Secondary
25.
Cleft Lip Surgery Secondary Unilateral Cleft Lip Surgery Secondary Deformity “The best effort of any surgeon at primary reconstruction of a hare-lip … [will] usually leave some deformity” Gillies and Kilner, Lancet 1932 Secondary Deformity § §
Secondary deformities are the rule rather than the exception, and in many aspects are more difficult to repair than primary deformities It is easier to avoid a secondary deformity than it is to correct it
Lip Deformities § § § § § §
Vertical excess Vertical deficiency Horizontal deficiency Vermillion Whistle deformity Scars
Vertical Excess § § §
Various degrees of elliptical skin excisions Only seen in unilateral cleft lip May need to re-advance repair
Timing of Secondary Revisions § § § §
Preschool years (age 4-5) Early adolescence Cessation of facial growth Emotional maturity
Vermillion Deficiency (Whistle deformity) Cause: Deficiency of muscle and mucosa Treatment: §
Mild Re-Do repairLocal tissue rearrangement (Re do repair) Z-plasties, re-advancement Reconstitute orbicularis Fat augmentation
§
Severe Abbe Flap
Vermillion Deformity Correction § § § §
Maintain tubercle pout Realign red line, mucocutaneous junction V-Y advancements, Zplasties Fat injections: mixed results
Vermilion Misalignment Z plasty rearrangement of white roll vermilion border to correct malalignment and scar contracture limited to white roll
Lip Scar § §
Most noticeable and striking stigmata Contributing factors § Orbicularis § Premaxilla § Cleft width § Extreme tension
Orbicularis Oris Muscle § §
§
Continuity cannot be overemphasized Implicated in: § Widened lip scar § Wide and convex philtrum § Whistle deformity § Lateral bulging with animation Repair muscle to establish continuity
Philtrum § § §
Keystone of the upper lip Progressively wide and convex Orbicularis oris and tension from repair Treatment Goals: § Excision of excess tissue § Reapproximation of orbicularis muscle § Scars simulating philtral
Philtral Column Reconstruction
Horizontal Deficiency Abbe Flap § § § § §
Lower lip transfer to deficient upper lip “Lip switch” More severe deformities Highly versatile Balances mouth
Cleft Nose Deformity § § §
At time of lip repair Undermine nasal skin, resuspend alar cartilage Recurrence possible
Pre-school age §
Columella
Adolescence §
Definitive rhinoplasty
Alveolar cleft § § § §
Ideal time: period of mixed dentition before eruption of canine 6-12 years old Erupting tooth induces alveolar bone generation Alveolar bone graft
Alveolar Bone Grafting: Function § Stabilize arches & teeth § Allow tooth movement into cleft § Close oronasal fistula Support alar base
Standard method of bridging alveolar clefts § § § § § § §
Iliac crest bone graft Followed by orthodontic tooth movement into cleft Ideal time for bone graf Period of mixed dentition When maxillary incisors visible, not yet erupted Before canines erupted (6-12 years old) Erupting tooth induces alveolar bone generation
Orthognathics
Hypoplastic Maxilla
Typical Stigmata § § §
Class III occlusion Protruding lower lip Flattened nasal tip Orthodontist and Maxillofacial surgeon
Le Fort I Osteotomy Maxillary Advancement-Maxillary or midface advancement is achieved using distraction osteogenesis techniques, and the results are often dramatic in improving occlusion and aesthetic balance to the face
Maxillary Distraction
Suggested Reading: Reinisch J, Li W. (2009) Complications of Cleft Lip and Palate Surgery. In: Losse J, Kirschner R: Comprehensive Cleft Care (pp. 465-473). McGraw-Hill Companies. Byrd S, El-Musa K, Yazdani A. (2009) Correction of Unilateral Cleft Lip and Nose Deformity. In: Losee J, Kirschner R: Comprehensive Cleft Care (pp. 473-486). McGraw-Hill Companies. Bruner T, Boyd V, Stal S, Hollier L. (2009) Correction of Bilateral Cleft Lip and Nose Deformities. In: Losee J, Kirschner R: Comprehensive Cleft Care (pp. 487-498). McGraw-Hill Companies. Stal S, Hollier L. Correction of secondary cleft lip deformities. Plast Reconstr Surg. 2002 Apr 15;109(5):1672-81; quiz 1682. Schulte D, Sherris D, Kasperbauer J. The anatomical basis of the Abbé flap. Laryngoscope. 2001 Mar;111(3):382-6. Lo L, Kane A, Chen Y. Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbé flap revisited. Plast Reconstr Surg. 2003 Oct;112(5):1219-27. Bagatin M, Most S. The Abbe flap in secondary cleft lip repair. Arch Facial Plast Surg. 2002 Jul-Sep;4(3):194-7.