|Year : 2022 | Volume
| Issue : 1 | Page : 95-100
Repair of Primary Bilateral cleft Lip
Puthucode V Narayanan
Consultant Reconstructive Surgeon, The Charles Pinto Centre for Cleft Lip, Palate and Craniofacial Anomalies, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
|Date of Submission||17-Sep-2021|
|Date of Acceptance||18-Oct-2021|
|Date of Web Publication||01-Jan-2022|
Dr. Puthucode V Narayanan
The Charles Pinto Centre for Cleft Lip, Palate and Craniofacial Anomalies, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala
Source of Support: None, Conflict of Interest: None
Bilateral cleft lips have traditionally been a challenge to repair and the results have not been very favorable. However, advances in the recent past in the understanding of the nature of the deformity, especially the nasal component have brought a revolutionary change in the approach to these patients, with remarkable improvement in the outcome. The management of the premaxilla and its alignment with the maxillary shelves presurgically is crucial for the optimal treatment of such patients. The treatment protocol and technique followed at our center are described. It is a modification of the Mulliken technique. The philtrum is designed to be small in keeping with its rapid growth potential. The philtral flap is raised and the orbicularis oris muscles from the two sides are mobilized and brought together in the mid-line. Adequate mobilization of the muscles is necessary to avoid closure under tension. The evolution of the concept of primary rhinoplasty is described. The technique of preschool columellar lengthening and open rhinoplasty that is followed at our center is described. Unfavorable results include scarring, dehiscence, and central vermillion deficiency.
Keywords: Bilateral cleft lip, central vermillion deficiency, columella lengthening, management of premaxilla, preschool rhinoplasty, primary rhinoplasty
|How to cite this article:|
Narayanan PV. Repair of Primary Bilateral cleft Lip. J Cleft Lip Palate Craniofac Anomal 2022;9:95-100
| Bilateral Cleft Lip Repair|| |
The treatment of the bilateral cleft lip has always been a challenge. It has been mentioned that it is twice as difficult as compared to the repair of a unilateral cleft lip but the results are only half as good. However, rapid strides have been made in the repair of bilateral cleft lips in the recent past, producing remarkable improvement in esthetic results.
| A Brief History of the Evolution of the Repair of Bilateral Cleft Lips|| |
Initially, radical excision of the premaxilla was performed to facilitate closure of the wide cleft lip with grossly protuberant premaxilla. This is to be condemned in view of the severe maxillary regression that follows., Subsequently, the premaxilla has been brought into better alignment with the lateral maxillary shelves by presurgical orthodontics-active (in the form of the Latham's device) or passive (Nasoalveolar Molding [NAM]). A discussion of the merits and demerits of these two modes is beyond the scope of this article.
The other major advance in the understanding of the nature of the deformity involves the nose; originally, it was thought that there was a deficiency of skin in the columella and that this had to be borrowed from the lip in the form of forked flaps or the Cronin's method, etc. Broadbent and Woolf, McComb, Mulliken et al. and Cutting among others established that the columella is in the nose. The nasal deformity with short columella and flared alar cartilages becomes worse with time if primary repair is not done. However, a prerequisite for primary correction of the nose in bilateral cleft lips is that the premaxilla should be brought into good alignment with the lateral maxillary shelves., Preoperative orthodontics arrived quite late at our center and we now have access to both active and passive techniques. However, optimal premaxillary alignment is still elusive. We hope that we will be able to achieve this in the near future. Only then can we add primary rhinoplasty in our bilateral cleft lip patients. At present, we continue with our practice of columellar lengthening and open rhinoplasty at about 5½ years. As we address both the skin and cartilage issues, we have been getting very satisfactory results with this approach.
| Principles of Repair|| |
Mulliken has clearly laid down the basic principles of bilateral cleft lip repair and this includes attention to symmetry, the establishment of muscular continuity across the mid-line, optimal design of the philtral flaps keeping in view that they are fast-growing areas, reconstruction of the vermillion using lateral turn-down flaps (and not prolabial mucosa), and primary rhinoplasty with sutural fixation of cartilages.
It needs to be borne in mind that the nature and position of the premaxilla play a vital role in the ability to achieve most of the above principles.
In addition, it is must be strongly emphasized that adequate mobilization of the lateral tissues is imperative to achieve a tension-free repair. Should the lip be closed under tension, it is liable to break down producing unacceptable results.
| Premaxillary Alignment|| |
The premaxilla is proturbent in children with bilateral cleft lips in view of the fetal tongue thrust and the growth of the septal cartilage which is unrestrained because of the lack of continuity with the lateral palatal shelves. In asymmetric bilateral cleft lip children, the premaxilla is also often rotated to one side.
