Bilateral Cleft Lip Deformity Research Articles

Mulliken's Bilateral Cleft Lip Repair: Early Outcome Analysis.

To determine the early surgical outcome of Mulliken's repair technique for bilateral cleft lip. Descriptive cross-sectional study. Place and Duration of the study: Burns and Plastic Surgery Centre, Hayatabad Medical Complex, Peshawar, Pakistan, from January 2020 to December 2021. This study included 51 patients with bilateral cleft lip deformity. Patients were evaluated preoperatively to exclude any associated congenital anomalies or comorbidities. Then the patients were classified into mild, moderate, severe, and asymmetrical cases. Outcomes were determined immediately and one week postoperatively, as good (score 16-20), fair (score 11-15), and bad (0-10) on the basis of anthropometric measurements on outcome evaluation criteria (OEC). Preoperatively mild, moderate, and severe bilateral cleft lips were observed in 18 (35.3%), 6 (11.85%), and 15 (29.4%), respectively, while 10 (19.6%) were bilateral asymmetrical cleft lips. The postoperative outcome score ranged from 16 to 20 (mean 19.2+1.03) which falls in the good outcome range. Nasal symmetry was good in 64.7% (n=33) cases while 31.4% (n=16) patients had satisfactory scores. Although Mulliken's repair is by far the most prevalent type of repair for bilateral cleft lip patients, the results can vary markedly. The early outcome evaluation criteria is an objective tool to measure the outcomes. Cleft lip, Bilateral cleft lip, Mulliken, Mulliken's repair, Day care surgery, Outcome.

Aesthetic evaluation of nasolabial reconstruction using abbe flap in bilateral cleft lip patients with secondary deformities

The Abbe flap is a common technique frequently utilized in secondary surgery for bilateral cleft lip deformities, but objective indications for the Abbe flap remain unclear, and postoperative aesthetic evaluations are limited. The study group consisted of 92 bilateral cleft lip patients with secondary deformities aged 7-39 years, and the control group consisted of 33 people aged 19-35 years. Thirteen objective nasolabial aesthetic parameters were selected to evaluate patients' nasolabial aesthetics. Minor secondary deformities were characterized by a smaller lip height index than severe deformities, as well as a smaller columellar angle compared with moderate and severe deformities (P<0.05). For all patients, significant differences were found between preoperative and postoperative values of intercanthal distance/medial upper vermilion height ratio, intercanthal distance/medial upper lip height ratio, lip height index, lip vermilion height index, lip protrusion angle, columellar-labial angle, and nasal tip angle (P<0.05). For patients with minor deformity, intercanthal distance/philtrum width ratio and intercanthal distance/medial cutaneous upper lip height ratio showed no significant change postoperatively (P>0.05), and labial protrusion angle was smaller than the control group (P<0.05). Patients undergoing secondary surgery using an Abbe flap achieved good nasolabial aesthetics. Intercanthal distance/medial upper vermilion height ratio, intercanthal distance/medial upper lip height ratio, lip height index, columellar-labial angle, nasolabial angle, nasal tip angle, and columellar angle are the objective aesthetic indicators for Abbe flap selection. Intercanthal distance/philtrum width ratio, intercanthal distance/medial cutaneous upper lip height ratio, and labial protrusion angle are reference parameters for choosing an Abbe flap for secondary bilateral cleft lip revision.

Embryological approach to philtral hair sparsity in bilateral cleft lip deformities

ObjectiveIn bilateral cleft lip cases, surgeons have long known that the medial nasal prominence or prolabium is devoid of muscle. Despite cheiloplasty restoring orbicular muscle continuity, moustache hair growth is less developed on the philtral skin. We sought to understand this hair disparity. Basic proceduresThe authors conducted a comprehensive literature search using reference materials on the physiological and pathological development of the face in utero and the PubMed database using the keywords 'embryology', 'bilateral cleft lip' and 'hair'. Main resultsIn bilateral cleft lip, the normal fusion between the maxillary and intermaxillary process does not occur, and the migration of cranial neural crest cells (CNCC) is disturbed. CNCCs from different locations and with different myoblastic differentiation potential are arrested on each side of the cleft. Therefore, a reduced concentration of myoblasts and myocytes as well as hormone receptors in the medial process could hinders the normal physiological development of the different layers of the philtral skin and especially the skin appendages. ConclusionPhiltral hair sparsity in patients with bilateral cleft lip can be explain by a defect in the migration of CNCCs to the prolabium, whose cells are not able to develop hair follicles, due to a disruption of the exchange of Wnt/β-catenin, EDA, and or Noggin signals and due to the absence of androgen receptor.

