Cheiloplasty for False Median Cleft Lip Associated With Holoprosencephaly: The Use of Skin Graft for Philtrum Reconstruction, the Risk of Simultaneous Columella Reconstruction

A false median cleft lip is a congenital malformation associated with holoprosencephaly. Cheiloplasty is an effective treatment for false median cleft lip. In the past, holoprosencephaly had a poor prognosis with extremely low survival rates; consequently, cheiloplasty was rarely performed. However, with the recent improvement in survival and prognosis with advances in medical care, patients survive and can now undergo cheiloplasty. We report a case of cheiloplasty performed using a skin graft for philtrum reconstruction. The lip contour was satisfactory because the insufficient tissue was resolved by filling the skin graft, which could not be resolved by midline suture closure. We did not perform columella reconstruction considering the safety; however, oxygenation temporarily destabilized owing to postoperative airway stenosis. Careful postoperative management is necessary even if the columella is not reconstructed.

An ex vivo model for education and training of unilateral cleft lip surgery

BACKGROUND

Unilateral cleft lip surgery is a complex procedure, and the outcome depends highly on the surgeon's experience. Digital simulations and low-fidelity models seem inadequate for effective surgical education and training. There are only few realistic models for haptic simulation of cleft surgery, which are all based on synthetic materials that are costly and complex to produce. Hence, they are not fully available to train and educate surgical trainees. This study aims to develop an inexpensive, widely available, high-fidelity, ex vivo model of a unilateral cleft lip using a porcine snout disc.

METHODS

A foil template was manufactured combining anatomical landmarks of the porcine snout disc and the anatomical situation of a child with a unilateral cleft. This template was used to create an ex vivo model of a unilateral cleft lip from the snout disc. Millard II technique was applied on the model to proof its suitability. The individual steps of the surgical cleft closure were photo-documented and three-dimensional scans of the model were analysed digitally. Sixteen surgical trainees were instructed to create a unilateral cleft model and perform a unilateral lip plasty. Their self-assessment was evaluated by means of a questionnaire.

RESULTS

The porcine snout disc proved highly suitable to serve as a simulation model for unilateral cleft lip surgery. Millard II technique was successfully performed as we were able to perform all steps of unilateral cleft surgery, including muscle suturing. The developed foil-template is reusable on any porcine snout disc. The creation of the ex vivo model is simple and inexpensive. Self-assessment of the participants showed a strong increase in comprehension and an eagerness to use the model for surgical training.

CONCLUSIONS

A porcine snout disc ex vivo model of unilateral cleft lips was developed successfully. It shows many advantages, including a haptic close to human tissue, multiple layers, low cost, and wide and rapid availability. It is therefore very suitable for teaching and training beginners in cleft surgery and subsequently improving surgical skills and knowledge. Further research is needed to finally assess the ex vivo model's value in different stages of the curriculum of surgical residency.

An ex vivo model for education and training of bilateral cleft lip surgery

BACKGROUND

Bilateral cleft lip surgery is very challenging and requires a high level of skill, knowledge and experience. Existing high-fidelity simulation models that can be used by novice cleft surgeons to gain experience and expand their knowledge are rare and expensive. In this study, we developed a bilateral cleft lip model using porcine snout discs, which are available anywhere and inexpensive.

METHODS

Anatomic reference points of a patient with a bilateral cleft lip were superimposed with landmarks of the porcine snout disc on a foil template. The template was used to construct an ex vivo bilateral cleft lip model. Surgery was performed on the model according to Millard and the surgical steps were photodocumented analogous to two clinical cases of bilateral cleft lip surgery. The suitability of the model was further tested by twelve participants and evaluated using self-assessment questionnaires.

RESULTS

The bilateral cleft lip ex vivo model made of a porcine snout disc proved to be a suitable model with very low cost and ease of fabrication, as the template is reusable on any snout disc. The Millard procedure was successfully performed and the surgical steps of the lip plasty were simulated close to the clinical situation. Regarding the nasal reconstruction, the model lacks three-dimensionality. As a training model, it enhanced the participants comprehension of cleft surgery as well as their surgical skills. All participants rated the model as valuable for teaching and training.

