Bilateral Cleft Lip: Primary Repair.

A whistle deformity is a common secondary deformity of upper lip volume deficiency in the tubercle following bilateral cleft lip repair. The whistle deformity is a significant aesthetic stigma of bilateral cleft lip repair and challenging to correct. In the most severe situations, it can also lead to functional speech issues due to the inability to seal the lips during plosive consonant sounds. Various secondary surgical methods have been proposed to address secondary tubercle deformities requiring revision surgery. Volume deficiency can occur in the tubercle with any surgical technique used, with some being more prone than others. We present a novel fibroadipose tissue flap to improve tubercle fullness during primary bilateral cleft lip repair using tissue that is otherwise normally discarded. The prolabial augmentation of the upper lip (PAUL) flap is a random pattern fibroadipose flap distally based off the undersurface of the prolabial skin flap. The fibroadipose tissue in the premaxillary segment is preserved, dissected and everted for auto-augmentation of the tubercle. The PAUL flap is inset into a submucosal pocket in the vermilion over the orbicularis muscle repair as one of the final steps of repair. This is an effective adjunct to prevent a whistle deformity and can be used with any skin pattern technique designed for the prolabial skin flap in the primary bilateral cleft lip repair.

In developing countries, children with cleft lip and palate present at various age for primary repair. Even if they come at an appropriate age, logistic and financial problems prevent us from providing preoperative orthopedic treatment for children with bilateral complete cleft lip and palate (BCLP). We present our protocol and technique of primary repair for BCLP without preoperative orthopedics at different ages. We operated on 240 children with BCLP from 2001 to 2003. One hundred ten children younger than 1 year were operated on for primary surgeries, 99 children were between 2 and 10 years, and 40 were older than 10 years. Of the 110 patients who had primary repairs for BCLP without preoperative orthopedic before age of 1 year, seventy children were studied for dental occlusion and premaxillary position at age of 5 to 7 years. Children operated on after the age of 1 year had palate repair before lip repair. Children operated on after 10 years, the protocol was modified to tackle protruding premaxilla at the time of palate repair. Of 70 patients operated on before 1 year of age, 83% had an occlusion with anterior and deep bites of the premaxilla of variable degree at age of 5 to 7 years. Thirteen percent had buccal bite, and these patients had small premaxilla before lip repair. Modification of protocol was necessary for children with BCLP who approached later than 1 year of age for primary treatment. Bilateral cleft lip repair without any preoperative orthopedic in young babies will mould the premaxilla. The size of premaxilla can predict the growth potential of maxilla.

After studying this article, the participant should be able to: 1. List five principles that guide synchronous repair of bilateral complete cleft lip and nasal deformity. 2. Explain how different growth rates for the principal nasolabial features are applied during primary repair. 3. Describe two approaches for positioning the alar cartilages to form the columella. 4. Discuss the influences on referral patterns for a newborn with bilateral cleft lip. --Traditional repair of bilateral cleft lip focused on labial closure but accentuated the nasal deformities, which were addressed later. By the end of the past century, single-staged labial closure had replaced the old multistaged procedures and the technical emphasis had begun to shift from secondary to primary nasal correction. Now, presurgical maxillary orthopedics sets the bony foundation for synchronous nasolabial repair and for closure of the alveolar clefts. The study of normal nasolabial growth and the typical stigmata of the conventional methods provides the necessary foreknowledge to guide surgical sculpture in three dimensions and to anticipate the fourth dimension. The convergence of several forces are changing referral lines for children born with bilateral cleft lip. These include affirmation of centers of excellence, surgeons' self-regulation, prenatal diagnosis, economics of health-care delivery, and increasing parental sophistication. These pressures are not necessarily in conflict. Care by a subspecialized plastic surgeon and experienced team is in the best interests of the child and the third-party payer.

Comparative study of the aesthetic outcomes of two techniques for bilateral cleft lip repair.

The purpose of this study was to utilize a multicenter dataset to elucidate whether socioeconomic factors were associated with access to cleft lip surgery, treatment by higher-volume providers, and family choice for higher-volume centers. Retrospective cohort study. Hospitals participating in the Pediatric Health Information System. Primary cleft lip repair performed in the United States between 2010 and 2020. Travel distance, hospital volume, hospital choice. During the study interval, 8954 patients underwent unilateral (78.4%, n = 7021) or bilateral (21.6%, n = 1933) primary cleft lip repair. Patients with unilateral cleft lip were repaired significantly earlier if they were White (P < .001) and significantly later if they lived in an urban community (P = .043). Similarly, patients with bilateral cleft lip were repaired significantly earlier if they were White (P < .001). Patients from above-median income households (P = .011) and living in urban communities (P < .001) were significantly more likely to be treated at high-volume hospitals, whereas those living in underserved communities (P < .001) were significantly less likely to be treated at high-volume hospitals. White patients were significantly more likely to be treated by high-volume surgeons (P < .001). Patients with White race were significantly more likely to choose a higher-volume hospital than the one most locally available (P < .001). Patients with White race are more likely to travel farther and be treated by high-volume surgeons although at smaller hospitals. Patients from underserved areas travel significantly farther for cleft care and are treated at lower-volume hospitals. Patients in urban communities have shorter travel distances and are treated at higher-volume hospitals.

