Methodology Cleft Lip and

Palate

Methodology

Cleft Lip and Palate

MATERIAL AND METHOD

This is a retrospective study of case series, data were obtained from
patient's files kept in Benghazi medical centre and Alnajda Clinic patient,
follow up sheets and patients' parents from December 2012 to current date in
2017. All patients were admitted to plastic surgery unit in the BMC and in
Alnajda clinic, all patients were evaluated by paediatrician before referral to
surgery. The Tennison's technique and Millard technique were adopted for
cleft lip repair, and the intervelar veloplasty and the push back technique for
cleft palate cases according to each case demands. The cleft lip operated at
the age of 3 months and then patients discharged home after one or two days
postoperative period and then followed up at the OPD after which the
mother was taught how to deal with patient postoperatively. Patients were re
admitted at the age of 9 months for repair of cleft palate, and seen by
paediatrician and nutritionist to evaluate the fitness for operation and by
orthodontist to evaluate the patient orthodontics.
The cases were defined by their name, date of birth, gender, file number,
residency ….etc. Questionnaire was designed to serve the aim of the study.
The Data were collected in their final form and then analysed. And finally an
Excel program was used to analyse the collected data and to make statistical
and pie charts for the results.

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Due to shortage of some required data as a result of poor documentation;

the files that do not contain any data regarding some point were excluded
from the study.
The used parameters and questionnaire were listed in an order to serve
the study; the incidence of cases according to years and months and in
comparison to the incidence all over the world, the male to female ratio, the
age at presentation, the geographical distribution of cases, the blood group in
each patient for the possible association between certain blood group and
developing cleft lip and palate, the associated anomalies, the CLP type and
its management and finally the complications occurred, if any, and their
management.
INITIAL MANAGEMENT
All patients were seen in the OPD either transferred from paediatric
hospital in Benghazi or from the surrounding towns. The patients were seen
and files were opened for them in the OPD in their first visit. History was
taken from the mother for the possibility of drug intake or gestational
problems. Family history was taken from both mother and father for the
possibility of previous similar cases in the family. All patients were
examined thoroughly for their general condition, their overall health and
their possible associated anomalies. The parents were counselled and the
plan for management explained for them in simple language. The mothers
were instructed for feeding methods according to the type of cleft lip or
palate present; some cases –in whom the defect were classified as minor
defect– the mother was told that the infant might do well if given extra time
to nurse or bottlefeed. If the baby was to be bottlefed; the mother was

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instructed to enlarge the size of the hole in the nipple or to use specially
fabricated nipples dedicated for use for cleft lip or palate patients. These
nipples are longer and larger than normal and are designed to occlude and
bypass the cleft. Mothers were also instructed to feed the babies in the seated
position to limit the amount of nasal regurgitation.
At the end of the first visit, children with cleft lip and palate were
transferred to paediatrician and nutritionist to be monitored closely in their
early life to ensure that they were feeding adequately and gaining weight,
and were scheduled for another visit prior to surgery; and files were archived
and kept in the hospital and clinic archive until the patient come to his next
visit prior to surgery.
TIMING OF CLEFT LIP AND PALATE REPAIR
Patients with cleft lip were scheduled for surgical repair at the age of 3
months; this age was chosen to correct the cosmetic deformity (12). Patients
were contacted by telephone to come to our OPD to be seen and weight
checked, brief examination done to ensure patient fitness for surgery.
Patients were admitted to paediatric ward to be operated in the next day.
Patients with isolated cleft palate were scheduled for surgical repair at the
age of 9 months; this age was chosen to restore function to the palate and
allow normal speech and feeding (12).
SURGICAL TECHNIQUE
REPAIR OF UNILATERAL CLEFT LIP
The standard and most commonly used technique in our department for
cleft lip is the Tennison (Randall-Tennison) technique was applied for
patients while Millard technique was used for patient. For patients with cleft

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palate; intervelar veloplasty was used for patients, while the push back
technique was applied for patients. The decision making for cleft lip and
palate cases is shown in (Fig 14) and the plan of management is shown in
(Fig 15). And the detailed plan of management for bilateral cases is shown
in (Fig 16).