CONCLUSIONS

The porcine snout discs can be used as a useful ex vivo model for bilateral cleft lip surgery with limitations in the construction of the nose, which cannot be realistically performed with the model due to anatomical differences with humans. Benefits include a realistic tissue feel, the simulation of a multi-layered lip construction, a wide and rapid availability and low cost. This allows the model to be used by novice surgeons also in low-income countries. It is therefore useful as a training model for gaining experience, but also as a model for refining, testing and evaluating surgical techniques for bilateral lip plasty.

A comprehensive review of surgical techniques in unilateral cleft lip repair

Unilateral cleft lip is a common congenital anomaly that affects the appearance and function of the upper lip and nose. Surgical repair of cleft lip aims to restore the normal anatomy and functionality of the affected structures. In recent years, several advances have been made in the field of cleft lip repair, including new surgical techniques and approaches. This comprehensive review discusses the surgical management of patients with unilateral cleft lip and palate and provides step-by-step instructions for the surgical procedures.

Bilateral cleft lip repair by new trending method: a case report

BACKGROUND

Bilateral cleft lip repair is one of the most difficult surgeries, and many techniques have been modified and developed to improve surgical outcomes. The current trend is toward preserving tissue as much as possible. When the reconstruction is based on the shape of the patient's own tissue, the most natural appearance is produced, and the relaxed remaining tissue can be benefitted from reducing tension and minimizing scarring.

CASE PRESENTATION

In the conventional surgical method, the rest of the prolabium is sacrificed, except for the tissue used to make the philtrum. We used all tissues for surgery and did not discard any. The tubercle of the median vermilion was used in its original form.

CONCLUSIONS

It is fundamental to restore function in cleft lip surgery. Both patients and surgeons have a desire for esthetic outcomes that go beyond function. In addition, the measure of the success of the surgery is the postoperative resemblance to normal midfacial features. Unlike the conventional method of making tubercles by collecting lateral vermilion flaps, we preserved the tissue of the prolabium. Rather than using an artificial tubercle, we were able to create a more natural shape of the upper lip using the patient's own anatomical structure. In addition, the remaining tissues of the discarded prolabium were used to make the oral mucosa, which may help to reduce tension compared to the conventional method. The modified repair method is expected to gradually become the mainstream method owing to its superior esthetic outcome and less surgical difficulty compared with traditional methods.

Nasoalveolar Molding for Unilateral and Bilateral Cleft Lip Repair

Nasoalveolar molding (NAM) is a powerful tool in the treatment of patients with unilateral or bilateral cleft lip and palate. The primary goal of NAM is to improve alignment of critical anatomic elements before surgical repair of the unilateral or bilateral cleft lip. Modifications of the position of the alveolar segments and their associated lip elements, the lower lateral cartilages, and the columella achieved with NAM are helpful for creating a suitable platform for tension-free lip repair.

Importance of various skin sutures in cheiloplasty of cleft lip

Last week, after our receiving online journal regarding Journal of the Korean Association of Oral and Maxillofacial Surgeons, we found a recently published original article by Alawode et al., entitled “A comparative study of immediate wound healing complications following cleft lip repair using either absorbable or non-absorbable skin sutures”. Although this clinical article was well written and provided a great deal of information regarding the suture materials in the cleft lip repair, I would like to add a few additional comments based on the importance of skin suture during cheiloplasties in the primary cleft lip or secondary revision patients with representative figures.

Orbicularis oris muscle reconstruction and cheiloplasty with Z-plasty in a patient with a transverse facial cleft

Background

Transverse facial clefts are Tessier’s number 7 facial cleft among numbers 1–15 in Tessier’s classification of craniofacial malformations, which varies from a simple widening oral commissure to a complete fissure extending towards the external ear.

Case presentation

In a patient with a transverse facial cleft, to functionally arrange the orbicularis oris muscle and form the oral commissure naturally, we performed a surgical procedure including orbicularis oris muscle reconstruction and cheiloplasty with Z-plasty.

Conclusion

We achieved good results functionally and esthetically by orbicularis oris muscle reconstruction and cheiloplasty with Z-plasty. The surgical modality of our anatomical repair and 3 months follow-up results are presented.

