BY DR MAHESH KUMAR FCPSHOD AND CHAIRMAN

PLASTIC & RECONSTRUCTIVE SURGERY DEPARTMENT

L.U.M.H.S.JAMSHORO

OBJECTIVES : The development of CLP The etiology of Cleft CLP The normal anatomy of CLP The anatomy of Cleft LP The classification of Cleft LP The key features of the Perioperative care of

the child with Cleft lip & Palate The associated complications of Cleft lip &

their management

DEVELOPMENT OF FACE :

After 8 weeks Embryo is called ‘Fetus’ due to the fusion of prominences.

Development of faceAppearance of ‘5’ prominencesGrowth of these prominencesFusion of the prominences

EMBRYOLOGY OF LIP:

EMBROLOGYPalatal development

7th to 10th weeks

Palatal shelves are initially oriented vertically

Head grows & the neck straightens , tongue falls

away allowing the palatal shelves to rotate upward

into normal horizontal position.

Growth factors & hyalronic acid

Frontonasal Forehead, bridge of nose, medial & lateral nasal prominences, nasal septum

Maxillary Cheeks, lateral portion of upper lip

Medial nasal Philtrum of upper lip, crest & tip of nose

Lateral nasal Alae of nose

Mandibular Lower lip

THE INCIDENCDE:

The isolated cleft palate is 0.5:1000 Cleft lip with or without palate is 1:1000 CL/P predominates in males Isolated CP predominates in females Majority of bilateral CL(86%) & unilateral

CL(68%) are associated with a CP Unilateral CL : Left side affected in 60% Unilateral CL are 9 times common than

Bilateral Typical distribution of cleft type is:

Cleft lip alone: 21%Cleft lip & palate: 46%Isolated cleft palate: 33%

ETIOLOGY Idiopathic Genetic defect Environmental Teratogens

Phenytoin , Other Anticonvulsants, steroids Maternal Smoking , old age marraiges Alcohol & Retinoic Acid

Familial- 1 Affected Child Or Parent, Risk Of Child Of The Next

Pregnancy Having CLP Is 4% If 2 Previous Children Have CLP Risk Increase To 9% If 1 Parent & 1 Child Were Previously Affected, Risk Is

17 Not associated with solar or moon eclipse

LIP ANATOMY

, White Skin Roll & Vermillion.

, Symmetrical Alar Arches & Equal Alar Base.

MusclLip – Consists Of Symmetrical Cupids Bow & Philtral Colum – Orbicularis Oris.

Nose – Straight Columella & Septum

CLASSIFICATION

CLEFT LIP UNILATERAL

BILATERAL

MEDDIAN

○ COMPLETE/ SEVERE

○ INCOMPLETE/ MODERATE

○ MICROFORM/ MILD

CLEFT ALVEOLUS 1. NARROW- NON

COLLAPSE

2. NARROW- COLLAPSE

3. WIDE- NON COLLAPSE

4. WIDE- COLLAPSE

NASAL DEFORMITY Mild

Lateral Displacement Of The Alar Base, called flaring of ala of nose

Normal Alar Contour & Dome Projection Moderate – flaring of Alar Base, Columella Deficiency A Depressed Dome. Severe- Flaring of ala nose deprressed Alar Dome Complete Collapse Of Lower Lateral Cartilage Severe Deficiency Of Columella Height. Hypoplasia of alar cartilage

MICROFORM CLEFT LIP Furrow Or Scar .

A Vermilion Notch.

Imperfection In White Roll.

Varying Degree Of Vertical Lip Shortness.

Nasal Deformity – May Be Present

UNILATERAL INCOMPLETE CLEFT LIP

Varying Degree Of Vertical Seperation Of Lip

An Intact Nasal Sill/ Simonart Band

UNILATERAL COMPLETE CLEFT LIP

Disruption Of The Lip, Nostril Sill & Alveolus(complete Primary Palate)

No Simonart Band

INCOMPLETE BILATERAL CLEFT LIP INCOMPLETE WITH

A NEAR NORMAL NOSE.

NORMALLY POSITIONED PREMAXILLA.

SIMONART BANDS & CLEFT INVOLVING ONLY LIP.

