whereas isolated bilateral clefts of the lip are distinctly uncommon [1].

Embryonic development of the primary (lip and alveolus) and secondary (hard and soft) palates occurs between the 6th and 9th week of human development. CL/P results from failure of the medial nasal process to contact or to maintain contact with the lateral nasal and maxillary processes and, therefore, constitute a disruption of normal development [2].

When examining a newborn with cleft lip, it is important to look for evidence of other congenital abnormalities [3]. In case of associated life-threatening congenital anomalies or illness, delay of surgical intervention is preferred. Safety of the patient takes priority over any urgency to repair a cleft lip [4]. In an otherwise healthy infant, a cleft lip can be repaired at any age. The rule of tens is a widely accepted guideline for initiating surgical treatment: 10 weeks age, 10 pounds in weight, and 10 g/dl of hemoglobin [5].

Repair of a bilateral complete cleft lip (BCCL) and nasal deformity represents a challenge in plastic surgery. The challenge is to construct the nasolabial complex in three dimensions, incorporating soft and hard tissue and anticipating four-dimensional changes in growth and distortion [6].

The traditional strategy for correction of the BCCL is staged operative repair. The primary focus, however, has always been on closure of the lip, with nasal deformities postponed for 'secondary' repair, commonly until childhood or early adolescence [7].

Although techniques have continued to evolve over the decades, the basic principles of cleft surgery remain the same. The main principles are to attain muscular continuity, to achieve an appropriate philtral size and shape, to position the cartilages in a more optimal position, and to ensure symmetry for optimal appearance and function [8].

Ideally, bilateral cleft lip nasal repair should include the following features:

  1. A single-stage operation at primary lip repair,
  2. A nose that is esthetically pleasing, falling within the normal anthropometric range and normal physiologic function,
  3. Technically reasonable with a low complication rate and little need for secondary corrective surgery or highly specialized appliances,
  4. Minimal scarring that is hidden as much as possible,
  5. No interference with growth, and
  6. Be a cost-effective procedure that equates the burdens and demands on the patient and caregivers with the final results [9].


Thus, the aim of this study was to evaluate the different modalities for the management of bilateral cleft lip deformities including primary and secondary repair according to age and shape of deformity.


  Materials and methods Top


This was a prospective study carried out on 16 patients with bilateral cleft lip deformity presenting to Menofia University hospital during the period from June 2013 to June 2014. There were 12 males and four females, classified according to the type of repair into 10 patients subjected to primary repair at age ranging from 40 days to 6 months in the form of lip adhesion, modified Millard, osslu technique, osslu and six patients at age ranging from 2 to 17 years subjected to secondary repair in the form of Bardach's technique and open rhinoplasty. Informed consent was obtained from all patients included in the study, which was approved by the local ethics committee. All patients were evaluated for family history, history of drug intake, and associated congenital anomalies. The general condition of the patients was evaluated: type: cleft lip only, cleft lip/alveolus, and cleft lip/palate; symmetry: symmetrical or not, and complete or incomplete. The following preoperative investigations were performed: complete blood picture and bleeding profile.

Patient preparation

Preoperative evaluation of the general condition of the patients was performed by a pediatric physician as a guideline for initiating surgical treatment: 10 weeks of age, 10 pounds in weight, and 10 g/dl of hemoglobin.

Surgical procedures

Anesthesia

General anesthesia was induced with an endotracheal tube placed and taped at the midline of the chin. The tube was further immobilized with a mouth pack.

Patient positioning

The patient was placed in a supine position. Head ring and shoulder rolls were placed. Sterile tapes were placed over the closed eyelids. The face was prepared and draped.

Lip adhesion

The adhesion is a straight-line muscle repair and begins with the complete marking of a rotation advancement chelioplasty. An L (lateral) flap is elevated from the lateral segment beginning ~3 mm medial to the Cupid's bow peak. This flap length provides adequate tissue for nose release. The L-flap is sutured into the nasal defect and the lateral lip element is advanced medially for closure. An M (medial) flap is also raised 3 mm from the Cupid's bow peak to maintain symmetry of repair. All dissection is maintained outside the margins for primary lip repair. No medial muscle dissection is performed at this stage. Closure is achieved with vicryl sutures placed in the undissected orbicularis layer along the pared margin and mucosal closure between the M (medial) flap and the lateral lip mucosa.