[Secondary nasal surgery with cleft palates]

Residual nasal deformity in patients with cleft palate remains the main demand of these patients. Performing primary nasal surgery has significantly improved the results. However, it is still often necessary to improve the nasal morphology. Respect of tissues during primary surgery is essential and allows easier secondary corrections. Anatomical reconstruction greatly facilitates the treatment of secondary deformities. Do not hesitate in case of major labionasales sequelae, to make revision, according to the rules of primary surgery, of the entire lip and nose.

[Paracommissural cleft of the lower lip: Therapeutic strategy]

We report the first case described in the literature of lateral, paracommissural cleft of the lower lip in a 2-year-old child. This anomaly caused labial incompetence requiring surgical correction. Different surgical techniques have been described for the treatment of the cleft of the upper lip. We studied each of them, analyzed the advantages and disadvantages of these techniques by inverting them and adapting them for the lower lip. We opted for the double "Z" plasty of Malek because the difference in height between the cleft side and the healthy side was important. In addition, this plasty hides part of the scar in the labiomental groove. The functional and aesthetic result at 6 months after surgery is satisfactory.

Development and application of a perioral force measurement system for infants with cleft lip and palate

BACKGROUND

Muscles converge or intertweave around the perioral area, and this can be treated with sequential therapy in infants with cleft lip and palate (CLP). The force of perioral muscles has a great influence on maxillary development and morphology. Perioral force in infants with CLP has not been well studied, and accurate and reliable measurement of perioral force in infants remains a challenge. This study aimed to investigate a new way to accurately and reliably measure perioral force in infants with unilateral CLP (UCLP) and explore the change before and after cheiloplasty.

STUDY DESIGN

A perioral force measurement system was developed and applied to measure perioral force at labial frenum area and the commissures on both the normal and the cleft sides of four infants with UCLP before and after cheiloplasty. The results were analyzed using the SPSS 19.0 software.

RESULTS

The perioral force measurement system appears to produce valid results in infants with UCLP. Before cheiloplasty, the perioral force of labial frenum area was 1.79 ± 0.94 g/cm² and that of commissure on the normal and cleft sides was 5.41 ± 1.01 g/cm² and 3.12 ± 1.55 g/cm², respectively (P < 0.05). After cheiloplasty, perioral force of labial frenum area was 12.73 ± 3.51 g/cm² and that of commissure on the normal and cleft sides was 7.64 ± 1.64 g/cm² and 7.27 ± 1.89 g/cm², respectively (P > 0.05).

[Approach of the unilateral cleft lip with Meara's cheiloplasty technique]

INTRODUCTION

Isolated cleft lip is the mildest form of the cleft lip and palate spectrum; however those patients are often treated with the same surgical techniques that are used for the more severe cases (advancement-rotation flaps, quadrangular flaps). Meara's cheiloplasty technique may be a less aggressive option for lip repair in isolated cleft lip or whenever the gap between labial segments is not wide.

MATERIAL AND METHODS

All children that had their cleft lip repaired following Meara's cheiloplasty between May 2014 and December 2015 were retrospectively reviewed. Duration of the surgical procedure, time to hospital discharge and complications were noted. Aesthetic results were evaluated in terms of lip height and symmetry, nose shape and symmetry, and scar appearance.

RESULTS

Thirteen patients underwent Meara's cheiloplasty during this period. The average age was 6.11 months (5 to 12 months). A primary rhinoplasty was done at the same time in case of nasal asymmetry. Duration of the lip repair averaged 85 minutes. Oral feeding was started 4 hours after the procedure; bottle-feeding was withheld for 2 weeks postoperatively, as our protocol recommends after other lip repair techniques. In all 13 cases the result was a symmetrical, adequately high upper lip and a well-balanced nose, except for one case of lip scar retraction that was solved with triamcinolone infiltration. There were no other intra or postoperative complications.

CONCLUSIONS

Meara's cheiloplasty corrects small or moderate gap cleft lip (usually cleft lip without cleft alveolus). Benefits over other teccniques are a shorter procedure and less geometric, undulate flaps that produce a harmonic lip.