The projecting premaxilla is aligned with the lateral shelves by presurgical orthodontics. At our center, when such children present early, we subject them to NAM [Figure 1]. For those who present after 2 months of age and those in whom NAM has failed to bring about significant changes, we offer active orthodontics in the form of the Latham's appliance.
|Figure 1: (a) Before Nasoalveolar molding (NAM) Frontal View (FV), (b) before NAM Worms-Eye View (WV), (c) after NAM FV, (d) after NAM WV|
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| Timing|| |
We operate on bilateral cleft lip patients at 6 months of age. It is only then that most of our children attain about 6 kg of weight. In most centers, the repair is done between 3 and 6 months of age.
| Procedure|| |
We use a modified version of the Mulliken repair adhering to most of the basic principles except that we do not do a primary rhinoplasty in view of the projecting premaxilla in most patients.
| Philtral Design|| |
Markings on the philtrum include a Cupid's bow width of 5–6 mm with a convergent philtrum, measuring 3–4 mm at the columellar base. The lateral points are marked on each side as the point where the lip begins to thin. A transverse incision is marked at the alar base for advancement medially [Figure 2].
A solution of 1:200,000 adrenaline in saline is infiltrated into both lateral elements subperiosteally. Similar infiltration is also done subperiosteally on the vomer. The prolabium itself is not infiltrated.
Paring incisions are made along the skin-mucosal junction on the prolabium. The philtral flap is raised with adequate subcutis to maintain vascularity. The flanking strips of skin on either side of the philtral flaps are deepitheliazed to provide better philtral ridges [Figure 3].
Laterally, an incision is made above the alveolus and the dissection is carried out in the subperiosteal plane extensively to the malar eminences laterally, to the infraorbital foramen superiorly and to the edge of the maxillary bone medially, The mucosa is raised off the underlying maxillary bone completely releasing any tethering that is present. Such mobilization is imperative to attain a tension-free closure. The orbicularis oris muscle is dissected both in the sudermal and in the subperiosteal plane.
On the vomer, we believe that it is necessary to preserve of strip of mucosa about 5 mm in width to prevent disruption of vascularity to the premaxilla. The vomerine mucoperiostem is raised on either side and is freed off the nasal septum to enable better closure.
Closure: The nasal floor is closed by bringing together the vomerine mucoperiosteum and the maxillary mucoperiosteum. Nonabsorbable sutures are then used to bring the orbicularis oris muscles from the two sides in the mid-line, beneath the philtral flap that has been raised.
The paranasal muscles from both sides are brought together in a cinch suture and anchored to the periosteum in the mid-line. The vermillion is reconstructed using lateral turn-down flaps. The orbicularis oris pars marginalis is sutured together providing good bulk at the mid-line to produce a good median tubercle.
The prolabial mucosa is trimmed as necessary and used to provide an adequate vestibular sulcus. It is not used for the vermillion. If it were to be used for the vermillion, it produces an unnatural, scalloped appearance.
The philtral flap is draped over the reconstructed orbicularis oris muscles and sutured to the lateral skin flaps, which may have to trimmed sometimes. Often, the philtrum appears diminutive, but it stretches to a great extent and can be aligned with the lateral flaps [Figure 4].
|Figure 4: (a) Before complete bilateral cleft lip repair FV, (b) before complete bilateral cleft lip repair WV, (c) after complete bilateral cleft lip repair FV, (d) after complete bilateral cleft lip repair WV|
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| Primary Nasal Correction|| |
The concept of primary nasal correction has been widely propagated by Broadbent and Woolf, McComb,, Mulliken et al.,, Cutting, and others.
McComb, used a mid-line columellar incision to approach the nasal cartilages which he sutured together. He performed a lip adhesion at that time with a definitive lip repair in the second stage. The columellar incision is often unpleasant.
Mulliken et al., uses bilateral alar rim incisions to approach and dissect the alar cartilages which are sutured with interdomal sutures and also ipsilateral lower to upper lateral cartilage sutures.
Cutting does not use rim incisions. He uses a retrograde dissection using converse tip scissors along the columella on either side and inserts an interdomal suture through the nasal vestibule. In our experience, the effect of such sutures usually does not last for long.
