S116: Cleft Lip/Nose and Palate: Muscle Surgery and Primary Functional Management

Abstract

Nasolabial musculature is an important element to address in cleft lip and nose cases for the achievement of a favorable clinical outcome. Disruptions of facial tissues in clefting disorders usually from skin down to bone, including muscles in between, exhibit an important functional role during facial growth and development. Due to loss of tissue continuity and hence the breakdown of the equilibrium of functional forces acting upon each half of lips, nose and the entire facial skeleton, stimulation and establishment of normal growth is also affected. Current understanding of surgical treatment of cleft lip and nose entails a reconstructive concept that requires a surgical maneuver by incorporating and taking into consideration anatomically misaligned and dysfunctional regional muscles and muscle groups. Proper reapproximation and reconstruction of labial and nasal muscles correct the discontinuity and thereby restore transmitting forces through these structures. The prime reason for this surgical step is to restore functional imbalance and hence resultant forces acting upon affected structures of the clefting disorder. The technique requires identification, isolation and reconstruction of these muscles and/or muscle groups that situate around lips and nose. Improved outcome on the basis of this concept requires execution of a proper surgical treatment sequence and protocol. However muscle surgery is not the only disrupted structure to be addressed as all tissues involved either directly or indirectly affected have to be taken into consideration and handled accordingly. Mucocutaneous structures need to be carefully analyzed for their aberrations and displacements from their correct positions in order to place correct incisions and reposition into their correct localizations. This particular issue is usually overlooked and may result in violation of subjacent esthetic units which in turn yield unacceptable clinical esthetic outcomes. Therefore identification of skin of lip and nose and their reconstruction is mandatory. In addition primary septorhinoplasty and nasal floor reconstruction are also important operative phases in the surgical correction of cleft lip and nose. The reconstruction of cleft palate and alveolus regarding timing and surgical technique is still a controversial issue as several regimens have been described to achieve the best functional and esthetic outcome as in cleft lip and nose. Soft palate in cleft patients being the posterior part of the face needs to be addressed just like the anterior face and a meticulous muscle surgery has to be accomplished. In addition a staged closure is generally followed that involves early reconstruction of soft palate, followed by hard palate surgery either at the time of alveolus closure or postponing the latter no later than 30 months of age if alveolar closure as primary gingivoperiostoplasty without grafting is planned. Early secondary alveolar closure with grafting may also be chosen instead of primary alveolar closure along with nasal base/floor reconstruction as last early stage. Functional closure of the complete cleft palate patients in a staged manner is carried out to strive restoring the imbalance of function and resultant deformity as early in the life as possible.