1. In the name of God

2. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate

3. Introduction Orofacial clefts are the most common craniofacial birth defects Cleft lip ± cleft palate is epidemiologically & etiologically distinct from isolated cleft palate Cleft LipCleft Palate

4. Differences Cleft LipCleft Palate YesEthnicity effectNo YesSocioeconomic statusNo MaleGender preferenceFemale 25 %Syndromic rate50 % 1 in 1000Incidence1 in 2000 Concordance of cleft in monozygotic twins is 50% Differences

5. Classification Complete or Incomplete entire vertical thickness of upper lip often associated with an alveolar cleft Cleft LipCleft Palate Classification

6. Complete or Incomplete Unilateral or Bilateral Cleft LipCleft Palate Classification

7. Complete or Incomplete (incisive foramen) Primary or Secondary Unilateral or bilateral Cleft LipCleft Palate Classification

8. Team work Cleft LipCleft Palate Otolaryngologist Maxillofacial surgeon Orthodontist Speech pathologist Audiologist Psychologist Nurse Plastic surgeon Team work

9. airway management otologic care evaluation of velopharyngeal insufficiency facial reconstructive surgeon Cleft LipCleft Palate Otolaryngologist

10. Feeding The most immediate concern in the care, other than the airway, is nutrition. Early swallowing therapy is required in infant with complete cleft palate to ensure near-normal feeding Cleft LipCleft Palate Feeding

11. – squeeze bottles with cross-cut nipples – Aerophagia – fail to gain weight – excessive aerophagia Cleft LipCleft Palate Palatal obturator Frequent burping Haberman feeder Feeding

12. When to Treat Cleft lip : the rules of ten: – weight at least 10 pounds – Hb at least 10 g – WBC count less than 10,000/mm3 – age more than 10 weeks Cleft LipCleft Palate When to Treat

13. Cleft lip : – wide complete clefts with marked premaxillary protrusion  staged repair lip adhesion performed at age 3 months definitive repair performed at age 5 to 6 months Cleft LipCleft Palate When to Treat

14. Cleft Palate Speech outcome or Facial growth This is a question? Cleft LipCleft Palate Proposed time is roughly 1 year old When to Treat

15. surgery freshening and approximation of cleft edges curved incisions to allow lengthening of lip – straight-line closure numerous geometric repairs – produced scars that violated the philtrum) Millard rotation-advancement technique Cleft LipCleft Palate Surgery

16. surgery Millard method: Cleft LipCleft Palate Surgery

17. surgery Millard Advantages: scar along the natural philtral border more flexible than geometric closures complete muscular repair and primary cleft rhinoplasty minimizes the discarding of normal tissue Millard Disadvantages: extensive undermining risk for nostril stenosis on the cleft side Cleft LipCleft Palate Surgery

18. surgery Rhinoplasty – primary rhinoplasty (at the time of lip repair) – intermediate rhinoplasty correct any residual lower cartilaginous deformity – V-Y advancement flaps from upper lip lengthen columella – Y-V alar advancement to narrow alar base, with fixation of base to nasal spine with permanent suture – Delayed rhinoplasty (after puberty) correct any bony dorsal deformity or nasal obstruction Cleft LipCleft Palate Surgery

19. surgery Complications – Notch in the vermilion – Malalignment of Cupid’s bow (whistle deformity) – Absence of median tubercle and part of Cupid’s bow Rx : Z-plasty c Cleft LipCleft Palate Surgery

20. surgery Goals – Closure of oronasal communication – (velum) Correct speech pathology mobility depends on six paired muscles (normally insert on soft palate) Cleft LipCleft Palate Surgery

21. surgery Cleft LipCleft Palate Surgery

22. surgery primary veloplasty (Schweckendiek) Cleft LipCleft Palate Surgery

23. surgery primary veloplasty (Schweckendiek) bipedicled flap palatoplasty (Von Langenbeck) Cleft LipCleft Palate Surgery

24. surgery primary veloplasty (Schweckendiek) bipedicled flap palatoplasty (Von Langenbeck) V-Y pushback palatoplasty (Oxford) unipedicled two-flap palatoplasty (Bardach) double-opposing Z-plasty (Furlow) Cleft LipCleft Palate Surgery

25. surgery Cleft LipCleft Palate Surgery

26. surgery primary veloplasty (Schweckendiek) bipedicled flap palatoplasty (Von Langenbeck) V-Y pushback palatoplasty (Oxford) unipedicled two-flap palatoplasty (Bardach) double-opposing Z-plasty (Furlow) Cleft LipCleft Palate Surgery

27. surgery Cleft LipCleft Palate Surgery

28. surgery primary veloplasty (Schweckendiek) bipedicled flap palatoplasty (Von Langenbeck) V-Y pushback palatoplasty (Oxford) unipedicled two-flap palatoplasty (Bardach) double-opposing Z-plasty (Furlow) Cleft LipCleft Palate Surgery

29. surgery Cleft LipCleft Palate Surgery

30. Complications – The most common : velopharyngeal insufficiency – Oronasal fistula Technical error Severity of cleft – airway obstruction Pressure of mouth gag during surgery Cleft LipCleft Palate Surgery

31. Postoperative care Continuous pulse oximetry for first 24 to 48 hours Intravenous hydration Intr venous pain medications (+ acetaminophen supp) Arm splints (first 2 wks) Clear liquids by syringe or cup on first day (1 to 2 wks) Discouraging nipple feeding Cleft LipCleft Palate Postoperative Care

32. Develops within the first months of life Frequency decreases with increasing age Due to abnormalities of cartilage and muscles surrounding the eustachian tube Cleft LipCleft Palate Otitis media

33. Abnormalities of cartilage and muscles – Hypoplasia of the lateral cartilage relative to the medial cartilage – The curvature of the eustachian tube lumen – width and angulation of skull base with respect to eustachian tube – Abnormal insertions of TVP and levator veli palatini muscles Cleft LipCleft Palate Otitis media

34. Management – Tympanostomy tube insertion Controversy : Type of VT Controversy : Time of VT Cleft LipCleft Palate Otitis media

35. Thanks for your attention