25

BILATERAL

CLEFT

GAME PLAN

REGROUPING
THE BILATERAL
CLEFT

BEFORE THE
AS THERE
IS

CHARGE
SIDE

NO NORMAL

WITH WHICH NORMAL

IN

TO

COMPARE

IT

IS

NECESSARY TO PROJECT

THE GENERAL IDEAL CASE

THE

MINDS

EYE JUST

ABOVE THE

SPECIFIC VERTICAL

CONSTANT
WILL

COMPARISON
FACILITATE

BETWEEN THESE TWO BY

TRANSFORMATION BEFORE

NYSTAGMUS

THE

WE MAKE
SPECIFIC

FINAL

OUTLINE

OF THE PRESENT APPROACH

LET

US

REVIEW AGAIN
LIP

BILATERAL

GOALS ALL OF US WANT TO PRODUCE OR TOO LONG VERTICALLYONE

THAT

IS

NOT TOO TIGHT ADEQUATE

TRANSVERSELY

THAT

HAS AN

UPPER
ROLL

SULCUS
FULL

MUSCLETOMUSCLE

UNION

WHITE MIDLINE

MUCOCUTANEOUS
TUBERCLE AND
TO ACHIEVE

VERMILION

CUPIDS BOW WITH

OF NATURAL

DIMPLED PHILTRUM
THESE IN INFANCY

SHAPE
TO

WE
HEAL

SHOULD LIKE

WHEN

SCARS TEND

SMOOTHLY
ALL OF US ABHOR HAVING HAS NEARLY ADEQUATE REOPENING
INVISIBLE TISSUE
IT

TO

GO BACK INTO AN
SURGICAL

EXCELLENT IN

LIP

WHICH
TO GET

SCARS

FROM

CLOSURE

INFANCY
LIP

TO CORRECT

THE NOSE

TO

GET

GOOD
FLAP
IS

AND AVOID
ULTIMATE

FORCES THE

BANKING OF THE FORKED

BUT THE PRINCIPLE

THE

MANNER OF BANKING
ALL OF US WANT
TO

MAY VARY
COLUMELLA

HERE TO STAY
TIP

LONG ENOUGH TO ALLOW THE NASAL

ALAR BASES THAT ARE IN

STAND PROUDLY

FORWARD WITH
NOSTRIL IF THIS
SILL

NORMAL BASE
SCARS

POSITION
IT

FORMING
IDEAL

WITH THE

FEET OF THE COLUMELLA

WOULD BE

COULD BE ACHIEVED

EARLYFOR

BETTER

FOR BETTER TIENTS

NASAL

GROWTH AND DEVELOPMENT AND

OF THE TYPICAL DURING

TO AVOID

THE

PA
LIP

ENDURING THE STIGMAS

NASAL TIP

MIDSTAGE

BROAD

AND

FLATTENED

DEFORMITIES

PRESCHOOL AND SCHOOL

LONGTERM BANKING
UES TO PROVE THAT DIVISION
PARTICULARLY TOO LONG IN IN

IS

INCONVENIENT

BUT EXPERIENCE
IN THAT

CONTIN
INFANCY
BECOMES CLEFTS
IS

OF THE NOSE FROM THE PROABIUM

BILATERAL CLEFTS RESULTS AT LEAST IN IN
ZZIB

COMPLETE

VERTICAL

DIMENSIONS

THUS

COMPLETE

THE SECONDSTAGE
BETTER

SHIFTING UNTIL FLAP

OF THE FORKED FLAP INTO PRESCHOOL AGE OF FIVE

THE COLUMELLA
SIX

POSTPONED

TO

YEARS

THE CON

TWOSTAGE FORKED
VERGENCE
THREAT

HAS THE ADDED ADVANTAGE OF FIVE

FLAPS ALL AT AT

OF AVOIDING

OF THE POINTS

THE SAME TIME

THIS

WITH THE

OF COMPROMISING

THE HEALING

CENTER OF SCAR

CON

FUSION

CHANGE OF
IN
THOMAS CRONIN
HAVE
RESPECT

