Repair Of Complete Unilateral Cleft Lip Research Articles

Scar Outcome in Unilateral Complete Cleft Lip Repair: A Comparative Analysis of Vertical Lip Lengthening Strategies Using the Rotation-Advancement Concept.

To assess the differences in scar outcomes between modified rotation-advancement techniques proposed by Drs. Mohler and Noordhoff, designed to address issues such as inadequate vertical lip length and scarring on the upper third of the lip in the original rotation-advancement technique. Retrospective single-surgeon (RD) study. Consecutive non-syndromic children (n = 68) with unilateral complete cleft lip and palate. Modified Mohler (columellar backcut reconstructed with C flap; n = 34) and modified Noordhoff (lower, medially-created backcut reconstructed with laterally-based triangular skin flap; n = 34) repairs. Using 12-month postoperative frontal photographs, scar evaluations (overall and superior, middle, and inferior portions of the lip) were appraised by an assessment panel composed by independent professional and nonprofessional raters employing four validated qualitative scar assessment scales: Manchester Scar Scale, modified Scar-Rating Scale, Stony Brook Scar Evaluation Scale, and Visual Analog Scale. Quantitative computerized photogrammetric scar widths of the superior, middle, and inferior portions of the upper lip were also measured. The modified Noordhoff method showed significantly (all P < .001) better scar quality for the overall scar and superior portion of the scar in all four scales compared to the modified Mohler method, with no significant (all P > .05) difference for the middle and lower portions. No significant difference (all P > .05) was observed for photogrammetric scar width measurements. The modified Noordhoff technique provided better qualitative results for unilateral complete cleft lip-related scars compared to the modified Mohler technique.

Complete unilateral cleft lip repair: A modification of the Mohler surgical technique

ABSTRACT Aims: Clefts manifested in cleft lip and palate are one of the most prevalent malformations in the craniofacial region. The objective of this study is to describe the surgical technique for the correction of unilateral cleft lip by means of a modification of the original Mohler technique with the same principle of rotation and advancement that allows us to obtain symmetry and balance on the cleft side. Patients and Methods: Two modifications were made to the original Mohler technique, one established in the preparation of two flaps for the conformation of the floor of the nostril, with which the mucocutaneous limit of the borders of the normal and cleft lip and the conformation of the vermilion were obtained. Using Z-plasty, clinical photographic records of the surgical technique and preoperative records as well as immediate, mediate, and late postoperative of the patients treated in our center were made. Results: In the patients who were treated under these modifications of the Mohler technique, the appropriate height was obtained on the cleft side compared to the healthy side, both 1 week and 1 month after surgery, it was discovered that the patients did not appear a discontinuity in the mucocutaneous line or at the vermilion level, the symmetry relationships at the vermilion level have significant differences in both height and thickness 1 week after surgery that improved at the control 1 month after surgery. Conclusions: The modifications made in the Mohler technique can be applicable and flexible for complete and incomplete clefts, obtaining favorable results in the functional and esthetic parts that allow following the patients with the stage of facial growth.

Growth-related nasal stability following unilateral complete cleft lip repair: A comparison of the standard and modified rotation-advancement technique

Growth-related nasal stability following unilateral complete cleft lip repair: A comparison of the standard and modified rotation-advancement technique

"Strategic Application of Anatomical Subunit Approximation Technique for Correction of Complete Unilateral Cleft lip".

To discuss advantages, disadvantages and strategical application of anatomical subunit approximation technique in complete unilateral cleft lip repair. Analysis of consecutive 28 cases. A single surgeon experience at a university hospital. Among 77 patients who underwent cleft lip repair between May 5, 2019 and June 30, 2021, 28 patients with complete unilateral cleft lip who received cheiloplasty by author's technique. Surgical outcomes were assessed by frontal view medical photographs obtained postoperatively at follow-up visits. The average length difference between cleft and noncleft sides was <10% for transverse lip length and philtral height. Nostril sill height demonstrated about twenty percent of difference with much variable results. Although the one sample t-test revealed that differences exist between the cleft and noncleft side, they were within an acceptable range. Understanding the strengths and limitations of anatomical subunit approximation technique enabled strategic application in complete unilateral cleft lip repair. Satisfactory outcomes were achieved not only regarding the scar placement but also regarding the symmetry of the lips and augmentation of nasal sill.