Miescher's cheilitis: Surgical management and long term outcome of an extremely severe case

INTRODUCTION

Miescher's cheilitis is clinically characterized by persistent swelling of the lip(s). Its pathogenesis is still unknown. Histopathologically is characterized by sub-epithelial edema, increased number of dilated lymphatic vessels and an inflammatory infiltrate and/or non-caseating/non- necrotic granulomas. Even if the disorder must be controlled by medical therapy, surgery may be required to treat most severe cases.

PRESENTATION OF THE CASE

We report a 30-year-old man who presented a persistent swelling of both lips since 8 years, previously treated with intralesional steroid and immunosuppressive therapy. Clinical examination did not show facial nerve palsy or other associated conditions. On the base of clinical and histopathological findings, a diagnosis of Miescher's syndrome was made. Patient underwent Conway's reduction cheilopasty repaired with local flaps. At one-year follow-up, the patient does not show local recurrence of the deformity; both oral continence and lip sensation are preserved.

DISCUSSION

Because of its extreme rarity and unknown etiopathogenesis, Miescher's cheilitis receives poor attention and may often remain misdiagnosed. Several medical therapies are proposed, in particular steroids and immunosuppression. Even if medical therapy remains the main treatment, surgery may be required.

CONCLUSION

Satisfactory results have been obtained combining medical therapy and surgical approach.

Regional anesthesia for maxillofacial surgery in developing countries

Regional anesthesia in the maxillofacial region is safer and more efficient than general anesthesia when its indications are carefully considered. In addition, the majority of medical institutions in developing countries are not well equipped for proper anesthesia and elective surgery. In this review, we describe regional anesthesia and cutaneous nerve divisions in the maxillofacial region. In addition, we summarize detailed regional anesthetic techniques adapted for representative cleft lip cases in developing countries.

Effects of early and late cheiloplasty on anterior part of maxillary dental arch development in infants with unilateral complete cleft lip and palate

Objectives. The objective of this study is to compare the impact of early and late reconstruction of complete unilateral cleft lip and palate on the growth and development of the front of the dentoalveolar arch. Methods. This study was carried out in the years 2012-2015 at the Clinic of Plastic, Reconstructive and Aesthetic Surgery in Banska Bystrica. Infants with unilateral complete cleft lip and palate were divided into 2 groups according to the timing of lip reconstruction. Group A consisted of infants with early lip reconstruction-realised in the first 14 days of life. Group B consisted of infants with later lip reconstruction-realised in the third month of age. Maxillary dental casts were obtained for each child in four periods-in the first 14 days of life, in the third month, in the sixth month and in the age of one year. These were followed by the identification, measurement and evaluation of anthropometric parameters. Results. Significant differences were occurred after the reconstruction of the lips in linear and angle measurements between infants in the A and B groups. Conclusion. The early surgical reconstruction of the lips in the first 14 days of life has a positive effect on the growth and development of the anterior segment of the dentoalveolar arch. Early lip reconstruction forms a continuous pressure on the frontal segment, resulting in the earlier remedy of anatomical properties and creates appropriate conditions for the best development of this area.

Bilateral Infraorbital Nerve Block Versus Intravenous Pentazocine: A Comparative Study on Post-operative Pain Relief Following Cleft Lip Surgery

BACKGROUND AND OBJECTIVES

Infra orbital nerve block is utilized for postoperative pain control in children undergoing cleft lip repair. This study was conducted to compare the effectiveness, advantages and disadvantages of infra orbital nerve block and opioids for postoperative pain relief following cheiloplasty.

MATERIALS AND METHODS

Sixty paediatric patients aged 3 months - 13 years undergoing cheiloplasty were selected by simple random sampling and were divided into two groups. All the children received standardized premedication with midazolam, were operated upon under general anaesthesia and the block was performed at the end of surgery before reversal. Group B patients were administered bilateral infra orbital nerve block with 0.25% Bupivacaine (upto 2 mg/kg). Group O patients received Pentazocine 0.5 mg / kg IV. Postoperatively, the heart rate and respiratory rates were recorded every 15 minutes for the first 60 minutes, half hourly till 4 hours and then at 12 and 24 hours. Behavioural assessment for pain / discomfort was done at intervals of ½, 1, 2, 3, 4, 12 and 24 hours. Need for supplementary analgesics and duration between the administration of block/opioid and the first dose of supplementary analgesics were noted. Side effects such as nausea and vomiting, pruritus, respiratory depression and bradycardia during each of these periods were noted.

