19. Unilateral Cleft Lip Repair I by Alex Campbell

Unilateral Cleft Lip Repair

19.

Surgical Goals § § § § § § § §

Lengthen cleft lip height to vertical height of non-cleft side Balance Cupid’s Bow Reorient and re-establish orbicularis oris Establish continuity of white roll Establish continuity of red line Re-establish philtrum column Recreate philtral dimple/tubercle pout Primary repair of cleft nose deformity

Key Points 1. 2. 3. 4. 5. 6. 7. 8. 9.

Lowest point Cupid’s bow Peak Cupid’s bow noncleft side Proposed peak Cupid’s bow cleft side Midpoint columella Base columella noncleft side Base columella cleft side Insertion alar base into nasal sill cleft side Insertion alar base into nasal sill noncleft side Position Cupid’s bow lateral lip element (Nordhoff’s point)

Nordhoff’s point § § § § §

(Future) peak of Cupid’s bow lateral lip element. Well developed white roll Well developed vermillion Same horizontal height as peak of Cupid’s bow noncleft side Distance of alar crease to height of Cupid’s bow on noncleft side duplicated on cleft side

Surgical Techniques § Type of skin incision defines techniques, but is probably is least important to final result. § Releasing and repositioning all the displaced nasal and lip elements in all three planes of space is necessary for optimal results. Triangular Flap §

Medial lip element lengthened by back-cut (1-2) and triangular flap (3-5) from lateral lip is introduced into it.

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Lengthening by distance equal to base of triangle

Disadvantages § § § §

Flattens Cupid’s bow Unnatural zigzag scar in visible portion lip Triangle breaks up philtral column Revision difficult if poor scarring

Fischer Anatomic Approximation Subunits

Millard Rotation Advancement Repair

Disadvantages: § §

Philtral column scar ends at opposite nasal floor Tip of lateral flap advanced to opposite philtral column and transverse cranial incision of flap often necessary

Modified Millard Technique

Mohler Repair: § Rotation advancement with columellar extrension Advantages: § Scar lies in philtral column and vertical extension is lateral to columella § Less advancement of lateral flap necessary and so minimal transverse component to superior aspect advancement flap

Unilateral Cleft Lip Repair: Steps of the Operation § § §

Patient Position: o End of table, doughnut, shoulder roll, mouth pack Preoperative photographs Marking: o Toothpick, methylene blue, 5cc syringe, 27 gauge needle, caliber, alcohol wipes, gauze o Precise marks with fine points o Tattoo marks with Methylene blue before infiltration of local anesthetic

Key Points Unilateral Cleft Lip

Key Points: Medial Lip §

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§ § § § § § § § §

Trough cupid’s bow o Caudal white roll-vermillion junction o Cephalic white roll-cutaneous junction Lateral peak cupid’s bow o Caudal white roll-vermillion junction o Cephalic white roll-cutaneous junction Medial peak cupid’s bow o Caudal white roll-vermillion junction o Cephalic white roll-cutaneous junction Red Line Midline base of columella at nasolabial junction Lateral base columella triangle at nasolabial junction Medial base columella triangle at nasolabial junction Peak Mohler triangle in columella (90 degree angle) Septum Medial footplate LLC noncleft side Medial footplate LLC cleft side Alar insertion into nasil sill noncleft side

Key Points: Lateral Lip § § § § § §

Nasofacial groove Junction nasal skin (vibrisse) and lip skin Alar insertion into nasil sill cleft side Peak of Cupid’s bow cleft side (Nordhoff’s point) Peak of proposed philtral column cleft side Red Line

Incisions Design Unilateral CL

Local Anesthetic § § §

Wide but controlled local infiltration dissection areas Preferred mixture: 0.25% Lidocaine, 0.125% Marcaine, 1:100,000 Epinephrine After injection, surgeon scrub and patient preparation for ample time for vasoconstriction

Surgical Steps: Incisions and Dissection Medial Lip Element § Release columellar triangle § Release C flap § Septal flap raised for nostril floor closure § M flap raised to base

§ § § § § §

Medial Muscle Dissection (1 mm) § White roll left intact Complete release orbicularis from abnormal insertion anterior maxilla Buccal sulcus incision lateral to frenulum to allow lip rotation M flap rotated and sutured into defect for buccal sulcus augmentation Subperiosteal relase nasal septum if needed Medial Nasal Dissection § Subcutanous dissection over tip and cleft side LLC via medial incision

Incisions and Dissection Lateral Lip Element § Dissection Lateral Lip Element § Skin Incisions § Release V flap § Incision extended posterior to piriform aperature § Lateral wall flap for nostril floor closure § L flap raised to base § Piriform aperature released to completely free cleft side alar base § L flap rotated to close defect in piriform aperature § Lower edge of L flap sutured to septal flap to close nostril floor § Lateral Muscle Dissection § Subcutaneous dissection for tension free closure § White roll left intact § Complete release of muscle from abnormal attachment nostril and piriform aperature cleft side. § Buccal sulcus incision lateral to release lip and allow advancement § Buccal sulcus incision advanced and closed to cleft with Vicryl

Nasal Floor Repair § § §

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Cleft side alae retracted cephalic Starting posteriorly, septal flap sutured to lateral nasal flap Repair continued anteriorly to complete nasal floor reconstruction to level of margin of lip skin. Muscular roll of nasalis muscle released at level of alar crease and sutured to nasal septum to support nasal sill, fixate septum in midline, and recreate alar crease.

C Flap § § § §

Labial Mucosa Closure § §

Suture at redline to determine equal distances medial and lateral mucosal edges Labial mucosa closed interrupted Chromic

Broad C flap to close defect caused by downward rotation medial lip element Insetting C flap to lengthen columella or for nasal lining Rotation-Advancement Tip trimmed to fit defect and sutured into place

Muscle Repair § §

Prolene horizontal mattress sutures along length of muscle Repair includes peripheral portion of muscle for a full vermillion up to level of nasal sill to prevent dimpling.

Nasal Ala Inset §

Symmetry in height, anterior-posterior position, and nasal sill width

Skin closure § § § § §

Line up superior and inferior edges of white roll Inset and Skin Trimming Check for symmetry, correct lip height If lip short, triangular flap lengthening superior border white roll Skin closure with running suture

Vermillion Closure § § § §

Trimming vermillion Red line lined up on both sides Vermillion flap inset Closure of mucosa

Nasal Reconstruction Maneuvers § § §

Alar suspension sutures Vestibular web-Nasofacial groove sutures Transdomal suture