Cupid's Bow Leveling and Preservation of Lip Height and Width: A Modified Rotation-Advancement Technique.

Several methods for cleft lip repair have been developed over time, with no clear method considered the standard. In the authors' department, the use of a modified rotation-advancement technique rather than the traditional rotation-advancement technique in unilateral complete cleft lip repair has increased over the past decade. This study aimed to determine which technique provides better outcomes. This retrospective study was conducted by analyzing the preoperative and postoperative aesthetic nasal and labial anthropometric measurements of the frontal and basal views of 213 consecutive patients treated between October of 2013 and June of 2019. A total of 141 participants were treated with the traditional rotation-advancement technique, and 72 with the modified rotation-advancement technique. The inclusion criteria were nonsyndromic unilateral complete cleft lip repair with high-resolution, good-quality photographs; no presurgical nasoalveolar molding; no revision in the lip or nose areas; and at least 1 year of follow-up. Patients who received the modified rotation-advancement technique had significantly improved Cupid's bow position and orientation ( P < 0.02 and P < 0.01, respectively) and enhanced vertical lip height symmetry ( P < 0.01) while preserving the lip width. The columellar length ( P < 0.03) and angulation ( P < 0.045) were also significantly improved, with enhanced nostril inclination in this group ( P < 0.06). According to the findings of the current study, modified rotation-advancement technique assisted surgeons in improving symmetrical leveling of the Cupid's bow and significantly aided in correcting lip height without compromising lip width. Moreover, the modified rotation-advancement technique resulted in better aesthetic nasal outcomes. Therapeutic, III.

Novel Reconstruction of Orbicularis Oris in Unilateral Complete Cleft Lip Repair.

Background: Orbicularis oris muscle repair is key to successful unilateral cleft lip repair. Objective: To measure the lip symmetry after repair of the lip muscles in the midline compared with traditional repair on the cleft side. Methods: A retrospective review and photographic analysis of patients with complete cleft lip treated with the modified approach were carried out. Anthropometric analysis was done at pre-, immediate, and 1-year postoperatively, and at 1-year follow-up. Four upper lip and six nostril landmarks were measured. Results: Fourteen patients met inclusion criteria. Immediate postoperatively, the horizontal lip length on the cleft side was shorter than that on the noncleft side, but the discrepancy decreased as facial development progressed over the course of a year. Lip measurements at the 1-year follow-up were approximately symmetrical in vertical lip height, philtral height, and lateral lip height. Small changes in the nasal correction occurred at 1 year. Conclusion: A modified technique in the unilateral complete cleft lip repair seeks to balance the perinasal and perioral muscles and improve symmetric outcomes.

Can surgeons rely on growth-related changes to achieve lip height and width symmetry in unilateral complete cleft lip repair?

Surgeons face difficulties achieving simultaneous lip height and width symmetry while repairing unilateral complete cleft lip, so one is often sacrificed at the expense of the other. The aim of this study was to evaluate the effect of growth on lip height and width symmetry, to guide the surgeon to the best decision. The study patients (N = 105) were divided into two groups based on the treatment method: 42 were treated with the modified rotational advancement technique (MRA group) and 63 with the Millard rotation-advancement technique (RA group). Furthermore, based on lip height and width symmetry at 6 months postoperative, the patients were divided into three groups: 38 with symmetrical lip height and width (SL), 41 with horizontal lip width more symmetrical than lip height (RAW), and 26 with vertical lip height more symmetrical than lip width (RAH). Measurements were taken preoperatively (T0), 6 months (T1) and 5 years (T2) postoperatively. The MRA group had significantly more symmetrical lip height than the RA group at T1 (P = 0.003) and T2 (P = 0.002); however no statistically significant difference in lip width symmetry was observed between the two groups. In relation to the effects of growth, only lip width symmetry in the RAH group improved significantly between T1 and T2 (P = 0.023). In conclusion the improvement in lip width symmetry following 5 years of postoperative growth did not achieve the same symmetry as when lip width symmetry was achieved intraoperatively. Thus, the MRA technique could be used to obtain intraoperative symmetry of lip height and width.