EMPHASIS PRINCIPLES
UNDER

WHOM WHOM

TRAINED

FOR

TIME

FOR

WHOM
STATED IN

AND WITH

OCCASIONALLY

DISAGREE

1971
CERTAIN PRINCIPLES

AND OBJECTIVES

OF TREATMENT

HAVE

BECOME

FAIRLY

WELL

ESTABLISHED

THESE ARE
PROLABIUM SHOULD FORM THE FULL VERTICAL LENGTH OF THE MIDDLE OF

THE

THE LIP

THE

VERMILION

RIDGE

OR

WHITE

LINE

OF

THE

INFERIOR

BORDER

OF THE

PROLABIUM

SHOULD

BE PRESERVED SHOULD BE BUILT UP WITH VERMILION HUT NO LATERAL SKIN FLAPS OF THE

THE THIN PROLABIAL VERMILION

FLAPS

MUSCLE

FROM THE

LATERAL

LIP

SEGMENRS

CORRECT DISPARITY

BETWEEN PREMAXILLARY

AND MAXILLARY

SEGMENTS

ALVEOLAR ARCH PREFERAHLY NONSURGICALLY PREVENT OR COTRECT

IF

POSSIBLE

COLLAPSE OF MAXILLARY

SEGMENTS BEHIND

THE PREMAXILLA EARLY ORTHODONTIA

BONE GRAFTING

TO

STABILIZE

THE PREMAXILLA

LENGTHEN THE SHORT COLUMELLA

FOUR OTHER FUNDAMENTAL

EVEN
PRIORITY

PRINCIPLES

MERIT

CONSIDERATION

AND

PREMEDITATED FOR LATER WASTEFUL SHAPE

FLAP
IS LZJ

ADEQUATE COLUMELLA

PLANNING

WILL

AVOID

THE NEED
IS

REENTY

MERE PARING

OF THE EDGES OF THE PROLABIUM

REDUCTION DESIRABLE

OF THE PROLABIUM TO NATURAL PHILTRUM SIZE AND THE COLUMELLA

IS IS

TOO

DAMN

SHORT SO THE FORKED

BANKING

MANEUVER

INDICATED

308

THE
ELEMENTS FUNCTION

CREATION

OF CONTINUITY JOINING

OFTHEPROLABIUM

WITH

THE LATERAL MUSCLES

LIP FOR

INVOLVES

LATERAL

MUCOSA

FOR SULCUS

BEHIND THE PROLABIUM AND WHITE

AND

ROLL

AND VERMILION

FOR SCAR CAMOUFLAGE

CUPIDS
NASAL

BOW BELOW
AAR

THE PROLABIUM
IS

EARLY PRIMARY

ANDPERMANENT
ROTATION TIPS OR

BASE POSITIONING

ENSURED BY BASES WITH

TO

MEDIAL

AND ADVANCEMENT OF
SUBCUTANEOUS
PEDICLES

THESE

DENUDED SEPTUM
FOR

ATTACHED

THE

STABILITY

TOTAL DIVISION PONED EVENTUAL

TO

OF THE PROLABIUM

FROM

THE

NOSE SHOULD BE POST

PICKING

UP OR UNFOLDING
THEIR

OF THE BANKED FORKS

AND
NASAL

ALAR BASES FLOORS

MAKE

POSSIBLE

MEDIAL
WILL

SWING
ACHIEVE

ACROSS

THE

AND UP INTO AND

STRUT NASAL

THE
TIP

COLUMELLA
RELEASE FOR

COLUMELLA

CON
SEPTAL

STRUCTION CARTILAGE

BANKED

HOMOLOGOUS

MAY

BE USED

EXTRA TEMPORARY

SUPPORT THIS
TO SIX

PROBABLY SHOULD BE ACCOMPLISHED

YEARS TO

BEFORE SCHOOL AGE OF FIVE

AVOID

IMPEDING

PHYSICAL

AND PSYCHOLOGICAL

GROWTH

TWENTYONE
THUS THE AND
PALATE STEPS IN

STEPS