Long-Term Evaluation of the Lip and Nose in Bilateral Complete Cleft Lip Patients following Lip Adhesion and Secondary Nose Correction.

Background Surgical correction of bilateral cleft lip deformities remains one of the most challenging areas in facial plastic surgery. Many surgical techniques and conservative devices have been offered for the early management of bilateral cleft lip in infants. The purpose of this study was to evaluate the effect of lip adhesion on the lip and nose of patients with bilateral cleft lip. Methods A retrospective review of 13 patients with bilateral cleft lip was performed and compared with age-matched noncleft children. Patients underwent lip adhesion at a mean age of 2.8 months, and cheiloplasty at 6.6 months of age using a modification the Mulliken method. Secondary rhinoplasty was performed at the age of 6 in 13 patients. The surgical results were analyzed using photographic records obtained at the age of 1 and 7 years. Twelve length measurements and one angle measurement were obtained. Results All measurements were not statistically different from those of the noncleft age-matched control group at the age of 1. At 7 years of age, upper lip height and vermilion mucosal height were shorter ( p < 0.05) than in the control group. Nasal tip protrusion and the nasolabial angle were greater ( p < 0.05) than in the control group. Conclusion Lip adhesion followed by secondary rhinoplasty resulted in an acceptable lip and nasal appearance. Although nasoalveolar molding is now widely used, lip adhesion can be an appropriate alternative if an orthodontist is not available due to geographical or economic constraints.

Primary Repair of Bilateral Cleft Lip Deformity and Absent Prolabium With a Full-Thickness Skin Graft.

Bilateral cleft lip deformities makeup 10% of orofacial clefts and are uncommon when compared to unilateral cleft lip.1,2 These cleft deformities have significant physical and long-term psychosocial effects on not only the patient but their family. With bilateral cleft lip deformity, the cutaneous approximation of the lateral lip segments are dependent on a sufficient prolabium to reconstruct the philtrum.3,4 Deficient skin equates to tight midline closure and subsequent unsightly scarringIn the subclinical phenotype of bilateral cleft lip and palate, where the patient has an absent or deficient prolabium, achieving tension free closure in the primary surgical setting is a reconstructive dilemma.5 This clinical report describes the use of a full-thickness skin graft to reconstruct the philtrum in a 12-month-old boy with bilateral cleft lip deformity, absent prolabium, absent columella and absent nasal septum to provide an aesthetic subunit repair.

The nasal cantilever technique in children undergoing primary cleft lip surgery: novel concepts and review

BackgroundNasal deformity associated with cleft lip deformity is a challenging issue, encompassing controversies, theories, and a diversity of techniques. Historically, esthetic outcomes have ranged from being below expectations to barely acceptable.MethodBased on the concept that the nasal cartilaginous framework in clefts is similar to that of a collapsing pyramid, a novel suspension technique has been described. The entire cartilaginous structure is lifted from the infratip segment with a loop suture and is secured in a cantilever fashion onto the periosteum overlying the nasal bone. This part of the operation is performed in a semiclosed manner. The technique is applied during primary surgery in bilateral and unilateral nasal cleft lip deformities, with changes in the orientation of the cantilever loop suture. Studies conducted by Masters S. Tajima, H. McComb, H. Thomson, D. Fisher, and J. Mulliken, which are most relevant to this article, have been reviewed and discussed throughout.ResultsThe technique was first applied over 10 years ago. A case series of nine children whose parents consented to the developing technique is presented with follow-up ranging from months to years, along with technical descriptions and illustrative drawings. None of these cases had preoperative orthopedic correction, molding, or postoperative nostril splints. The esthetic outcome was optimal enough; none of the cases requested a secondary correction.ConclusionThe nasal cantilever technique is a novel concept in cleft nasal deformity, which can be used in conjunction with an appropriate lip technique, per the surgeon’s discretion. Other than a learning curve, we believe that it provides a solid correction by securing the cartilaginous structures after they have been mobilized to a stable base, the nasion.