Stability of nasal symmetry following primary cleft lip and nasal repair: five years of follow-up

Despite advances in cleft lip treatment, various levels of residual deformity remain after primary repair of cleft lip and palate. The aim of the current study was to compare the stability of short- and long-term postoperative nasal symmetry. This retrospective study included 100 consecutive non-syndromic patients with unilateral complete cleft lip who underwent primary cleft lip repair with follow-up of 5 years. Measurements taken from basal and frontal standard photograph views, obtained preoperatively (T1) and immediately (T2), 1 year (T3), and 5 years postoperative (T4), were analysed. Paired and independent t-tests were applied to assess the significance of differences and relationships, while the inter-class correlation coefficient was used to assess reliability; P < 0.05 was considered significant. The male to female ratio was 1:1; mean age at the time of surgery was 0.43 ± 0.25 years. All patients showed significant improvements following unilateral complete cleft lip repair. All variables measured at T3 revealed a significant relapse when compared to T2, except alar base position, which showed a constant mean across all postoperative follow-ups. Late relapse (T3–T4) was not significant for alar collapse, alar base position, or columellar angle (all P > 0.05). On the other hand, columellar height (P = 0.003), and nostril height (P = 0.038) and width (P = 0.007) showed significant improvements during the late relapse period. In conclusion, the majority of the relapse and changes following the nasal cleft repair occurred within the first postoperative year. However, nasal asymmetries tended to remain stable or reduced during the first 5 postoperative years.

Comparative study of complete unilateral cleft lip repair by Millard’s rotation advancement procedure and triangular flap repair of Tennison

This study was done to evaluate and compare the surgical outcomes of primary repair of Complete Unilateral Cleft lip by Millard’s rotation advancement technique and Randall-Tennison’s Triangular flap technique in terms of Quantitative and qualitative assessments like cupid bow pouting, vermilion symmetry, nasal floor alar base symmetry and scar appearance was analysed by 5 different Plastic surgeons. 40 patients of complete Unilateral Cleft Lip operated using either Millard’s technique or Randall-Tennison’s Triangular flap technique (20 each) in the Department of Burns, Plastic and Reconstructive Surgery, SCB Medical College and Hospital, Cuttack for 2 years. They were compared with 20 normal patients (control). Overall mean age was 5.07 ± 1.41 months and 1st birth order comprised of 45.0%. Family history was found among 6.7% cases. 78.3% patients were in age group 3 – 6 month, 21.7% in 6 -12 months age group. Postoperatively there was significant difference in total nasal width between Tennison and control , Millard and Tennison but insignificant between Millard and Control.There was no statistical difference between Modified Millard’s rotation advancement technique and Randall-Tennison’s Triangular flap technique for the primary repair of the unilateral cleft lip under the hands of a qualified and skilled Plastic Surgeon.

Modified Rotational Advancement Technique for Primary Unilateral Complete Cleft Lip Repair.

Importance: Leveling Cupid's bow while maintaining lip height and width in unilateral complete cleft lip patients with improved nose outcomes is a significant challenge for surgeons. Objective: This study aimed to measure the symmetry of the nasal and labial anthropometric points after using this modified cleft lip repair technique. Design, Setting, and Participants: In this retrospective study, 72 consecutive nonsyndromic unilateral complete cleft lip patients underwent a modified rotational advancement technique. Photos of at least 1 year follow-up period were collected. Main Outcomes and Measures: The nose measurements included columella length, nostril height and width, ala width, nostril inclination, columella angle, and ala bases angle. The lip measurements included lip height and width, vermillion height; midline-philtrum angle, and angles of Cupid's bow peaks. Descriptive quantitative analysis of the lip and nose measurements, intraclass correlation coefficient, and ANOVA tests were conducted. Results: Well-aligned Cupid's bows with symmetrical lip height and width were obtained with satisfactory aesthetic nasal outcomes. Conclusions: The present technique had leveled the Cupid's bow while preserving the lip height and width, with resultant satisfactory nasal outcomes.

