1. Postoperative deformities of the upper lip and palate: etiology, pathogenesis, clinical features, surgical treatment of deformities. Voles of the maxillofacial area, salivary glands, etiology, symptoms, diagnosis, surgical treatment.

5. Cleft Variants Great anatomic variation in types of clefts!
Anatomic Classification based on:
1) Location
2) Completeness (Incomplete/Complete)
3) Extent
Since lip, alveolus, and hard palate differ in embryologic origin, any combination can occur
Clinical Aspects of Cleft Lip/Palate Reconstruction

6. Iowa Classification Group I Clefts of lip only Group II
Clefts of palate only (2o)
Group III
Clefts of lip, alveolus, palate
Group IV
Clefts of lip and alveolus (primary cleft palate and lip)
Group V
Miscellaneous
Clinical Aspects of Cleft Lip/Palate Reconstruction

7. Cleft Variants Cleft Lip
Expressed in structures anterior to incisive foramen
- prepalatal alveolus, maxilla, lip, nasal structures
Deficiency in skin, muscles, mucous membranes, maxillary/nasal bones, nasal cartilages
1) Isolated Incomplete
Bilateral/Unilateral
Intact skin/muscle between the lip and nose
Less distortion brought on by abnormal muscle pull
Gaping cleft of alveolus/lip structures to mere ‘scar’ (forme fruste)
Clinical Aspects of Cleft Lip/Palate Reconstruction

8. 2) Isolated Complete * Bilateral/Unilateral
Cleft runs entire length of lip to floor of nose
Abnormal muscle pull distorts nose extensively and creates wide clefts between the lip segments
Clinical Aspects of Cleft Lip/Palate Reconstruction

9. Cleft Variants Isolated Cleft Palate Primary Palate (CL)
Secondary Palate
Soft Palate
Hard Palate
Complete/Incomplete
-cleft can extend into the hard palate to any extent
Clinical Aspects of Cleft Lip/Palate Reconstruction

10. Cleft Variants Combined Clefts Complete lip/palate
Incomplete lip/palate
Clinical Aspects of Cleft Lip/Palate Reconstruction

11. Surgical Management Cleft Lip and Palate Multidisciplinary approach
Beyond lip repair are other issues:
Hearing (otolaryngologists)
Speech (speech pathologists)
Dental (oromaxillofacial surgeons)
Nutrition
Psychosocial
Integration with team-based approach
Each case is assessed independently by those involved and a global treatment plan is instituted based on present need in his/her development
Clinical Aspects of Cleft Lip/Palate Reconstruction

12. Surgical Management Cleft Lip Cleft Palate
Staging and Timing of Surgery
Different institutions = different practice
Cleft Lip
Cleft Palate
Rule of 10’s
IWK months of age
Hgb = 10g
Weight of 10lbs
Age 10wks
IWK weeks
Clinical Aspects of Cleft Lip/Palate Reconstruction

13. Surgical Management Unilateral Complete Cleft Lip
Goal: Symmetric shaped nostrils, nasal sill, and alar bases; well defined philtral dimple and columns; natural appearing Cupid’s bow; functional muscle repair
Surgical Principle: Lengthen medial side of cleft so that it equals the vertical dimensions of non-cleft side
Flap designs:
1) Triangular (Tennison-Randall)
2) Quadrangular
3) Rotation-advancement (Millard*, Mohler)
Clinical Aspects of Cleft Lip/Palate Reconstruction

14. Millard Technique In simple medical student terms:
“Cut as you go” technique
Preserves’ cupid’s bow and philtral dimple
Scar placed in more anatomically correct position along philtral column
Tension of closure under the alar base; reduces flair and promotes better molding of the underlying alveolar processes
In simple medical student terms:
1) Medial flap rotates downward to achieve necessary lengthening
2) Lateral flap advances into the defect produced by downward displacement of medial flap
3) Small pennant-shaped medial flap can be used to restore nostril sill or lengthen the columella
Clinical Aspects of Cleft Lip/Palate Reconstruction