Bilateral modified millard

Reference points are marked using methylene blue on a sharpened applicator stick. The borders of the philtral flap (A) are designed to ultimately resemble the dimensions of a normal philtrum. The inferior border of the philtral flap (A) is placed 1 mm below the vermilion-cutaneous junction, two superiorly based forked flaps (C) adjacent to the philtral flap (A). The forked flaps (C) are kept thin and are elevated in the subdermal plane; this preserves the normal anatomic ridge and results in an improved postoperative scar. The central portion and two lateral strips of the skin of the prolabium are raised. The orbicularis oris muscle is dissected from the skin on both sides. All incisions are completed and ready for suture closure. The floor of the nose is closed and the mucosa from the lateral lip elements is sutured to the mucosa from the prolabium. The orbicularis oris muscle is sutured together, and the vermilion flaps are prepared for reconstructing the vermilion. The vermilion is ready for closure. Final closure of bilateral cleft lip/nose is performed.

Osslu technique

Superior-based vomerine flap incised then transverse mattress suture until reaching floor of nose closing the defect.

Bardach's technique for secondary repair

Correction of the midportion of the lip is based on the principle of using lateral lip elements for lengthening the central portion of the lip by downward advancement and rotation. In some cases of secondary bilateral cleft lip deformity with a very short prolabium and severe whistle deformity, lip reconstruction can be performed using another of Bardach's designs in which the central portion of the lip (in the form of a triangle) is moved downward and the defect created is filled with triangular lip flaps from the lateral lip elements that cross each other. The incision starts at the base of the ala on one side and is carried through skin, muscle, and mucosa into the sulcus, and then beneath the base of the columella to the base of the ala on the other side. From this incision in the midline, two divergent incisions are carried downward to the peaks of the Cupid's bow. In this manner, the existing part of the prolabium is moved downward, creating defects beneath the base of the nose or on both sides of the prolabium. By interdigitating the lateral lip elements, all defects are closed.

Open rhinoplasty

An open approach is used with exposure of the lower lateral cartilage, and a horizontal mattress suture on the scored area of the reverse-U flap that modifies the concave shape for easy redraping into the concave nasal surfa to create a symmetrical nasal tip, costal cartilage graft make umbrella and columellar strut used for projection of the nasal tip, undermining and redraping the skin of the nose. Suturing of mucosa by vecrile 5/0 and skin by prolene 6/0, internal nasal retainer placed bilateral.

Postoperative care and follow-up

For all operated patients, the following was carried out: soft arm restraints were placed on the patient at the completion of the lip repair. These were used for 2 weeks to prevent any trauma. All patients were kept in the hospital overnight until adequate oral intake was achieved. Feeding was performed using a syringe with a soft-tipped catheter for 5-7 days. No nipples or pacifiers were used for 1 week. Oral antibiotics were administered for 7 days postoperatively. The parents were instructed to clean the wound and apply an antibiotic cream twice daily, and to use nasal drops and an oral antifungal gel. The sutures were removed 7 days postoperatively. Postoperative massage of the scar was started 2 weeks after the operation and was continued for 8 weeks, twice daily, to soften the scar. The first follow-up visit was after 1 week to remove stitches, the next visit was at 3 weeks after sutures removal to ensure no immediate postoperative complication, followed by routine interval plastic surgery and craniofacial team visits.


  Results Top


The study included 16 patients divided into two groups; their age ranged from 40 days to 17 years, mean age 4.87 ± 6.42. The maternal age range was 20.0-38.0, mean ± SD 28.68 ± 5.60. The patients presented by cleft lip and palate 13 (81.2%) represent the majority of cases. A positive family history and consanguinity were present in 31.1% of the patients. The presence of associated congenital anomalies was found in only one case (6.2%) of nonsignificant hazards [Table 1].
Table 1: Distribution of the characteristics of the studied patients

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According to the type of cleft, the majority of the patients, 13 (81.2%), had bilateral complete cleft, complete at one side and incomplete at the other side 2 (12.5%) and bilateral incomplete one case only (6.25%).

All patients were classified for primary repair: 10 patients for lip adhesion, 18.8%, Millard technique, 31.2% [Figure 1], and Osslu, 12.5% [Figure 2], and patients were classified for secondary repair for lip revision, 25% [Figure 3], and open rhinoplasty, 12.5% [Figure 4], as shown in [Table 2].
Figure 1: Modified Millard technique .

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Figure 2: Osslu technique (superior-based vomerine flap) .

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Figure 3: Secondary lip revision technique .

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Figure 4: Open rhinoplasty (costal cartilage graft) .

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Table 2: Distribution of the characteristics and outcome of the patients studied

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The results were evaluated after 6 months for symmetry of the lip and nose, vermilion and red line alignment, quality of the scar postoperatively and scar mobility, and parents' satisfaction. These factors were assigned a score for evaluation by the surgeon and the patients' parents. Postoperative complications occurred in the form of wound dehiscence in two patients and a hypertrophic scar in three patients, which were treated conservatively by dressing and local creams without surgical intervention [Table 3].
Table 3: Distribution of the studied operation groups in terms of group classifi cation

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  Discussion Top


Repair of a BCCL and nasal deformity is a challenge in plastic surgery. The challenge is to construct the nasolabial complex in three dimensions, incorporating soft and hard tissue and anticipating four-dimensional changes of growth and distortion [10].