Fig [14]: Overall treatment plan in the Chang Gung craniofacial centre

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Fig [15]: Surgical algorithm for cleft lip repair in the Chang Gung Craniofacial Centre

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Fig [16] Algorithm for correction of asymmetrical bilateral cleft lip (complete/incomplete)
and contralateral incomplete or lesser form cleft. DFO = dentofacial orthopaedic, GPP=
gingivoperiosteoplasty.

POSTOPERATIVE CARE
Postoperative considerations after cleft lip repair
Feeding was started as soon as the baby desires. Mothers were instructed
to deliver the milk using a syringe to avoid the process of suckling.

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Alternatively, a soft nipple with good flow was used with bottle-feeding.
Parents were instructed in suture-line care and to keep the nostrils clean.
Antibiotic ointment was placed on the suture line after it was cleaned, to
keep it from drying out or crusting. This regimen continued for two weeks
postoperatively.
Percutaneous sutures are removed 5–6 days postoperatively under
general anesthesia using mask induction and insufflation.
After suture removal, a 1/2 inch transverse Steri-Strip® was trimmed and
placed over the labial scars to aid healing. If placed, the tape was typically
changed as needed for 6 weeks.
After adequate healing has occurred, the parents were instructed how to
perform digital massage to hasten scar maturity and counselled about the
importance of application of sun-block ointment
Postoperative considerations for cleft palate repair
Postoperative hypoxemia is not uncommon, but generally
resolves after 24–48h.
• The use of a traction suture in the tongue during
the immediate period after extubation may avoid the
need for utilizing any oral devices for maintaining the
airway.
• Some centers use nasal trumpets routinely to improve
ventilation.
• Monitoring with continuous pulse oximetry and
minimizing narcotic use will help to avoid catastrophic
problems.

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• Acetaminophen 15mg/kg alternating with ibuprofen

10mg/kg will usually give adequate pain relief.
• Any patient who has had prolonged surgery (over 2h)
with the mouth gag in place should be observed for at
least 48h for tongue edema.
Children with Pierre Robin sequence and any other
children with syndromes that may affect breathing must
be observed closely, even in an ICU setting.
• There are inevitably raw surfaces which may ooze for
12–24h.
• Bleeding can be reduced by surgery that takes less than
90–120 min because the epinephrine will still have some
effect during emergence from anesthesia.
• Light pressure on the hard palate repair at the conclusion
of the procedure will often control bleeding as well.
• The author has found that application of ice packs to the
posterior neck is almost always effective in stopping
postoperative bleeding in recovery or on the ward.
• Postoperative feeding is generally limited to liquids for
10–14 days, to prevent particulate matter lodging in the
areas that are left open at the end of the procedure.
• The parents must learn to time feeding for 30 min or so
after analgesic administration.
• Arm splints may be used as well to prevent children from
putting their fingers, or more likely foreign objects, in

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their mouth.

used for the repair of a unilateral cleft lip is the rotation advancement
technique developed by Ralph Millard, the father of modern cleft lip and
palate surgery. This procedure provides excellent cosmetic results. In the
past, cleft lip operations closed the defect but sacrificed the Cupid’s bow in
the process. The results were eye-catching and unsightly, but Millard
developed a repair that could preserve Cupid’s bow (11). This technique
utilizes a rotation and an advancement flap to close the defect while
preserving Cupid’s bow. His technique repositions the laterally displaced
alar base restoring symmetry to the nostril and ala and closing the floor of
the nose defect.
The Millard repair uses four flaps to close the cleft lip and restore the alar
base to a more natural position: rotation flap, advancement flap, alar flap,
and columellar flap. The rotation flap lowers the medial aspect of the lip to
level the Cupid’s bow and add length to the lip. The advancement flap
includes the portion of the lip lateral to the cleft and is used to close the cleft
defect by suturing it to the rotation flap. Medialization of the alar flap
restores the ala to a more natural position. Suturing the alar flap to the
columellar flap closes the cleft in the floor of the nose.
The following is a summary of the technique first described by Millard
and still frequently used today. The first and most important step in the
Millard repair is identifying the landmarks and marking the key points used