RESULTS

Both the groups were comparable for age, sex, weight and operative time with no statistical difference. The mean duration of analgesia for infra orbital nerve block was 357.5 minutes i.e. 5 hours 58 minutes and that for opioid was 231 minutes i.e. 3 hours 51 minutes which was significantly lower than the hours of analgesia provided by the block. Further, at the 4th hour, 76.6% of the patients in Group O required supplementary analgesics, in contrast to only 16.6% in Group B. The incidence of nausea and vomiting and pruritus was also higher in Group O.

CONCLUSION

The results indicate that bilateral infra orbital nerve block provides effective analgesia in the postoperative period, lasting for 6 hours in comparison to 3½ - 4 hours following the administration of intravenous Pentazocine, with no major untoward effects.

Anesthetic management for Smile Train a blessing for population of low socioeconomic status: A prospective study

Background:

The Smile Train is an international charity with an aim to restore satisfactory facial appearance and speech for poor children with cleft abnormalities who would not otherwise be helped. A total of 241 children of cleft lip and palate anomaly, scheduled for surgery under general anesthesia, were studied. Cleft abnormality requires early surgery. Ideally cleft lip in infants should be repaired within the first 6 months of age; and cleft palate, before development of speech, i.e., at the age of 2 years. But in our study, only 27% of children underwent corrective surgery by ideal age of 2 years, which may be due to ignorance, poverty or unawareness about the fact that cleft anomaly can be corrected by surgery.

Context:

Smile Train provides care for poor children with clefts in developing countries. The guidelines were designed to promote safe general anesthesia for cheiloplasty and palatoplasty.

Aims:

Smile Train promotes free surgery for cleft abnormalities to restore satisfactory facial appearance and speech.

Settings and Design:

This was a randomized prospective cohort observational study.

Materials and Methods:

A total of 241 consenting patients of American Society of Anesthesiologt (ASA) I and II aged 6 months to 20 years of either sex, scheduled for elective cheiloplasty and palatoplasty, were studied. Children suffering from anemia, fever, upper respiratory tract infections or any associated congenital anomalies were excluded. Approved guidelines of the Smile Train Medical Advisory Board were observed for general anesthesia and surgery.

Statistical Analysis:

The Student t test was used.

Results:

The infants were anemic and undernourished, and two thirds of the children were male. Only 27% of the children presented for surgery by the ideal age of 2 years.

Conclusions:

Pediatric anesthesia carries a high risk due to congenital anomaly and shared airway, venous access and resuscitation; however, cleft abnormality requires surgery at an early age to make the smiles of affected children more socially acceptable.

CAD/CAM silicone simulator for teaching cheiloplasty: description of the technique

Techniques of virtual simulation have been used to teach junior surgeons how to do a cheiloplasty, but still do not meet the trainees' demands. We describe a CAD/CAM silicone simulator, which we made using several maxillofacial prosthetic techniques. An optical scanning system was used to collect the data about the cleft lip. Reverse engineering software was then used to build the virtual model, and this was processed in wax by machine. The definitive simulator was made with prosthetic silicone and extrinsic colourants. The surgical trainees practised the basic skills of cheiloplasty on the simulator, and proved its worth.

Unilateral cleft lip repair

Modern cleft surgery requires four-dimensional and functional anatomic understanding of the cleft (and noncleft) lip, nose, and alveolus. Some techniques for nasolabial repair rely more on precise anatomic geometry, whereas others afford the surgeon a more flexible design. Consistent anthropometry enables accurate assessment and reporting of long-term outcomes; such reports are needed to guide perioperative care, delineate optimal repair principles, and resolve ongoing controversies.