A Surgical and Educational Video of the Inferior Turbinate Mucosal Flap for the Nasal Floor and Intraoral Reconstruction in Unilateral Complete Cleft Lip Repair.

Since the original description of Millard rotation advancement principle for cleft lip repair, many important contributions have subsequently been described by other surgeons worldwide. However, the reconstruction of the nasal floor and intraoral lining has received less attention over time. This article demonstrates a modified unilateral complete cleft lip repair using the rotation advancement principle plus multipurpose inferior turbinate mucosal flap. The accompanying videos display the 10 key steps for rationale, design, and proper execution of the inferior turbinate mucosal flap for the nasal floor and intraoral reconstruction.

Esthetic evaluation of early rhinoplasty with complete unilateral cleft lip repair after nasoalveolar molding

Background: The aesthetic outcome of primary rhinoplasty with complete unilateral cleft lip repair is a challenging due to nasal deformities, tissue deficiencies and alveolar ridge displacement. The aim of this study is aesthetic evaluation of primary rhinoplasty with complete unilateral cleft lip repair after nasoalveolar molding (NAM). Patient and methods: The study was applied on 30 patients with complete unilateral cleft lip, mean age at presentation was 89.17± 73.02 days (range 15-260 days). Presurgical nasoalveolar molding (PNAM) was done for all patients with mean duration of molding 78.48± 5.635 days (range 66-87 days). Measurements of nose and alveolar defect were taken by caliper before application of the device and after application of the device and after one month of operation and compared with each other’s. All patients were subjected to lip repair with Millard technique with primary closed rhinoplasty. Primary rhinoplasty with cleft lip repair becomes easier since NAM diminishes the tension over the soft tissues and reduces severity of deformity in the lower lateral alar cartilages. Postoperative nasal stent has a great role in improve the esthetic outcome of primary rhinoplasty. Results: There were significant improvement of nasal symmetry and reduction of alveolar gap width (AGW) after use of NAM. Conclusion: This study suggests that PNAM within 15 days post-delivery is effective at reducing alveolar gap width, alignment of cleft alveolar segments and improvement of nasal symmetry as long as the parents cooperate in placing and maintaining the NAM device in the newborn’s mouth and nose.

Esthetic evaluation of early rhinoplasty with complete unilateral cleft lip repair after nasoalveolar molding

Background: The aesthetic outcome of primary rhinoplasty with complete unilateral cleft lip repair is a challenging due to nasal deformities, tissue deficiencies and alveolar ridge displacement. The aim of this study is aesthetic evaluation of primary rhinoplasty with complete unilateral cleft lip repair after nasoalveolar molding (NAM). Patient and methods: The study was applied on 30 patients with complete unilateral cleft lip, mean age at presentation was 89.17± 73.02 days (range 15-260 days). Presurgical nasoalveolar molding (PNAM) was done for all patients with mean duration of molding 78.48± 5.635 days (range 66-87 days). Measurements of nose and alveolar defect were taken by caliper before application of the device and after application of the device and after one month of operation and compared with each other’s. All patients were subjected to lip repair with Millard technique with primary closed rhinoplasty. Primary rhinoplasty with cleft lip repair becomes easier since NAM diminishes the tension over the soft tissues and reduces severity of deformity in the lower lateral alar cartilages. Postoperative nasal stent has a great role in improve the esthetic outcome of primary rhinoplasty. Results: There were significant improvement of nasal symmetry and reduction of alveolar gap width (AGW) after use of NAM. Conclusion: This study suggests that PNAM within 15 days post-delivery is effective at reducing alveolar gap width, alignment of cleft alveolar segments and improvement of nasal symmetry as long as the parents cooperate in placing and maintaining the NAM device in the newborn’s mouth and nose.

Anatomical Reconstruction of the Nasal Floor in Complete Unilateral Cleft Lip Repair.