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in the repair (Fig. 3). The marking process consists of identifying and
measuring 12 points along the upper lip and base of nose (Table 1) (11).
Point Location
Point 1 Low point of Cupid’s bow
Point 2 High point of Cupid’s bow on the noncleft side
Point 3 High point of Cupid’s bow on the cleft side
Point 4 Alar base on the noncleft side
Point 5 Columellar base on the noncleft side
Point 6 Oral commissure on the noncleft side
Point 7 Oral commissure on the cleft side
Point 8 High point of Cupid’s bow on the lateral lip segment
Point 9 Medial limit of the advancement incision
Point 10 Alar base on the cleft side
Point 11 Intersection of nasolabial fold and alar crease
Point 12 Lateral extent of advancement incision

Table [1] 12 points of the Millard Repair

The columella base on the noncleft side is identified and marked with a 5.
This point will correspond to the superior limit of the incision for the
rotation flap. If additional rotation is needed to add length to the lip, a 1–
2mm back cut is made from point 5 to point X.
Point 8 represents the measured location of the high point of Cupid’s bow
on the lateral portion of the lip. This is found by measuring the distance from
the commissure to the high point of Cupid’s bow on the normal side: the
distance from point 6 to point 2. This distance is measured from the
commissure on the cleft side to the point that will represent the high point of
the Cupid’s bow on the cleft side. The distance from point 6 to point 2 must
equal the distance from point 7 to point 8 (Fig. 4).

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Figure [3] Landmarks of Millard repair are identified before beginning the procedure (11).
The final area to be marked is the alar base on the cleft side. Point 9
marks the medial limit of the advancement flap. When the incisions are
closed, point 9 will lie in the triangular defect created by the rotation of the
medial lip segment. The total length of the rotational incision, point 3–5–X,
will determine the exact location of point 9. The incisions from point 3 to 5
to X must equal the incision from point 8 to 9 since these two segments will
be sutured together and must line up evenly. Millard recommended using a
malleable piece of wire to measure the length of the rotational incision and
then placing point 9 exactly this far from point 8 (Fig. 5).
The circumalar incision is then marked to allow the ala to be advanced
medially and assume a more natural position (Fig. 6). The alar base on the
cleft side is identified and marked with 10. Point 11 should be placed along

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the border of the ala at the point where it intersects with the nasal labial fold.
Point 12, also along the alar facial crease, represents the most lateral aspect
of the advancement flap. The amount of medialization of the ala will
determine the final location of this point.

Figure [4] Calipers are used to determine the proper location of Cupid’s bow. The distance
from bow peak to commissure should be the same for the two sides.

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Figure [5] A section of malleable wire is used to measure the length of the rotation and
advancement incisions. These two lines must be of equal length to ensure a good result (11).
The medial and lateral aspects of the cleft are drawn together and sutured
in layers. According to Millard, there is a single key stitch that must be
placed perfectly to ensure that the wound edges line up properly (Fig. 7).
The stitch is placed in the leading edge of the advancement flap and in the
depth of the defect in the rotation flap. When this stitch is tied, the
advancement flap and rotation flap are fixed into their final position (8).

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Figure [6] The circumalar incision allows the alar flap and advancement flap to be moved
independently. The helps to reposition the nose to a more natural position (11).

The defect is closed in three layers including the mucosa, orbicularis oris,
and skin. The suture line and resulting scar approximate the philtral ridge
and are well camouflaged (Fig. 8).
There is always some degree of nasal deformity associated with unilateral
cleft lip. The nasal deformity is produced both by the embryological error
that led to the cleft and by the deforming effects of inappropriately inserted
fibres of the orbicularis oris muscle. These actions lead to a laterally
displaced ala and displacement of the columella and caudal septum to the
noncleft side. By releasing the inappropriately inserted fibres of orbicularis

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oris and performing the nasal release, the columella and ala can be restored
to a more natural position.
Postoperative care focuses on feeding and wound care. Feeding is
typically performed using a syringe with a soft catheter attached to deliver
formula to the oropharynx. Since sucking requires use of the orbicularis oris
and stresses the wound, it is avoided when possible. However, some
surgeons permit breastfeeding in the early postoperative period. Routine
feeding can be resumed 3 weeks postoperatively.