An embryological approach to philtral hair depletion in bilateral cleft lip deformities

An embryological approach to philtral hair depletion in bilateral cleft lip deformities

Surgical outcomes of 14 consecutive bilateral cleft lip patients treated with a modified version of the Millard and Manchester methods.

BackgroundBilateral cleft lip deformity is much more difficult to correct than unilateral cleft lip deformity. The complexity of the deformity and the sensitive relationships between the arrangement of the muscles and the characteristics of the external lip necessitate a comprehensive preoperative plan for management. The purpose of this study was to evaluate the repair of bilateral cleft lip using the Byrd modification of the traditional Millard and Manchester methods. A key component of this repair technique is focused on reconstruction of the central tubercle.MethodsFourteen patients with mean age of 5.7 months presented with bilateral cleft lip deformity and were operated on using a modification of the Millard and Manchester techniques. Patients with a very wide cleft lip and protruded or rotated premaxilla were excluded from this study. We analyzed 30 normal children for a comparison with our patients in terms of anthropometric measurements.ResultsBy the end of the follow-up period (between 9 and 19 months), all our patients had obtained a full central segment with adequate white roll in the central segment and a deep gingivolabial sulcus, and we obtained nearly normal anthropometric measurements in comparison with age-matched normal children.ConclusionsWe recommend this modified technique for the treatment of bilateral cleft lip deformity.

Reoperation of bilateral cleft lip deformity after primary Manchester or Veau III repair

Residual bilateral cleft lip deformities are commonly attributed to neglect of oral sphincter reconstruction during primary repair. This report describes a straightforward technique for reoperation that is applicable for most patients. It also describes the results of a retrospective observational cohort study of 21 patients that underwent reoperation performed by the senior author (MYM) from 1991 to 2018. The patients had undergone primary lip repair at other institutions. Their mean age at reoperation was 17 years. Pre- and post-operative photographs (at 3.5 years' postoperation) were assessed for 15 parameters. Overall configuration, scar appearance, philtrum anatomy, Cupid's bow shape, and esthetic aspects of lip dynamics improved considerably. This procedure is the same as that used by the authors in 4-month-old children who have undergone a nasolabial adhesion procedure at 4 weeks of age. We discuss the rationale of using this procedure for primary lip repair, thus eliminating the need for reoperation.

Repair of the Nasal Floor by the Cleft Margin Flap in Bilateral Complete Cleft Lip.

Bilateral complete cleft lip deformity has been the most challenging to plastic surgeons, and lots of methods of repair have been described in the literature. The basic principles are to achieve continuity of the orbicularis oris muscle, a balanced Cupid's bow with nasal ala, and a complete reconstruction of the nasal floor. The last one is, however, easily neglected. A well-reconstructed nasal floor serves as a good support of the nasal cartilage, which minimizes secondary deformity. In addition, a nasal floor with sufficient soft tissue and minimal contracture makes bone grafting easier in the future. The cleft margin flap was first introduced by Tajima in 1983 and used for the nasal floor repair in the unilateral complete cleft lip. The authors have used this technique in bilateral complete cleft lip repair, and from our practice, tension-free repairs of the nasal floors could easily be achieved by the cleft margin flaps. The results were satisfying and no significant scar contracture or deformity of the nasal floor was observed during follow-up. The authors conclude that the cleft margin flaps are viable and alternative choices for the repair of the nasal floors in bilateral complete cleft lip without major complications.

Fascial Graft Repair of Wide Bilateral Cleft Lip Deformity.