Chen et al. uses a semi-open approach with bilateral Tajima reverse U incision. He too uses interdomal sutures through the nasal vestibule [Figure 5] and [Figure 6].
|Figure 5: (a) Bilateral partial cleft lip repair using Philip Chen technique of primary rhinoplasty preoperative FV, (b) Bilateral partial cleft lip repair using Philip Chen technique of primary rhinoplasty preoperative WV, (c) bilateral partial cleft lip repair using Philip Chen technique of primary rhinoplasty immediate postoperative FV, (d) bilateral partial cleft lip repair using Philip Chen technique of primary rhinoplasty immediater postoperative WV, (e) bilateral partial cleft lip repair using Philip Chen technique of primary rhinoplasty long-term result FV, (f) bilateral partial cleft lip repair using Philip Chen technique of primary rhinoplasty long-term result WV|
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|Figure 6: (a) Bilateral complete lip repair using Philip Chen technique of rhinoplasty before FV, (b) bilateral complete lip repair using Philip Chen technique of rhinoplasty before surgery WV, (c) Bilateral complete lip repair using Philip Chen technique of rhinoplasty after repair FV, (d) Bilateral complete lip repair using Philip Chen technique of rhinoplasty after repair WV|
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Trott and Mohan and Thomas advocate an open rhinoplasty with the philtral incision carried up along the sides of the columella on to the alar rims. There is the danger of impairing the philtral blood supply in this technique.
As mentioned previously, we have not been correcting the nasal deformity in the primary stage, for reasons mentioned. Instead, we perform an open rhinoplasty with bilateral Tajima reverse U incision connected along the sides of the columella to a V-shaped incision at the columellar base, extending into the philtrum. The lower and upper lateral cartilages are dissected. Sutural fixation is done with nonabsorbable sutures, bringing the medial crura together. Tip esthetics is improved by transdomal and interdomal mattress sutures. The lower lateral cartilages are hitched through the septum to the contralateral upper lateral cartilages. This is done at the preschool age, about 5½ years [Figure 7].
|Figure 7: (a) Before Bilateral complete cleft lip with no primary nasal correction FV, (b) before Bilateral complete cleft lip with no primary nasal correction WV, (c) after Bilateral complete cleft lip with no primary nasal correction but with preschool rhinoplasty FV, (d) after bilateral complete cleft lip with no primary nasal correction but with preschool rhinoplasty WV|
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The mid-line scar of the upper lip almost always fades off with hardly a trace. We were directed to use this by IT Jackson (Personal Communication) and we have never regretted its use. With this technique, we are able to obtain very satisfactory results on the nose. In this technique, we address the skin deficiency while reconstructing the columellar framework simultaneously. Hence, we do not see the blemishes that were common when techniques such as Millard's forked flap or the Cronin's method were used without any cartilaginous framework reconstruction.
| Variations|| |
Asymmetrical bilateral cleft lip.
When one side is partial and the other side complete, we operate on the two sides simultaneously. The partial side obviously does not need a nasal floor repair [Figure 8].
|Figure 8: (a) Before Microfom and partial lip repair FV, (b) before Microfom and partial lip repair WV, (c) after 1st stage repair FV, (d) after 1st stage repair WV, (e) after 2nd stage repair FV (f) after 2nd stage repair WV|
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When one side is microform and the other is complete or partial, we operate in two stages using Millard's procedure. This leads to better results in such patients.
In any patient, where there is a very wide cleft or grossly protruded premaxilla or both, it may well-nigh be impossible to bring the orbicularis oris muscles of the two sides together in the mid-line. In such cases, we fix the orbicularis oris on each side to the subcutis on that side of the prolabium. The philtral flap is not raised. During the subsequent rhinoplasty, the philtrum can be refashioned and muscle continuity established. This approach is much safer than trying to bring the muscles together under tension with resultant breakdown. With such aggressive techniques, it is possible to lose the entire premaxilla.
| Unfavorable Results|| |
This is less when there is good muscle repair. It used to be more in the Rose-Thompson type repairs.
Central vermillion deficiency or “Whistle deformity”
When the lateral turn-down flaps are used with good muscle approximation for the vermillion, it is usually possible to avoid central deficiency. Should this still occur or when we encounter patients operated elsewhere with such a deformity, then we perform a bilateral medial advancement of the vermillion and build up the muscle in the mid-line. It is usually possible to do this without revising the entire lip repair [Figure 9].
|Figure 9: (a) Before vermillion correction with medial advancement FV, (b) before vermillion correction with medial advancement WV, (c) after vermillion correction with medial advancement FV, (d) after vermillion correction with medial advancement WV|
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This can be avoided if one always repairs the lip without tension. Should dehiscence occur, it would require re-repair once the wound has healed. The results may not be optimal.
Residual nasal deformity
If, after primary or preschool rhinoplasty, there is still a residual nasal deformity with a broad tip, depressed dorsum, flared alar, etc., then a definitive repair is done after 15–16 years of age.
Lip that is too tight
will need an Abbe flap to bring in tissue from the lower lip.
Thus, though the repair of the bilateral cleft lip continues to be a challenge, the improved understanding of the nature of the blemish has led to superior strategies in the management. This has led to better results overall.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Thomas C. Primary rhinoplasty by open approach with repair of bilateral complete cleft lip. J Craniofac Surg 2009;20 Suppl 2:1715-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]