Figure [7] The key stitch is so named because it determines the exact amount of rotation.
Correct placement of this stitch is essential to a good outcome (11).
The wound is cleansed several times daily with half-strength hydrogen
peroxide and topical antibiotic ointment is applied. Skin sutures are removed

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on or around postoperative day 5. Although controversial, Logan’s bow is

sometimes used to reinforce the suture line: an arched metal bar that bridges
the two sides of the incision and is attached to both cheeks with adhesive.
All children will require the use of Velcro arm restraints to prevent them
from manipulating the wound.
In recent years there has been a renewed interest in the primary repair of
cleft nasal defect (14). With the Millard repair the nasal floor is closed and
the alar base is reapproximated. However, the nasal deformity may also
include the nasal septum, lower lateral cartilage, columella, vestibular dome,
nasal tip, and nasal pyramid.

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Figure [8] The incision line has a gentle curve that mirrors the natural philtrum of the
noncleft side. A small flap of muscle can be used to add volume to the lateral segment of the lip if
needed (11).
Some surgeons have recently been performing primary nasal repair at the
time of lip repair. The early nasal repair is typically done at 3 months of age
and focuses on the deformed and malpositioned lower lateral cartilage. By
rearranging and reshaping the lower lateral cartilage, the surgeon is able to
improve nasal tip projection and create a more symmetrical nostril and ala
(15).
Even with primary nasal repair, revision nasal surgery is usually needed
to correct any remaining distortions. These distortions are slight but are
expected in the majority of cases of primary nasal repair (15). Depending on
the extent of the nasal deformity, secondary surgery may also include nasal
osteotomies and onlay bone grafting to augment the paranasal region.
A complete unilateral cleft lip involves the lip, nose and alveolar ridge.
The repairs discussed above do not address the defect in the alveolar ridge.
The goal of alveolar bone grafting is to bridge the gap in the alveolus with
cancellous bone so that the adult dentition can erupt naturally. The optimal
time for alveolar bone grafting is 8 years of age, which is the time when the
adult canine teeth typically erupt. Alveolar bone grafting has been one of the
major improvements in the treatment of patients with unilateral cleft lip
deformity (15).
REPAIR OF CLEFT PALATE
Repair of the cleft palate includes the hard palate posterior to the alveolus
and the soft palate. The soft and hard palate should be considered separately
since the goals of repair are different in each. The primary goal of the repair

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of the soft palate is to restore normal function. In repairing the hard palate
the surgeon strives to achieve normal facial growth, dentition, and aesthetics
(16). In the ideal patient, after repair the soft palate should be able to
periodically, voluntarily, and completely isolate the nasopharynx from the
oropharynx. Normal soft palate function is essential for speech and feeding.
If, after repair, the soft palate is too short to contact the posterior pharyngeal
wall, the child will have poor articulation and nasal regurgitation of food and
liquid.

Figure [9]: Anatomy of the palate

Defects in the palate can include the primary and secondary palate or
may be isolated to the secondary palate alone. Clefts isolated to the
secondary palate, posterior to the incisive foramen, range from complete
clefts involving the entire secondary palate to a simple bifid uvula. Defects

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in the primary palate are always associated with a cleft lip since they share a
similar embryological origin. The defect in the primary palate may be
unilateral or bilateral.
Closure of the hard palate involves raising mucoperiosteal flaps on the
oral and nasal side of the hard palate. Relaxing incisions are often used in
order to achieve a tension-free closure. If the mucoperiosteum is not
adequately undermined the closure will be under tension and there is an
increased risk of fistula formation. Therefore, the surgeon must undermine
enough to allow a tension free closure.

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Figure [10]. The von Langenbeck repair. Two bipedicle mucoperiosteal flaps are created by
incising along the oral side of the cleft edges and along the posterior alveolar ridge from the
maxillary tuberosities to the anterior level of the cleft. The flaps are then mobilized medially with
preservation of the greater palatine arteries and closed in layers. The hamulus may need to be
fractured to ease the closure.

Conversely, wide undermining of the mucoperiosteum with denuded

areas of palatal bone can have adverse effects on facial growth (16). The
surgeon is charged with the challenge of undermining just enough
mucoperiosteum to achieve tension-free closure while limiting the risk of
adverse facial growth (16). It is also important to limit trauma to the soft
tissues of the palate since this will limit the amount of postoperative scar
tissue formation.
For a complete cleft of the secondary palate with no involvement of the
primary palate, a three-flap repair is used. The incisions are made at the
anterior extent of the cleft and extended towards the canine teeth on both
sides, forming a V. The incisions continue posteriorly along the alveolar
ridge to the maxillary tuberosities.
Next, the free edges of the cleft mucosal flaps are incised.
Mucoperiosteal flaps are raised using a periosteal elevator. At the posterior
lateral margin of the bony palate the greater palatine neurovascular bundle is
identified and preserved. The nasal mucosa is dissected free from the
palatine bones using a right-angle elevator.
The nasal mucosa is elevated as far as the nasal sidewalls to ensure
adequate tissue for a tension-free closure. Mucoperiosteal vomer flaps can
be raised and used to help close the nasal mucosa.