Cleft of the lip and palate is the most common craniofacial birth defect with a worldwide incidence of one in 700 live births. Early surgical repairs are aimed at improving appearance, speech, hearing, psychosocial development and avoiding impediments to social integration. Many interventions including the Smile Train partner model have been introduced to identify and perform prompt surgical procedures for the affected babies. However, little is known about the trends of the incidence and surgical procedures performed at our hospital. Nothing is also known about the relationship between the clinical characteristics of the patients and the timing of primary repairs. To determine the trends in cleft surgeries, patterns of cleft surgeries and identify factors related to late primary repair at the University College Hospital, UCH, Ibadan, Nigeria. A retrospective cohort study and trends analysis of babies managed for cleft lip and palate from January 2007 to January 2019 at the UCH, Ibadan was conducted. The demographic and clinical characteristics were extracted from the Smile Train enabled cleft database of the hospital. The annual trends in rate of cleft surgeries (number of cleft surgeries per 100,000 live births) was represented graphically. Chi square test, Student's t-test and Mann Whitney U were utilised to assess the association between categorical and continuous variables and delay in cleft surgery (≥12 months for lip repair, ≥18months for palatal repair). Kaplan-Meier graphs with log-rank test was used to examine the association between sociodemographic variables and the outcome (late surgery). Univariable and multivariable Cox proportional hazard regression was conducted to obtain the hazard or predictors of delayed cleft lip surgery. Stata version 17 (Statacorp, USA) statistical software was utilised for analysis. There were 314 cleft surgeries performed over the thirteen-year period of study. The male to female ratio was 1.2:1. The mean age of the patients was 58.08 ± 99.65 months. The median age and weight of the patients were 11 (IQR:5-65) months and 8 (IQR: 5.5-16) kg respectively. Over half (n = 184, 58.6%) of the cleft surgeries were for primary repairs of the lip and a third (n = 94, 29.9%) were surgeries for primary repairs of the palate. Millard's rotation advancement flap was the commonest lip repair technique with Fishers repair introduced within two years into the end of the study. Bardachs two flap palatoplasty has replaced Von Langenbeck palatoplasty as the commonest method of palatal repair. The prevalence of late primary cleft lip repair was about a third of the patients having primary cleft lip surgery while the prevalence of late palatal repair was more than two thirds of those who received primary palatoplasty. Compared with children who had bilateral cleft lip, children with unilateral cleft lip had a significantly increased risk of late primary repair (Adj HR: 22.4, 955 CI: 2.59-193.70, P-value = 0.005). There has been a change from Von Langenbeck palatoplasty to Bardachs two-flap palatoplasty. Intra-velar veloplasty and Fisher's method of lip repair were introduced in later years. There was a higher risk of late primary repair in children with unilateral cleft lip.