MANAGEMENT OF
TO BILATERAL CLEFTS OF THE LIP

THE

CAN

BE INCREASED

21
OF THE PREMAXILLA
IN

PRACTICAL

BUT UNDERCORRECTED POSITIONING

FOR LIP

PREPARATION
ELASTIC

SURGERY

OR

BAND

TO

HEADCAP

ORTHODONTICS MECHANICAL

MCNEILLBURSTONHOTZROSENSTEIN
SQUEEZER

GEORGIADELATHAM

EARS PALATE AND

LIP

AT TWO AT AT

TO

FOUR WEEKS INSERTION

CLOSURE

OF EAR

TUBES

IF

INDICATED

THE SAME TIME THE SAME TIME

OF THE SOFT PALATE

LIP

WHEN POSSIBLE

DEFINITIVE

CLOSURE

DEFINITIVE

CLOSURE

USE OF ANY
LARY

EXCESS

PROLABIUM MUCOSA

TO

COVER THE PREMAXIL

RAW AREA
OF

REDUCTION

PROLABIUM

TO

PHILTRUM

DIMENSIONS
SIDES

TO

MM BY
309

PARING

FORKED FLAP FROM LATERAL

TURNDOWN OF

INFERIOR

PROLABIUM VERMILION

WITH CUPIDS

BOW

INCISION

FOR USE AS INVISIBLE

BACKING

TO

THE CENTRAL

TUBERCIE

FREEING

THE PROLABIUM

FROM THE PREMAXILLA FROM UPPER PORTION

DEFECT IN LATERAL

TURNUP
LATERAL
LIP

OF CLEFT EDGE MUCOSAL FLAP

OF

SEGMENTS

TO BE

USED TO

FILL

VESRI

BULE

FOLLOWING
CLEFT

RELEASE

OF THE

ALAR

BASE

FROM THE MAXILLA WHITE

LIP ROLL RIDGE IF

10

REMAINING
AS

EDGE MUCOSA CARRYING

FLAP

CUT THE
THIS

FULLBODIED

FROM EACH
RIDGE

LATERAL
IS

ELEMENT

PROLABIUM

MUCOCUTANEOUS

OUTSTANDING

THEN

RIDGE SHOULD BE PRESERVED AND NEED NOT BE BROUGHT WITH THE

LATERAL FLAPS LIP

11

LATERAL SLIGHTLY

ELEMENT

FREED

FROM THE MAXILLA

AND SKIN EDGE

FREED

FROM THE MUSCLE

OF THE MUCOSA AND MUSCLE OF THE
JOIN LATERAL LIP

12

ADVANCEMENT
ELEMENTS PREMAXILLA
TO

EACH

OTHER IN THE

THE MIDLINE
TO

IN

FRONT OF THE AN UPPER

AND BEHIND

PROLABIUM

OBTAIN

SULCUS AND MUSCLE CONTINUITY

13

REPLACEMENT OF THE PROLABIUM OVER THE JOINED BETWEEN THE

VERTICAL

MUSCLES THE

AND
FULL SCARS

SKIN

EDGES

OF

THE

LATERAL TENSION

ELEMENTS

LENGTH

OF THE LIP

WITH NO
CREATED

ON

THE SKIN

14
15

DIMPLE

OF THE PHILTRUM

ALAR BASES CUT FREE FROM THE LATERAL LIP ELEMENTS

FLAPS

AS FULLBODIED

AND EACH

FLAP

DIVIDED

INTO
FLAP

TWO COMPONENTS

SKIN

FLAP

AND

SUBCUTANEOUSMUSCLE
DEEPER SUBCUTANEOUS
SIDE

16 THE

FLAP TO

ADVANCED
IT

TO

ITS

MATE OF THE
SPINE

OPPOSITE

AND

SUTURED

AT

THE TOP

NASAL

WITH

VICRYL

ALAR BASES

THUS ADVANCED

ON

OF THE LIP

ADVANCE

MENTS WITH PERMANENT REDUCTION

POSITIONING OF THE ALAR BASES THE FORKS BASE SKIN