15. In Complex Resident/Staff Terms:
Clinical Aspects of Cleft Lip/Palate Reconstruction

16. Clinical Aspects of Cleft Lip/Palate Reconstruction

17. Post-op Management Cleft Lip
1) Feedings administered with catheter tip syringe fitted with small red rubber catheter for the first 10 days post-op
2) Nipples are avoided to minimize strain on the muscle/skin sutures
3) Velcro arm restraints to protect repair from flailing hands/fingers
4) Suture line care: PRN cleansing with half strength peroxide followed with polymixin B-bacitracin ointment
Clinical Aspects of Cleft Lip/Palate Reconstruction

18. Post-op Management Inform the parents of: Scar contracture Erythema
Firmness
Avoid placing in direct sunlight until the scar fully matures
Clinical Aspects of Cleft Lip/Palate Reconstruction

19. Post-op Management Complications Aesthetic Other
vermilion-cutaneous mismatch
vermilion notching
tight appearing lateral lip segement
lateral muscle buldge
laterally displaced ala
constricted appearing nostril
Other
dehiscence
excessive scar formation
Clinical Aspects of Cleft Lip/Palate Reconstruction

20. Surgical Management Cleft Palate Two most common repairs:
Goal: Production of a competent velopharyngeal sphincter
Two most common repairs:
1) V-Y (Veau-Wardill-Kilner)*
2) von Langenbeck
Main difference: V-Y repair involves elongation of the palate, while von Langenbeck does not
Clinical Aspects of Cleft Lip/Palate Reconstruction

21. Wardill-Kilner
1) Incisions made along free margins of cleft and extend anteriorly to apex
2) Dissection continued posteriorly along oral side of alveolar ridge to retromolar trigone
Clinical Aspects of Cleft Lip/Palate Reconstruction

22. Wardill-Kilner
3) Mucoperiosteal flaps are elevated from nasal/oral surfaces of bony palate
4) Dissection of the greater palatine vessels from the foramen lengthens the pedicle
5) Tensor veli palatini muscle is elevated off the hamulus to aid in relaxing the midline closure
Clinical Aspects of Cleft Lip/Palate Reconstruction

23. Wardill-Kilner
6) Nasal mucosa freed from bony palate and closed to either side, or if necessary closed by using vomer flaps
7) Muscle and oral mucosa closed in a second single layer in a horizontal fashion
Clinical Aspects of Cleft Lip/Palate Reconstruction

24. Wardill-Kilner
8) Anteriorly, the oral mucoperiosteal flaps are attached to the third flap (mucosa overlying the primary palate
9) Posteriorly, the palate is closed in 3 layers
Nasal mucosa
Levator muscle
Oral mucosa
Clinical Aspects of Cleft Lip/Palate Reconstruction

25. Post-op Management Cleft Palate Immediate concerns:
1) Airway management
Change in nasal/oral airway dynamics
2) Analgesia
Risk of oversedation and subsequent airway comprimise
Acetominophen, Codeine sufficient: cont’d for 7-10 days
Arm restraints to prevent placing fingers in mouth
Diet restricted to liquids, soft foods (x3wks): bottles avoided
Clinical Aspects of Cleft Lip/Palate Reconstruction

26. Post-op Management Complications Airway obstruction
Intraoperative bleeding
Palatal fistula
Midface abnormalities (early interventions)
Clinical Aspects of Cleft Lip/Palate Reconstruction

28. NORMAL LIP MUSCULAR ANATOMY
CLEFT LIP ANATOMY

29. Problems in Cleft Lip and Cleft Palate
Feeding
Frequent upper respiratuary tract infection
Frequent gas regurtation
Otitis media
Nasal regurtation of food
Aspiration pneumenia
Growing retardation
Other anomalies
Psycological problems (family)

30. Cleft lip and palate treatment team
Surgeon experienced in cleft management
Pediatrist
Orthodontist
Pediatric Otorhinolaryngologist
Pediatric dentist
Geneticist
Spech Terapist
Social Worker
Nurse experienced in cleft problems