The different techniques have continued to evolve over the past decades; however, the basic principles of cleft surgery remain the same. The main goals are to attain muscular continuity, to achieve an appropriate philtral size and shape, to place the cartilages in a more optimal position, and to attain symmetry for optimal appearance and function [11].

Brown et al. introduced their 1947 article with the brief statement that a bilateral cleft lip is twice as difficult to repair as a unilateral cleft and the results are only half as good. Indeed, techniques for correction of a bilateral cleft lip have lagged behind those for a unilateral cleft lip. Infants with bilateral cleft lip generally undergo multiple procedures, only to undergo various revisions throughout childhood and early adulthood for example, rhinoplasty [12]. In our study all cases either with primary repair will need other stages for cleft palate and nose deformites or patients with secondary repair do multistage-operative repair (lip revision, rhinoplasty) untill the age of adulthood searching for better aesthetic and function results.

Over the past decade, two important advancements have been made in the repair of bilateral cleft lip and nasal deformity:

(a) Evolution to single-stage nasolabial closure with positioning of the alar cartilages and sculpting of the soft tissues to shape the columella and nasal lobule, and

(b) Improved techniques for presurgical maxillary alignment to enable closure of the alveolar clefts and facilitate primary nasolabial repair.

Although the principles for single-stage repair are established, craftsmanship continues to evolve [12].

The traditional strategy for correction of the BCCL is staged operative repair. The primary focus has always been on the closure of the lip, with nasal deformities postponed for 'secondary' repair, commonly until childhood or early adolescence. These delayed or secondary surgical efforts are usually termed 'columellar lengthening' procedures [13]. In our study patients with primary deformities, we performed lip repair, with postponed nasal deformities to adolescence, we think that leaving a virgin anatomy without distortion or scarring is better choice as most of the cases needs multistage procedures.

A preliminary lip adhesion was originally advocated by Millard and colleagues to bring the maxillary elements into satisfactory alignment before the lip is closed by surgical means. Lip closure using lip adhesion reduces the tension of the lip closure and renders a complete cleft into an incomplete one with a symmetrical nasal platform. It also achieves the main goal of moving the cleft lip and palate into a normal position. It avoids the difficult anterior fistulae and presents a more symmetrical platform on which the lip can be united and the nose can be corrected early. Lip adhesion retracts the premaxilla in an uncontrolled manner and does not mold the nasal cartilages [14]. In our study, patients with a premaxillary projection of more than 8 mm underwent lip adhesion at age of 6-8 weeks to reduce tension of the lip and to enable good repositioning of the premaxilla for further repair.

Initially, Mulliken performed a two-stage correction of BCCL. In the first stage, he designed a much smaller philtral flap than that of other surgeons. Like Millard, he banked the tines of the forked flap. In the second stage, the tines were transposed intranasally to yield tip projection. The alar cartilages were opposed and suspended through rim incisions and a vertical tip incision. Mulliken's principles remained unchanged, but his techniques evolved. He realized that the forked-flap tissue was not needed to build the columella. Thus, he was able to achieve a single-stage nasolabial repair and construct a normal columella. Later, he stopped using the nasal tip incision as he was able to position and secure the alar cartilages through only the rim incisions [15].

Mulliken made it clear that the columella is in the nose. Accordingly, the columella in the BCCL seems short because of an abnormally placed medial angle and dome of alar cartilage. Therefore, there is no need to take any tissue from the nose or lip as it does not lack skin [15]. In our study, we used the forked-flap procedure of the Millard technique for single-stage repair; excess skin from the prolabium was banked into the floor of the nose not used for columellar lengthening. We believe that optimum results can be achieved using this procedure, especially with wide supra periosteal dissection, mobilization, and repositioning of the alar base.

Results were evaluated after 6 months for symmetry of the lip and nose, vermilion and red line alignment, quality of the scar postoperatively, and parents' satisfaction. These factors were assigned a score for evaluation by the surgeon and the patients' parents.

Early postoperative complications in the form of wound dehiscence occurred in two cases, which were treated conservatively by dressing and use of creams to promote healing without surgical intervention, and late complications in the form of hypertrophic scar occurred in three patients, which were treated by local antiscar creams and silicone sheet.

