Millard believed that this typically was caused by inadequate rotation of the medial flap, but it led him to introduce the addition of a back-cut at the top of the rotation incision to enable greater downward movement of the medial lip segment. The function of the C-flap then evolved to fill the defect created by the back-cut, and thus to lengthen the columella. Several surgeons have advocated the addition of a small triangular or rectangular flap from the lateral element into the lower part of the repair to provide additional length, break up the line of the incision, and preserve the contour of the vermilion.
He and others also advocated the incorporation of a triangular lateral vermilion flap to augment the deficient vermilion of the medial lip segment. Some surgeons have objected that the scar produced by the Millard repair obliquely and unnaturally crosses the philtrum in the upper third of the lip. In he reported a study of philtral shape in school children without clefts. He classified them into three groups based on whether the philtral columns were divergent or convergent and, in the latter case, whether they converged at or below columellar-lip junction Fig.
He subsequently altered the design of his repair for such patients in the superior portion of the lip so as to mirror the philtral shape on the noncleft side. In his technique, the rotation incision is drawn in a curvilinear fashion to mimic the shape of the normal philtral column and extended into the base of the columella.
A degree back-cut is made in the columella without crossing the normal philtral column, allowing downward rotation of the medial lip segment. The C-flap is advanced into the defect at the columellar base and used to lengthen the shortened columella on the cleft side 44 Fig.
A more recent addition to cleft lip repair techniques is the anatomic subunit approximation technique, described by David Fisher 47 from the Hospital for Sick Children in Toronto, who published this technique in Using both the principle of Rose-Thompson lengthening as well as a lower Randall-Tennison type of triangular flap, Fisher designed this repair to maintain the scars at the seams of the anatomic subunits of the lip and nose Fig.
Modifications and long-term results of this technique, which are described in detail in a later chapter, have recently been reported by others. The incisions used have evolved from a straight-line closure on each side to various types of flaps like those used in unilateral clefts. Historically, many surgeons would simply replicate their unilateral repair patterns on each side.
Some brought flaps back from the lateral side of the cleft to the midline below the prolabium to lengthen the central lip. In William Rose pared the central tubercle in a V-shaped manner and curved his incisions in the lateral segments, bringing them together in the midline below the apex of the central segment.
Le Mesurier applied his quadrilateral flap design to the bilateral defect, also transposing flaps below the prolabium. Brown, McDowell, and Byars introduced a pair of triangular flaps that were brought together under the prolabium and described several variations to accommodate either a long or short prolabium.
Louis Schultz of Chicago contributed significantly to the bilateral repair in the s by emphasizing the importance of muscle approximation from the lateral elements behind the central prolabial segment. As early as , Pierre Joseph Desault of Paris advocated surgical closure of both sides at the same time after initial premaxillary compression by a cloth bandage. He pared the cleft edges, approximated the lip segments using the prolabium for the central portion of the lip, and fixed the repair with through-and-through sutures in a figure-eight fashion.
Other surgeons were in favor of a staged repair of the bilateral cleft deformity. These surgeons choose to close the wider cleft first to pull the deviated premaxilla back to the midline. The protruding premaxilla was one of the first challenges in the history of the bilateral lip repair. In early repairs, it often was excised completely, leading to a loss of incisors, collapse of the lateral maxillary segments, severe restriction of anterior maxillary growth, and a marked anterior cross bite Fig.
Pancoast 53 did not excise the premaxilla, but instead forcefully fractured it to a better position. Other historic attempts to reposition the protruding premaxilla have included removal of the buccal plate of the alveolus, usually with destruction of the incisor teeth.
More recently, orthodontic appliances have been used to reposition the premaxilla. This has been done both actively with screw attachments for retropositioning the premaxilla and for repositioning the lateral maxillary segments and passively with staged dental plates.
This approach has now reached a high degree of sophistication and has evolved to include additional appliances to reshape the nasal tip cartilages and to lengthen the columella. The lip adhesion procedure was another method developed to reposition the protruding premaxilla. First described by Gustav Simon in , this procedure attached flaps from the lateral lip segments to the prolabium to reshape the lip and underlying alveolus before definitive lip repair.
In addition to repositioning the premaxilla, the adhesions also acted as tissue expanders of the prolabium, creating more tissue in the central lip segment. Only gold members can continue reading.
Log In or Register to continue. In most cases, this is a Latham-type appliance. A dentist inserts this device in the operating room when a child is around 2 or 3 months old. You will need to turn a small screw on the device to slowly bring the gums together. The device is removed at the time of either lip-nasal adhesion or complete cleft lip repair. For some children with unilateral cleft lip who have more severe nasal asymmetry, nasal molding may be recommended.
This device slowly rounds and elevates the nasal cartilage to improve nasal shape and can be used with or without a Latham-type appliance. For some children with a unilateral cleft lip, the first operation recommended is a lip-nasal adhesion.
This operation is performed at about 3 months of age, and involves:. When a single operation is recommended, either for unilateral or bilateral cleft lip, it typically occurs when the child is between 3 and 5 months of age. During this operation, the baby's nasal asymmetry unevenness in the shape of the nose is also corrected. A plastic surgeon uses the existing muscle and tissues of your child's lip and nose to close the cleft.
Repair of a unilateral cleft lip is performed in the operating room under general anesthesia. Your child will stay in the hospital for one to two nights after the operation.
In children for whom two operations are recommended, the first is lip-nasal adhesion. The second operation is a more comprehensive repair of the cleft lip and correction of the nose. This procedure usually takes place around three months later, at 5 to 6 months of age.
After the operation, your child's lip, nose, and face will be swollen for a few days. The scar may be red for several months. It will take 6 to 12 months for the scar to soften and fade. Although it will never completely disappear, in time, the scar will become difficult to see. Your child's lip and nose will be nearly normal in appearance after the swelling and scar have subsided.
Unilateral complete cleft lip and palate before repair left and after nasal molding with DynaCleft, alveolar correction with a Latham appliance, single-stage cleft lip repair, and cleft palate repair. It's done in the hospital while the baby is under general anesthesia. If the cleft lip is wide, special procedures like lip adhesion or nasal alveolar molding NAM might help bring the parts of the lip closer together and improve the shape of the nose before the cleft lip repair.
Cleft lip repair usually leaves a small scar under the nose. A cleft palate usually is repaired with surgery called palatoplasty PAL-eh-tuh-plass-tee when the baby is 10—12 months old. The goals of palatoplasty are to:. This surgery requires general anesthesia and takes about 2—3 hours.
Most babies can go home after 1 or 2 days in the hospital. The stitches will dissolve on their own. Your child will need a liquid diet for a week or two, then will eat soft foods for several more weeks before going back to his or her regular diet. You may be asked to keep your baby in special sleeves "no-nos" that prevent the elbows from bending.
This is so your baby can't put any fingers or hard objects into the mouth, which could make the cleft palate repair come open. Cleft lip and palate surgeries have greatly improved in recent years. Most kids who undergo them have very good results. There are risks with any surgery, though, so call the doctor if your child:. It's important to work with a care team experienced in treating children with cleft lip and palate. Besides the pediatrician, a child's treatment team will include:.
Some kids with cleft lip and palate may need other surgeries as they get older. These might include:. Most kids with cleft lip and palate are treated successfully with no lasting problems. A team experienced in treating children with cleft lip and palate can create a treatment plan tailored to your child's needs.
The psychologists and social workers on the treatment team are there for you and your child. So turn to them to help guide you through any hard times. You also can find more information and support online:.
Reviewed by: Brian C.
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