BackgroundCleft of the lip and palate is the most common craniofacial birth defect with a worldwide incidence of one in 700 live births. Early surgical repairs are aimed at improving appearance, speech, hearing, psychosocial development and avoiding impediments to social integration. Many interventions including the Smile Train partner model have been introduced to identify and perform prompt surgical procedures for the affected babies. However, little is known about the trends of the incidence and surgical procedures performed at our hospital. Nothing is also known about the relationship between the clinical characteristics of the patients and the timing of primary repairs.ObjectiveTo determine the trends in cleft surgeries, patterns of cleft surgeries and identify factors related to late primary repair at the University College Hospital, UCH, Ibadan, Nigeria.MethodsA retrospective cohort study and trends analysis of babies managed for cleft lip and palate from January 2007 to January 2019 at the UCH, Ibadan was conducted. The demographic and clinical characteristics were extracted from the Smile Train enabled cleft database of the hospital. The annual trends in rate of cleft surgeries (number of cleft surgeries per 100,000 live births) was represented graphically. Chi square test, Student’s t-test and Mann Whitney U were utilised to assess the association between categorical and continuous variables and delay in cleft surgery (≥12 months for lip repair, ≥18months for palatal repair). Kaplan-Meier graphs with log-rank test was used to examine the association between sociodemographic variables and the outcome (late surgery). Univariable and multivariable Cox proportional hazard regression was conducted to obtain the hazard or predictors of delayed cleft lip surgery. Stata version 17 (Statacorp, USA) statistical software was utilised for analysis.ResultsThere were 314 cleft surgeries performed over the thirteen-year period of study. The male to female ratio was 1.2:1. The mean age of the patients was 58.08 ± 99.65 months. The median age and weight of the patients were 11 (IQR:5–65) months and 8 (IQR: 5.5–16) kg respectively. Over half (n = 184, 58.6%) of the cleft surgeries were for primary repairs of the lip and a third (n = 94, 29.9%) were surgeries for primary repairs of the palate. Millard’s rotation advancement flap was the commonest lip repair technique with Fishers repair introduced within two years into the end of the study. Bardachs two flap palatoplasty has replaced Von Langenbeck palatoplasty as the commonest method of palatal repair. The prevalence of late primary cleft lip repair was about a third of the patients having primary cleft lip surgery while the prevalence of late palatal repair was more than two thirds of those who received primary palatoplasty. Compared with children who had bilateral cleft lip, children with unilateral cleft lip had a significantly increased risk of late primary repair (Adj HR: 22.4, 955 CI: 2.59–193.70, P-value = 0.005).ConclusionThere has been a change from Von Langenbeck palatoplasty to Bardachs two-flap palatoplasty. Intra-velar veloplasty and Fisher’s method of lip repair were introduced in later years. There was a higher risk of late primary repair in children with unilateral cleft lip.

The basket-weave method is an orbicularis oris muscle reconstruction method used in primary unilateral cleft lip repair. We compared the long-term results of the basket-weave method with those of a conventional method. For primary unilateral cleft lip repair, we compared the long-term results of 7 cases in which the orbicularis oris muscle was reconstructed by use of the basket-weave method, and of 7 cases in which the reconstruction was performed by use of the conventional method. The average postoperative follow-up period was 12 years and 7 months for the basket-weave method, and 11 years and 9 months for the conventional method. Using photographs of the front and elevation angle views, we evaluated the results as good if the philtrum ridge was formed on the fissure side and was almost symmetrical in height; as fair if the philtrum ridge was lower than the normal side; and as poor if the philtrum ridge had disappeared. For the basket-weave method, the results were good in 6 cases (85.7%), fair in 1 case (14.3%), and poor in 0 cases. For the conventional method, the results were good in 2 cases (28.6%), fair in 4 cases (57.1%), and poor in 1 case (14.3%). A significant difference was found between the 2 groups (Mann-Whitney U test, P = 0.0417). The philtrum ridge shape could be reconstructed by use of the basket-weave method, which gave better results in the long-term than did the conventional method for orbicularis oris muscle reconstruction in primary unilateral cleft lip repair.

Background: Bilateral cleft lip is a complex congenital deformity of face. Restoration of the normal facial form is one of the primary goals for reconstructive surgeons. Surgical repair of bilateral cleft lip is complex and still controversial, though various techniques have been reported and described in detail. The repair can be a challenge even to an experienced surgeon and the results of primary repair of bilateral cleft lip traditionally have been less satisfactory than those of unilateral cleft lip. Objective: This study aimed to evaluate the surgical outcome of bilateral cleft lip surgery by the modified Millard technique using a simplified scoring system. Materials and Methods: This study was conducted from January 2013 to December 2021 at a private Hospital, a cleft center of Smile Train. 46 cases of bilateral cleft lip were operated by the modified Millard technique during this study period. Data analysis included age and sex of patients, type of cleft deformity and type of surgery (primary or secondary) and whether the cleft deformity was syndromic or non-syndromic. Technique of repair, surgical outcome and complications were also recorded. The photographic evaluation was done between 3 months to 3 years after lip operation by a surgeon and a social worker on three regions- lip, nose and general facial appearance with a total score of 10. Results: A total of 46 cases of BCL (Bilateral Cleft Lip) comprising of 29 males and 17 females were operated which constituted 9.2% (46/500) of all cases of cleft surgery done during this study period. The age of patients at the time of surgery ranged between 4 months and 16 years. 38 patients had bilateral cleft lip and palate deformities and 8 had only bilateral cleft lip deformities. Primary surgery was performed in 45(97.82%) cases and secondary (revision) surgery was performed in only 1(2.18%) case. There was no syndromic case. All cases were operated by the modified Millard technique. Aesthetic outcome was evaluated by a simplified scoring system. The outcome was good with this repair technique and evaluated by this scoring system. Conclusion: This is an effective scoring system to evaluate the outcome of bilateral cleft lip repair. Bang Med J Khulna 2022; 55 : 03-07