Repair of a bilateral cleft lip is characterized by several different treatment protocols that are often associated with poor long-term outcomes. Controversy on the merits of one-stage against two-stage repair, preliminary lip adhesion, dissection of nasal cartilage, and presurgical orthopedics has interfered with the development of any discernible uniformity in treatment [16]. There is no doubt that primary rhinoplasty with reshaping of the alar cartilage and direct suturing can produce satisfactory early results, but they are not always predictable. An open approach to the alar cartilage allows for nasal reshaping and may contribute toward better and more predictable outcomes, but concern over the long-term effects of such radical primary nasal surgery still remains [17]. Previous attempts of primary repair of bilateral cleft nasal deformity have not been enough. Accordingly, we attempted through this study to assess whether primary repair of bilateral cleft nasal deformity is useful or not; in the absence of presurgical orthopedics of the premaxilla, we classified patients for primary repair with the choice of technique according to age, amount of premaxillary projection, and type of cleft and secondary repair with the choice of technique according to the presentation of deformities with postponed nasal deformities to adolescence.

We think that leaving a virgin anatomy without distortion or scarring is a better choice as most of the cases need multistage procedures; the primary focus has always been on the closure of the lip, with nasal deformities postponed for 'secondary' repair, commonly until childhood or early adolescence.

Cleft care requires the coordination of the medical team and the awareness of the family of the deformity. With patience, time, a well-planned intervention, and a dedicated professional team, many of the stigmata of the primary deformity can be corrected and many of the iatrogenic secondary deformities can be avoided.


  Conclusion Top


This comprehensive study of primary muscle, soft tissue, and skin reconstruction in bilateral cleft lip addressed the major sites of distortion in the lip, sulcus, and nasal floor, producing a full central segment, prominent philtral ridges, adequate white roll, and thick vermilion with a seam-like median tubercle, in addition to a deep gingivo-labial sulcus and alar base symmetry. Nasal deformity postponed with secondary repair.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

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2.
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Forbes GB. Pediatric nutrition hand book. 2nd ed. Elk Grove Village: American Academy of Pediatrics; 1985. 12-16.   Back to cited text no. 3
    
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Andre Panossian and David Fisher. . B Bauer, R Zuker, M Bentzeds. Bilateral cleft lip repair. In:Principles and practice of pediatric plastic surgery. St Louis, MO: Quality Medical; 2008. 460.  Back to cited text no. 4
    
5.
Bardach J, Salyer K. Surgical techniques in cleft lip and palate. 2nd ed. St Louis, MO: Mosby Co.; 1991. 65-192.  Back to cited text no. 5
    
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Mulliken JB. Bilateral cleft lip. Clin Plast Surg 2004; 31 :209-220.   Back to cited text no. 6
    
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Mulliken JB. Repair of bilateral complete cleft lip and nasal deformity. Cleft Palate Craniofac J 2004; 37 :342-347.   Back to cited text no. 7
    
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Pham AM, Senders CW. Management of bilateral cleft lip and nasal deformity. Curr Opin Otolaryngol Head Neck Surg 2006; 14 :278-282.   Back to cited text no. 8
    
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Grayson BH, Shetye PR. Presurgical nasoalveolar moulding treatment in cleft lip and palate patients. Indian J Plast Surg 2009; 42 :S56-S61.  Back to cited text no. 10
    
11.
Bardach J. Bardach J, Morris HLeds. Bilateral cleft lip repair.In:Multidisciplinary management of cleft lip and palate. Philadephia, PA: WB Sauders Co 1990; 31 :298-322.  Back to cited text no. 11
    
12.
Afifi GY, Hardesty RA. Craig AV, Edwin GW, Victoria MVeds. Bilateral cleft lip. In:Plastic surgery; indications operations and outcomes, vol. 2, craniomaxillofacial, cleft, and pediatric surgery. St Louis, MO: Mosby Co.; 2000. 796-797.   Back to cited text no. 12
    
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Mulliken JB. Primary repair of bilateral cleft lip and nasal deformity. Plast Reconstr Surg 2001; 105 :181.   Back to cited text no. 13
    
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Charles J. Repair of bilateral cleft lip deformity. Facial Plast Surg 2007; 100-106.   Back to cited text no. 14
    
15.
Kim SK, Lee JH, Lee KC, Park JM Mulliken method of bilateral cleft lip repair: anthropometric evaluation. Plast Reconstr Surg 2005; 116 :1243-1251discussion 1252-1254.  Back to cited text no. 15
    
16.
Penfold C, Dominguez-Gonzalez S. Bilateral cleft lip and nose repair. Br J Oral Maxillofac Surg 2011; 49 :165-171.  Back to cited text no. 16
    
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Xu H, Salyer KE, Genecov ER. Primary bilateral one-stage cleft lip/nose repair: 40-year Dallas experience: part I. J Craniofac Surg 2009; 2: 913-1926.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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