Numerous methods exist for repairing unilateral cleft lips and mainly focus on cutaneous design to achieve sufficient rotation of the medial (M) cleft lip and produce a natural Cupid's bow and philtrum. However, precise nasal floor reconstruction has not been described in detail. This is the first study to introduce a technique for repairing complete unilateral cleft lips with a focus on nasal floor reconstruction. In our technique, "Straight-Line Advanced Release Technique (StART)," the nasal floor is considered a 3-dimensional cuboid structure; the M mucosal and lateral (L) mucosal flaps constituted the posterior surface. The M flap became the roof of the orbicularis oris muscle sling and the posterior side of the nasal lining. The B flap met the L lip flap at the superior border of the M flap, and together they formed the roof and anterior surface. The B flap also formed a transitional zone connecting the columella and nasal floor. Seventy-two patients with complete unilateral cleft lip were treated from 2003 to 2015. The difference in the height of the nostril sills between the cleft and non-cleft sides was not significantly different from that in control patients (P = 0.472) 1 year postoperatively. Twenty operations for secondary deformities were performed: 8 for nose deformities not involving the nasal floor. The transverse scar at the alar base was concealed within the nostril. Nasal floor reconstruction is important in complete unilateral cleft lip repair. Our technique provides a naturally shaped, symmetrical nasal floor without conspicuous scarring.

The efficacy of vomer flap for closure of hard palate during primary lip repair

This study presents the institutional experience of the use of vomer flap for early closure of hard palate during unilateral complete cleft-lip repair. The purpose of this study was to determine the survival rate of the vomer flap and to investigate its effect on the subsequent palatoplasty. This retrospective analysis includes 101 non-syndromic patients with complete unilateral cleft lip who received a vomer flap for the closure of the hard palate during cleft-lip repair. Patients were aged 6 months to 28 years (median 1 year). Success rates of the vomer flaps were assessed clinically and through pre-operative photographs taken at the time of subsequent palate repair. Ninety-two patients returned for second-stage palate repair, and 74 patients with adequate post-operative follow-up information were statistically analysed. Of the 101 patients who were operated with primary lip repair and simultaneous vomer flap, only 54 (52.4%) vomer flaps healed completely. Out of 92 patients who returned for subsequent palatoplasty, 71 (77.2%) were operated with the two-flap technique, and 19 (20.7%) received von Langenbeck repairs. Seven (9.1%) patients had a surgical complication. The failure of previous vomer repair and von Langenbeck surgical technique were identified as factors associated with post-operative complications. We conclude that failed vomer flaps increased the risks of complications in the subsequent palate repair. Furthermore, efforts to use von Langenbeck technique rather than the two-flap technique also resulted in increased surgical complications. As a result, we have abandoned the use of the vomer flap with primary lip repair.

Effect of music therapy on acute postoperative analgesic requirement in unilateral complete cleft lip repair by Tennison′s triangular variant technique: A double-blinded randomized control trial

This clinical study aims at evaluating the effect of music therapy on pain relief and postoperative analgesic requirement in patients with unilateral cleft lip undergoing repair by Tennison's triangular variant, in the age group of 6-12 months. A total of 105 patients fulfilling the inclusion criteria were included in this study with 50 patients receiving music therapy and 55 patients not receiving the same. The hemodynamic parameters and objective pain scale by Hanallah were assessed by a person blinded to the groups. When tested, the results showed a statistically significant decrease in the mean number of times fentanyl was required and in the mean pain score. However, there was no significant difference between the 2 groups with respect to oxygen saturation and heart rate.

Lip Height Improvement during the First Year of Unilateral Complete Cleft Lip Repair Using Cutting Extended Mohler Technique

Objective. To compare the cutaneous lip height at early and late postoperative periods and to objectively determine the average amount of lip height improvement during the first year of unilateral complete cleft lip repair using Cutting extended Mohler technique. Methods. In this prospective cohort study, 26 unilateral complete cleft patients and 50 noncleft subjects were included. Photographs were taken between 12 and 16 weeks (T1) and also taken between 12 and 13 months after surgery (T2). The cutaneous lip height distance (photogrammetric lip analysis) obtained in these two periods of time were measured and statistically analyzed. Results. The average lip heights were 24% ± 9% in T1 and 8% ± 6% in T2 (P < 0.01). The average lip height asymmetry in the noncleft individuals was 4.52% ± 1.89%. Conclusion. Since all principles to obtain a symmetrical Cupid's bow were performed, the postoperative pull-up of Cupid's bow is probably owed to the scar contracture, which improves by 2 times during the first year after surgery.