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The nasal mucosa is closed first using interrupted sutures. Next the
muscular sling of the soft palate is reapproximated and the mucosa is closed.
Because this repair involves relaxing incisions along the alveolar ridges,
there remains a section of denuded palatal bone in this area. This should heal
well by secondary intention.
The hard palate is closed in two layers while the soft palate includes the
muscular layer for a total of three layers. It is not necessary to close the
defect in the bony palate.
After completion of the repair, the soft palate is assessed to ensure that it
has adequate length to function normally. To function properly, the soft
palate should be able to touch the posterior pharyngeal wall easily. If the soft
palate is too short at this stage, two options are available to the surgeon.
First, length can be added to the palate by converting the V-shaped incision
at the medial margin of the cleft into a Y. This modification is known as the
V-Y pushback technique (7).
A second option is to create a superiorly based flap from the posterior
pharyngeal wall that is sutured to the nasal surface of the soft palate.
Because the flap is narrow, the primary defect can be closed primarily. This
is generally not performed during initial repair of the palate.
A two-flap technique uses similar principles to repair clefts involving the
primary and secondary palate whether unilateral or bilateral. The major
difference between this repair and the three-flap repair described above is
that there is no anterior margin to the cleft since the palate defect is
contiguous with a cleft lip. Therefore, instead of creating the V-shaped

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incision as described above, the incision along the alveolar ridge is

continued anteriorly until it reaches the alveolar ridge.

Figure [11]. Two-flap palatoplasty. A) After lateral relaxing incisions are performed,
bilateral flaps are elevated based on greater palatine vessels. B) Closure of the nasal mucosa is
performed. The hamulus may be fractured, the muscle is repaired, and the oral mucosa is closed
as a separate layer.
As with the three-flap technique, the edges of the cleft are incised and
mucosal flaps are raised on the nasal and oral side. The hard palate is closed
in two layers and the soft palate in three.

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In a bilateral cleft of the primary palate there is inadequate tissue

available to close the defect on the nasal side; therefore, bilateral vomer
mucoperiosteal flaps are rotated to close the nasal floor.
The musculature of the soft palate is not oriented properly when a cleft is
present. The repairs described above close the muscular layer but do not
address the problem of improper orientation. In 1978, Leonard Furlow
introduced a unique approach to the repair of soft palate. His technique
differed from traditional repairs in two dramatic ways. First, it used two
opposing Z-plasties to close the defect and reorient the muscular sling of the
soft palate. Second, the hard palate is closed without relaxing incisions to
prevent adverse effects on facial growth (17). The Furlow repair uses a nasal
and an oral Z-plasty flap to close the defect and add length to the soft palate.
This repair affords the additional benefit of realigning the muscle fibres of
the palatal sling. The nasal and oral Z-plasties consist of an anterior and a
posterior flap. The anterior flap of each side includes only mucosa, either
oral or nasal. The posterior flap consists of mucosa and the underlying
palatal muscle. Transposition of the posterior nasal flap draws the palatal
muscular sling across the cleft and reorients the fibres so they run
transversely across the palate. Transposition of the posterior oral flap
likewise draws the muscle across the cleft and overlies the muscle fibres of
the nasal flap. This repair adds length to the palate while improving function
of the palatal musculature.

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Figure [12]. Double-opposing Z-plasties. Furlow’s single-stage palatal closure technique

consisting of double opposing Z-plasties from the oral and nasal surfaces. The double Z-plasty
minimizes the need for lateral relaxing incisions to accomplish closure. The palate is lengthened
as a consequence of the new position of the velar and pharyngeal tissues.
A retrospective study of the Furlow palatoplasty compared to the
intravelar veloplasty found that the Furlow technique might provide a better
functional result; however, further study is needed (18).

POSTOPERATIVE CARE
ADDITIONAL SURGICAL PROCEDURES

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