31. Feeding Rules Swallowing is not impaired, oral feeding is possible
Bottle feed with additional cross cut in the end
Elastic plastic bottle
Bulb syringe with a nipple
Feeding with a spoon
The child should be held in a head-up position at about 45 º during and after feeding
Lateral position during sleeping

32. When to Operate Generally (Rules of 10’s)
Weight > 10 pound (4500 gr)
Hb > 10 gr
Age > 10 weeks
Cleft lips between 3-6 months
Cleft palate between months (preferred before speech devolops)

33. Cleft Lip Treatment Cleft lip
Mikroform cleft lip
Unilateral cleft lip
Bilateral cleft lip
Associated nasal deformity is classified as mild, moderate or severe
Alveolar arc position evaluated. If necessary “presurgical maksiller orthodontics” applied

35. Operation technique in Microform cleft (Straight line closure)

36. Surgical technique for unilateral cleft lip
(Millard Rotation-Advancement)

37. Surgical technique for unilateral cleft lip (Tennison Triangular Flap)

38. Surgical technique for unilateral cleft lip and palate
Millard techniques provides primary lip and nasal repair . It is possible “gingivoperiostoplasy” after “Presurgical maksiller ortopedics”

39. Pre -Orthodontic treatment
After 3 months of Grayson molding plate application

40. A.M.Kul, right unilateral primary and secondary cleft palate
Pre -Orthodontic therapy
After 3 months of Grayson molding plate application

41. Postoperative 6 months

42. Postoperative 1,5 years

51. Bilateral Cleft Lip More complex and difficult to treat
Projectil premaksilla
Broad and flared nasal tip
Prolabium
Short columella or absent columella
Incomplet or complet
It is important to retropositon the premaksilla with presurgical orthopedic treatment
Surgical techniques used for unilateral cleft lip repair are used for bilateral cleft lip repair in one or two stage operation (Millard, Tennison...)

52. Treatment of Premaksilla
Lip repair or “Lip-adeshion”
Elastic traction ( with a Head Bonnett)
Premaksillary retantion (Latham)
Nazoalveoler molding (Grayson)
Surgical premaksilla excision or set-back (severe maxillary retrusion)

56. Bilateral Incomplet Cleft lip Operation Technique
Millard (Two stage)

57. Bilateral Incomplet Cleft lip Operation Technique
Straight Line Closure (One stage)

61. Cleft Palate Palate and palatal muscles close the velopharengeal valve
Velofarengial closure can not be done in cleft palate patient.
Patient can not create intraoral pressure
Feeding and speach are effected

62. Problems with cleft palate
Feeding
Speech
Hearing and middle ear problems
Additional anomalies (% 30)
Psychological problems

63. Goal of Palatal Repair
Understanble speech
No maxillary retrusion
No hearing problem
Good occlusion

64. Palatoplasty Technique

65. Surgical treatment of isolated cleft palate
Von Langenback Method
“Double opposing Z Plasty”

66. Breathing and feeding problem
Pierre Robin Sequence
Micrognathy
Glossoptosis
Airway obstruction
Cleft palate( % 50 )
Breathing and feeding problem

67. Treatment of Velopharyngeal Insufficency
Patient should evaluate by speech terapist before any treatment
Nasendoscopic evaluation and Multiview videofluoroscopy is importany diagnostic tests
Goal is to provide normal velopharyngeal anatomy

68. Surgical Treatment of Velopharyngeal Insufficency
Pharyngeal Flaps (Superior, inferior pedicled)
Pharyngoplasty (Hynes, Orticochea)
Soft palate lengtening and levator muscle repair
Posterior wall augmentation (teflon, proplast)

69. Other Operations Fistula Repair
Velopharyngeal Insufficency correction (5 yeras)
Secondary Onarımlar (preschool age)
Alveolar bone grafting (before canine theth eruption)
Orthodontic Surgery (12-14 years)
(Le-Fort I Maksillary osteotomy, Mandibular split ramus osteotomy)
Rhinoplasty (16-18 years)

71. Thank you for your Attention