Postnatal treatment factors affecting craniofacial morphology of unilateral cleft lip and palate (UCLP) patients in a Japanese population

We have evaluated the craniofacial morphology of Japanese patients with unilateral cleft lip and palate (UCLP) and assessed the various postnatal factors that affect it. Lateral cephalograms of 140 subjects (mean (SD) aged 7 (2) years) with UCLP were taken before orthodontic treatment. Surgeons from Hokkaido University Hospital had done the primary operations. The craniofacial morphology was assessed by angular and linear cephalometric measurements. Cheiloplasty, palatoplasty, and preoperative orthopaedic treatment were chosen as postnatal factors. To compare the assessments of the postnatal factors, we made angular and linear cephalometric measurements for each subject and converted them into Z scores in relation to the mean (SD) of the two variables. Subjects treated by the modified Millard cheiloplasty had larger sella-nasion-point A (SNA) and nasion-point A-pogonion (NA-POG) measurements than subjects treated by the modified Millard with a vomer flap cheiloplasty. Two-stage palatoplasty showed consistently better craniofacial morphology than the other palatoplasty. Subjects who had preoperative orthopaedic treatment with a Hotz plate had significantly larger upper incisor/sella-nasion (U1-SN) measurements than who had no preoperative orthopaedic treatment or an active plate. We conclude that in subjects treated by a modified Millard type of cheiloplasty, a two-stage palatoplasty, and a Hotz plate there were fewer adverse effects on craniofacial morphology.

Assessment of deformities of the lip and nose in cleft lip alveolus and palate patients by a rating scale

INTRODUCTION

Labial and nasal deformities have always been a fundamental problem in the treatment of cleft lip, alveolus and palate patients. The primary surgical treatment of nasolabial area is of paramount importance in order to obtain both an esthetical correction of the deformity and a progressive and a balanced development of mid-face. In this study the nasal deformities in patients with cleft lip, alveolus and palate (CLAP) were analyzed and the relevant role of the perinasal, perioral muscular balance and the inborn dislocation of the alar cartilages are presented.

PATIENTS AND METHODS

50 CLAP patients were analyzed, 40 UCLP and 10BCLP. The lip repair was done by modification of Millard's technique. The severity of the cleft appearance was evaluated pre and post operatively, according to a pre-agreed visual rating scale. There are 4° of severity of the deformity pre operatively (mild, moderate, severe and very severe) and post operatively 5 categories of outcome (excellent,very good, good, satisfactory and poor), depending on the scores obtained by summing up the points corresponding to different types of deformity. This scale is closely related to the American Cleft Palate classification of clefts.

RESULTS

In the 40 UCLP patients, 8 excellent, 10 very good, 16 good and 6 satisfactory results were obtained following primary cheiloplasty. In 10 BCLP patients 1 very good, 7 good, 1 satisfactory and 1 poor result were obtained.

CONCLUSIONS

During the primary repair, it is important to correct the abnormal position of ala nasi, the nasal floor and the base of the columella. Abnormalities in the insertion of the nasolabial muscles with their abnormal function contribute to the cleft nose deformities. Therefore the reconstruction not only the orbicularis muscle but also of the paranasal muscles is therefore important for a symmetrical growth of the nose. Separate suture of intrinsic orbicularis oris provide a better shape to the vermillion. The position of the alar cartilage plays an important role for the symmetry of the nose. It is necessary to place the alar base symmetrically in three dimensions.

Unilateral cleft lip and palate: Simultaneous early repair of the nose, anterior palate and lip

Unilateral cleft lip and palate is a defect involving the lip, nose and maxilla. These structures are inter-related, and simultaneous early correction of all the aspects of the defect is necessary to obtain a satisfactory result that will be maintained with growth. The surgical technique combining various procedures is presented and compared with previously published reports.

Use of botulinum toxin in cheiloplasty: A new method to decrease tension

OBJECTIVE

To determine if the use of botulinum toxin during cheiloplasty could help in the management of tension at the surgical wound level.

INTERVENTIONS

Five children younger than six months of age, who were born with complete cleft lip and palate, were treated with a dose of 10 units of botulinum toxin injected into the upper lip during surgery. Before the surgery, an electromyographic study was carried out on the patients' upper lips. A Millard-type cheiloplasty was performed and 10 days later, a second electromyographic study was performed on the upper lips of all the patients.

RESULTS

There was a significant change (P<0.039) in the electromyographic tracing obtained after the application of botulinum toxin, especially during rest.

CONCLUSION

As confirmed by electromyography, botulinum toxin effectively inhibits the action of the orbicularis oris muscle, especially when at rest; consequently, the tension is decreased at the level of the surgical wound.