Wide bilateral cleft lip deformity reconstruction represents a special difficulty as it affects the lip, nose, and maxillary segments making single-stage reconstruction sometimes unobtainable. Many surgical and nonsurgical techniques have been prescribed to facilitate the definitive repair. Although some of these techniques proved to be useful, they have their inherent limitations and add another treatment step with all its possible complications and costs. The authors present a new method to address muscle layer repair in 1-stage procedure. It entails using fascial graft obtained from the temporalis muscle fascia or fascia lata, to reconstruct orbicularis oris lip muscle. Seven patients of wide bilateral cleft lip deformity (mean 17 mm) with a mean age of 4.4 months were subjected to single-stage lip reconstruction. After measuring the defect between both lateral muscle segments in front of the premaxilla intraoperatively ensuring that direct muscle repair could not be obtained, a fascial graft was harvested and sutured to both muscle edges. The authors found that, regardless the defect size or premaxilla protrusion, all wide clefts could be reconstructed satisfactorily in 1 stage procedure. No serious postoperative complications have been encountered in the lip or donor areas. Early follow-up reporting of the patients revealed stable repair. However more follow-up is still needed to assess late sequelae. In conclusion, fascial graft muscle repair of wide bilateral cleft lip deformity enables early 1-stage lip reconstruction without tension. The added donor morbidity is minimal and well tolerated.

Bilateral cleft lip revision: techniques and results

Bilateral cleft lip deformities can be difficult to correct and it is universally agreed that a large number of cases will require further revisions after the primary repair. The need for secondary repair and the type of secondary deformities is determined by the following:1.Type and severity of the initial cleft.2.The principles applied in the primary repair of these deformities. This presentation will look at the effect of different principles applied during the primary repair and how to manage the secondary deformities resulting from use of different principles of repair. The principles of repair will be considered under the following heads:1.Presurgical orthopaedics2.Lip adhesion procedures3.Staging of bilateral lip repair4.The utilisation of the prolabial tissues5.Muscle approximation6.Reconstruction of the central vermilion7.Sulcal release incision8.Management of the nasal deformities.

Correcting the secondary bilateral cleft lip deformities using an innovative partial-thickness musculomucosal pedicle cross-lip flap

Objective According to the fine artery anatomy of the lower lip, we developed an innovative partial-thickness myocutaneous flap based on the vascular network of the submucosal and subcutaneous layers of the lower lip. We attempted to treat the secondary bilateral cleft lip deformities using this innovative cross-lip flap. Methods From July 2009 to June 2015, this new technique was used in 98 patients with secondary bilateral cleft lip deformities. The central defects usually occurred in these patients. The defects were reconstructed partially or completely according to the severities of the defects. The operative procedures were as follows: The split flap was elevated from the posterior portion of the oris orbicularis muscle after the inferior labial arteries were divided. Then the partial-thickness flap was rotated 180 degrees horizontally and inverted 180 degrees upward to the upper lip defect. Results All 98 musculomucosal pedicle flaps were viable. The upper lips were reconstructed according to the severities. Conclusions This myocutaneous cross-lip flap with musculomucosal-pedicle has a more reliable blood supply, better flexibility and plasticity. It is an effective method for aesthetic reconstruction for the secondary bilateral cleft lip deformities. Key words: Bilateral clefit lip; Secondary deformity cleft lip; Cross-lip flap; Upper lip deformity

Different modalities for the management of bilateral cleft lip

Objectives The aim of this randomized prospective trial was to evaluate the different modalities for the management of bilateral cleft lip including primary and secondary deformities. Background Cleft lip repair will remain the aim of cleft surgeons. The complexity of deformity and the delicate interrelation between muscular arrangement and external lip features require a comprehensive approach for proper management. This study describes technical refinements in the skin design and modifications in the muscle repair in bilateral cleft lip. Materials and methods From January 2012 to April 2014, 16 patients with bilateral cleft lip deformities received surgical treatment in the form of either (group A, n = 10 patients) closure of the primary cleft according to the type and amount of protrusion of the premaxilla or (group B, n = 6 patients) repair of secondary deformities according the presentation. Demographic data, operative time, post, hospital stay, duration of incapacity for work, postoperative complications (infection, wound dehiscence, hypertrophic scar), symmetry, vermillion red alignment, quality of the scar, and patient satisfaction were recorded. Results The overall results were very satisfactory in function and appearance, without major complications. The lip adhesion procedure was performed at the age of 2-8 weeks postnatally, definitive lip closure at the age of 3-6 months (primary repair 10 cases), and secondary repair at the age of 2 years until adulthood (secondary repair six cases). Wound dehiscence occurred in two cases that healed spontaneously without intervention. Conclusion This method of comprehensive primary muscle, soft tissue, and skin reconstruction in bilateral cleft lip addresses the major sites of distortion in the lip, sulcus, and nasal floor, producing a full central segment, prominent philtral ridges, adequate white roll, and thick vermilion with a seam-like median tubercle in addition to a deep gingivo-labial sulcus and alar base symmetry. Nasal deformity postponed with secondary repair.