Lag screw fixation of the premaxilla during bilateral cleft lip repair

The central third of the face is distorted by the bilateral cleft of the lip and palate and restoring the normal facial form is one of the primary goals for the reconstructive surgeons. The history of bilateral cleft lip repair has evolved from discarding the premaxilla and prolabium and approximating the lateral lip elements to a definitive lip and primary cleft nasal repair utilising the underlying musculature. The aim of this study was to review surgical outcome of bilateral cleft lip surgery (BCLS) done at the Lagos University Teaching Hospital. A review of all cases of BCLS done between January 2007 and December 2012 at the Lagos University Teaching Hospital was done. Data analysis included age and sex of patients, type of cleft deformity and type of surgery (primary or secondary) and whether the cleft deformity was syndromic and non-syndromic. Techniques of repair, surgical outcome and complications were also recorded. A total of 39 cases of BCLS involving 21 males and 18 females were done during the period. This constituted 10% (39/390) of all cases of cleft surgery done during the period. There were 5 syndromic and 34 non-syndromic cases. Age of patients at time of surgery ranged between 3 months and 32 years. There were 24 bilateral cleft lip and palate deformities and 15 bilateral cleft lip deformities. Thirty-one of the cases were primary surgery, while 8 were secondary (revision) surgery. The most common surgical technique employed was modified Fork flap (Millard) technique, which was employed in 37 (95%) cases. Bilateral cleft lip deformity is a common cleft deformity seen in clinical practice, surgical repair of which can be a challenge to an experienced surgeon. A modified Fork flap technique for repair of bilateral cleft lip is a reliable and versatile technique associated with excellent surgical outcome.

To evaluate long-term results in the bilateral cleft lip repair by Mulliken's method, using anthropometric measurements, we assessed the growth of the nose and upper lip after the operation by comparing with those from 30 children without bilateral cleft lip. Forty-four patients had their bilateral cleft lip and nasal deformity repaired simultaneously by Mulliken's method during the period from July 1997 to December 2007. Of these patients, 15 patients had bilateral complete cleft lip, 17 patients had bilateral incomplete cleft lip, and 12 patients had a mixed type of complete and incomplete bilateral cleft lip.To follow up on the growth of the lips and nose after the operation, the following 6 anthropometric measurements were analyzed: nasal tip protrusion, nasal width, columellar length, upper lip height, cutaneous lip height, and vermilion mucosa height. In most patients, nasal length, nasal tip projection, columellar length, and upper lip shape were appropriate. Nasal tip protrusion, nasal width, upper lip height, and vermilion-mucosal height were within normal limit. However, columellar length and cutaneous lip height were relatively shorter than the average values of children without bilateral cleft lip. By performing Mulliken's method, we can achieve natural lip and nasal shape, harmonious Cupid's bow, appropriate nasal projection, and natural philtrum.

Complete or incomplete cleft lip may include a contralateral lesser form of incomplete cleft lip to give rise to an asymmetrical bilateral cleft lip deformity. The principle of simultaneous bilateral cleft repair remains an area of contention with regard to asymmetrical cases, including a lesser form deformity. The cleft lip database of the senior author (D.M.F.) was searched for patients with complete or incomplete bilateral cleft lip with a contralateral lesser form defect. Results were assessed by reviewing photographs and recording revisions. Of 111 patients with bilateral cleft lip, 35 (32 percent) had asymmetrical cleft lip, with 13 patients having contralateral lesser form defects. All infants with complete cleft lip-cleft palate underwent presurgical orthodontics. All patients subsequently went on to single-stage bilateral cleft lip repair. Seven revisions were performed in the symmetrical complete bilateral cleft lip group; no revisions were performed in the asymmetrical bilateral cleft lip group. The authors recommend a single-stage operation for repair of the bilateral cleft lip irrespective of the extent: complete, incomplete, lesser form, symmetrical, or asymmetrical. This approach provides the best opportunity to achieve symmetry of the Cupid's bow and of the resultant scar, and provides the ideal opportunity for reconstruction of the prolabial deficiencies of the cutaneous roll, vermilion, and median tubercle. Therapeutic, IV.

Primary Bilateral Cleft Lip Repair Using the Modified Millard Technique

A new all-purpose bilateral cleft lip repair: Bilateral cheiloplasty suitable for most conditions