LIP

OF THE ALAR FLARE AND FIXED

17

BANKING
THE ALAR

BY SUTURING
FLAPS IN

THEM

IN

PYRAMID

FASHION

TO

THE FLOOR
ALAR BASES IN

OF THE NOSE WHISKER

OR BETTER

BETWEEN THE

AND THE

FASHION

COLUMELLA

LENGTHENING RELEASE BASES

18

NASAL

TIP ALAR

BY SECONDARY ADVANCEMENT OF THE FORKED

TO

FLAP

AND

FORM

NOSTRIL

SILLS

AND

COLUMELLA
SIX

THE
TO SIX

TIMING

OF THIS

MANEUVER MAY VARY FROM

MONTHS
POINTS

YEARS THIS

STAGED FORKED FLAP AVOIDS

THE FIVE

OF THE

310

ONESTAGE PROCEDURE
STRUT

BANKED HOMOLOGOUS
IN

SEPTAL

CARTILAGE AT 15 TO

CAN BE USED FOR EARLY SUPPORT

FINAL SCAR REVISIONS

THE CHILD

AND

16 YEARS DURING CAN BE ADDED

AN AUTOGENOUS SEPTAL STRUT

NOTE

MERSILENE

SUTURE HAS BEEN

REPLACED BY VICRYL

BECAUSE

OF

OCCASIONAL

POSTOPERATIVE

INFECTION

AND

PALATE

19

CLOSURE OF THE HARD PALATE WITH VOMERINE FLAP AT 18

IF

MONTHS

PREMAXILLA INCLUDES

IS

WELL WITHIN ANY FISTULAE

PALATE FLAP
IF

THE ARCH CLOSURE OF THE ALVEOLAR

CLEFTS

20

LENGTHENING OF
AGE

NECESSARY REDUCTION
FLAP

AFTER

FOUR TO FIVE THE

YEARS

OF

WITH

ISLAND

OR

OF

VELOPHARYNGEAL

APERTURE

WITH

PHARYNGEAL
GRAFTS INTO

21

CANCELLOUS

BONE

THE ALVEOLAR

GAPS AT EIGHT

YEARS
ARE

THIS
THERE

IS

NOT BE

21POINT
ADAPTED
STILL

BLUEPRINT THE

FOR ALL

CASES

THE

PRINCIPLES

TO

TO

SPECIFIC

PROBLEMS

DENTIST

SIMON THEM IMPOR

IN

HULLIHEN

WAS

PARING

THE CLEFT EDGES AND APPROXIMATING NEEDLES AND YET HE REALIZED CASE THE

WITH PARTYPE

TRANSFIXING

TANCE OF VARIATION AMERICAN JOURNAL

FOR THE INDIVIDUAL

HE

WROTE IN 1844

THE

OF DENTAL

SCIENCE

BUT

IN

ADDITION
IN

TO THESE GENETAL

INDICATIONS

PARTICULAR

PLAN

SHOULD

BE

ADOPTED
THIS

EACH OPETATION

WITH THE VIEW OF MAKING

STRICT

WELL FORMED LIP

AND

PLAN MUST HE MADE WITH

REFERENCE TO THE PECULIARITIES

LIP

OF THE CASE
IS

AND BE CAREFULLY

AND PLAINLY MARKED OUR UPON THE

BEFORE THE OPERATION

COMMENCED
TO REFLECT ON THOSE

AGAIN
SPECIFIC

IT

IS

IMPORTANT
LARGE
IS

WHO HAVE
DESIGN

HAD ANY

INFLUENCE

OR SMALL ON THE FINAL

CREDIT LINE IN

BEING

DE

SCRIBED

AND

THIS

THEIR

ALPHABETICAL

ALLOCATION

ADAMSBERKOWITZBROWNEBURSTONCOLLITOCRONINDESAULTDUFFY FARAFEDERSPIELGEORGIADEGILLIESHORRONKERNAHANLATHAMMIRY MIRMUIRONEALRANDALLSCHULRZWALKER

II

311