Harvey Cushing's Contributions to Plastic Surgery: Bilateral Cleft Lip Repair

Harvey Cushing has been deemed by many as the neurosurgeon of the 20th century. Cushing's unknown contributions to the field of plastic and reconstructive surgery were only recently reported. Further review of his teaching and operative records, brought from Johns Hopkins to Yale University, revealed an unpublished case of bilateral cleft lip repair that he performed. In this article, we present in detail this comprehensive case and describe, with the help of his personal teaching notes and illustrations, how Cushing combined methods from world-renowned surgeons to approach bilateral cleft lip deformities.

An evaluation of surgical outcome of bilateral cleft lip surgery using a modified Millard′s (Fork Flap) technique

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.

Single-Stage Repair of Asymmetrical Bilateral Cleft Lip with Contralateral Lesser Form Defects

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.

Repair of bilateral cleft lip and nose by the Mulliken method: a case report

J Korean Assoc Oral Maxillofac Surg 2012;38:360-5) The simultaneous surgical correction of bilateral cleft lip and nasal deformity has become a more common surgical technique that has greatly changed conventional strategies for secondary nasal correction. Mulliken has been known as one of the earliest proponents for the synchronous repair of bilateral cleft lip and nasal deformity, and he emphasized the responsibility of the treating surgeon to evaluate nasolabial growth by comparing anthropometric measurements with age-matched normal patients. Good outcomes from this surgical method have been reported in clinical cases worldwide. Herein, we describe the management of two cases of bilateral cleft repair, following the principles and methods established by Mulliken. We also provide a relevant review of the literature.

Improved Black procedure in microsurgical repair of bilateralcomplete cleft lip

Objective To discuss the effect of cheiloplasty we designed an improved Black procedure that with microsurgical technique the tissue from lateral lips on the bilateral cleft lip were used to reconstruct the skin of anterior lip and the vermilion tubercle. Methods 36 cases of congenital bilateral complete cleft lip deformity were repaired through improved Black procedure and microsurgical method, including 19 patients with very short prolabium tissue, repairing insufficient skin and vermilion tubercle tissue by fissure lateral lip tissue. Results Following-up for 3 months to 3 years after treatment showed that 36 patients were with normal and symmetrical high of anterior lips, the chubby vermilion tubercles, the natural morphous of labial archs, the appropriate strength of labrums and the vermilion tubercles and lips without color difference, and the effects were satisfactory. Conclusion The improved Black procedure redeems the shortages of traditional Black procedure for the case with bilateralcomplete cleft lip and smaller anterior lip, such as the deficient height of anterior lips, eclabium and inadequate vermilion tubercles. By applying microsurgical technique, the procedure gives better upper lip function and aesthetic effect, and therefore it is worthy to be recommended in clinic. Key words: Bilateralcomplete cleft lip; Improved Black procedure; Repair

Correction of complete bilateral cleft lip by using post nasal septal arterie's flap

Objective To develop a new method for correction of the deformity of the complete bilateral cleft lip with short pre-lip. Methods Two specimens with the complete bilateral cleft lip was chosen to investigate the arterial supply to the pre-lip. The arteries were observed by radiography when the specimen was infused with lead oxide. 16 patients with the complete bilateral cleft lip and shortage in the length of pre-lip were enrolled in this study. Taking advantage of the unique character of arterial supply of complete bilateral cleft lip, those with short pre-lip were corrected. Photos of them were taken when preand post-operation for further measurement. And more than 1 year following-up was conducted to judge if the results were good enough or not. 30 babies were chosen as a control group to confirm the results of surgury objectively. Results Post nasal septal arteries were found to supply the pre-lip of the bilateral complete cleft lip. Appearance of 16 patients was good after surgery or 1 years later. There was no statistical significant difference between the patients and control group in the measurement data but nasal-lip angle. Conclusion It is an effective way to correct deformity of the bilateral cleft lip with short pre-lip by taking advantage of post nasal septal arterie's flap. Key words: Bilateral compelet cleft lip with short pre-lip; Surgical correction; Post nasal septal arteries; Short pre-lip