3D stereophotogrammetric analysis of lip and nasal symmetry after primary cheiloseptoplasty in complete unilateral cleft lip repair

The aim of this study was to evaluate symmetry of the lip and nose in patients with CUCLP after primary cheiloseptoplasty (Afroze technique), in comparison to non-cleft controls. In this prospective study, forty-four patients with operated non-syndromic CUCLP were included. The control group consisted of 44 volunteers without cleft defects of approximately the same age and sex. Primary septoplasty was performed in conjunction with the cleft lip (CL) repair using the Afroze incision. 3D facial images were acquired using 3D stereophotogrammetry. After a 3D cephalometric analysis of the lip and nose was performed in both groups, linear and volumetric data were acquired. Lip and nose symmetry were calculated and compared using Student`s t-tests as well as the Chi square test. For all measurements, the control group was up to 36% closer to perfect symmetry compared to the CUCLP group after primary surgery. This difference was statistically significant. After primary cheiloseptoplasty according to the Afroze technique in patients with CUCLP, asymmetry in the nose and lip area still exists as compared to non-cleft controls. Although non-cleft individuals also show some degree of asymmetry, the results of this study stress the difficulty in obtaining near normal symmetrical relations.

3D stereophotogrammetric analysis of lip and nasal symmetry after primary cheiloseptoplasty in complete unilateral cleft lip repair

Background: The aim of this study was to evaluate symmetry of the lip and nose in patients with CUCLP after primary cheiloseptoplasty (Afroze technique), in comparison to non-cleft controls. Methodology: In this prospective study, forty-four patients with operated non-syndromic CUCLP were included. The control group consisted of 44 volunteers without cleft defects of approximately the same age and sex. Primary septoplasty was performed in conjunction with the cleft lip (CL) repair using the Afroze incision. 3D facial images were acquired using 3D stereophotogrammetry. After a 3D cephalometric analysis of the lip and nose was performed in both groups, linear and volumetric data were acquired. Lip and nose symmetry were calculated and compared using Student`s t-tests as well as the Chi square test. Results: For all measurements, the control group was up to 36% closer to perfect symmetry compared to the CUCLP group after primary surgery. This difference was statistically significant. Conclusions: After primary cheiloseptoplasty according to the Afroze technique in patients with CUCLP, asymmetry in the nose and lip area still exists as compared to non-cleft controls. Although non-cleft individuals also show some degree of asymmetry, the results of this study stress the difficulty in obtaining near normal symmetrical relations.

Current Surgical Practices in Cleft Care: Unilateral Cleft Lip Repair

The purpose of this study was to report objectively on practice trends in unilateral cleft lip repair in the United States and Canada. This study details current technique preferences, modifications, and adjunct procedure use. All surgeons in the American Cleft Palate-Craniofacial Association and the Canadian Society of Plastic Surgeons (n = 1138) were mailed a survey inquiring about their management of unilateral cleft lip. Responses were received from 622 surgeons (55 percent response rate), of whom 269 currently perform cleft surgery. The results arise from this group of 269 active cleft surgeons. Eight-four percent of surgeons perform rotation advancement for complete unilateral cleft lip repair. Nine percent perform a variation of the triangular flap repair. Among those using rotation advancement, 45 percent use a modified technique. The most common modifications are the Noordhoff vermilion flap, the Mohler modification, and the Onizuka triangular advancement flap. Surgeons rarely use more than one technique in their practice, and 86 percent use the same repair for every unilateral cleft lip. Over half of surgeons routinely perform some form of primary nasal correction. Lip adhesion, presurgical orthopedics, nasoalveolar molding, and postoperative nasal stenting are performed by limited numbers of respondents, and the use of these surgical adjuncts is discussed. Rotation advancement remains the most frequently used technique for unilateral cleft lip repair. However, almost half of those using rotation advancement perform a modification to the original technique. Surgeons should be familiar with both the rotation advancement repair and its common modifications. Among adjunct procedures, only primary nasal correction currently garners widespread use.