COMPLETE BILATERAL CLEFT LIP

Protuded PremaxillaPoorly Formed Or Absents Anterior Nasal Spine

Severe Nasal Deformity, Flat Nasal Tip

The Portion Of LIP between Philtral Columns Form Wide, Short Disk Called Prolabium.

classification of Cleft Palate

EMRYOGENICCleft of primary palateCleft of secondary palate

ANATOMICCeftt of uvula

Cleft of soft palateCleft of hard palate

Cleft of alveolusSIMPLEAnterior and posterior

Classification

Kernehans striped Y-Classification

Veau Classification - 1931

Veau Class I: isolated soft palate cleft

Veau Class II: isolated hard and soft palate

Veau Class III: unilateral CLAP

Veau Class IV: bilateral CLAP

SymptomsSeparation of the

lip

Separation of the palate (roof of the

mouth)Nasal distortionMisaligned teeth

Recurring ear infections

Symptoms (cont.)Failure to gain

weightNasal

regurgitation when bottle

feedingPoor speech

Growth retardation

PROBLEMS (PATHOPHYSIOLOGY)

LIPInability to have a tight sealMalocclusion, alveolar defect & teeth deformities

PALATEInability to separate nasal from oralFeeding difficultyRegurgitationMiddle ear diseaseSpeech problem

PROBLEMS

Upper airway

Speech

Feeding difficulty

Ear infection

Airway Problems Cleft Palate patients e.g. Pierre-Robin Sequence

Micrognathia ,Cleft Palate, GlossoptosisCYANOSIS develop airway distress from

tongue fall and touch pharanyx lodged in palatal defect

FEEDING PROBLEM

FEEDING IN HEAD ELEVATED POSITION

FEEDING WITH SPCIAL CP BOTTLES OR D/SYRINGE OR DROPPER

AFTER FEED LAY BABY ON SHOULDER AND SLAB ON BACK

TILL RETCHING

Hearing problem

ETD- Due to abnormal insertion of levator veli palatini and salpingo

pharyngeus muscle into hard palatemilk enter into eustachian tube and

lead to serous otitis media and infective otitis media and finally

ankylosis of oscicles30% develop permanent deafness

Speech Disorders

Errors in Articulation: Fricatives, Affricates

Velopharyngeal Competence- competence after initial palate

surgeryIncompetence- nasal emission or

snortEvaluation- Direct exam , Fiberoptic

Exam

TIMING OF SURGERY RULE OF TENS

FOR CL:1O POUNDS10 gm OF Hb10 WEEKS OF AGE10,000 TLC

FOR PALATE10 KG10 GM Hb10 MONTH10000 Tlc

Treatment

Treatment involves many

things which include plastic

surgery, orthodontics,

and speech therapy

PRIMARY MANAGEMENT Antenatal Diagnosis

Diagnosed By US 3D After 18 Weeks’ Gestation

Parents Need Counseling Reassure The Parents Explain Functional

Problems Advise On

FeedingTiming Of Surgery

○ Ideally, The Newborn Infant With A Cleft Is Evaluated By Cleft Team In 1st Weeks Of Life

PRESURGICAL MANAGEMENT

1:Presurgical infant orthopedics: Appliances

latham appliance for collapsed alveolar arch

2:Presurgical nasoalveolar molding :

objective of NAM : To align & approximate the alveolar segment To correct the malposition of the nasal cartilage & alar base on

affected side To idealize the position of philtrum & columella

Naso alveolar mold

Surgical techniques: For unilateral cleft lip: Modern accepted technique is the

modified Millards rotation & advancement repair

For microform cleft lip:

Straight line repair

Modified Millard rotation – advancement repair

For bilateral cleft lip: 1,Manchester repair

2. bilateral millard repair

MANCHESTER REPAIR

Surgical Repair- Cleft Palate

Several Techniques - less scarring and less tension on palate

Scarring of palate may cause impaired mid-facial growth(alveolar arch

collapse, midface retrusion, malocclusion)

Facial growth may be less affected if surgery is delayed until 18 months, but

feeding, speech, socialization may suffer .

Surgical techniquesVon langenback operation

Veau, Wardill, Kilner push back palatoplasty

Intravelar veloplasty

Furlow z – plasty

Bordeck palatoplasty

Complications of lip repair

Unilateral cleft lip: Deficient tubercle Vermilion deficiency & irregularity Short upper lip or Long upper lip Tight upper lip Unfavorable scar

Bilateral cleft lip: Whistle deformity Nostril stenosis

complications

ImmediateBleeding

DelayedFistula formationFailure of repairSpeech problem

Bilateral incomplete cleft lipbilateral millard procedure

bilateral millard repairBilateral complete cleft lip

unilateral Complete cleft lip

Incomplete cleft lip

POSTOPERATIVE CARE Soft arm restrain for 2 weeks

Analgesics

Feeding

Suture line care

Stitch removal Avoid oral suction

POSTOPERATIVE CARE

Fluids for one week Water after every feedSemi solids for next two weeks and

water after every dietSolids are allowed after three

weeksNo need to remove stiches (vicryl)

Cleft palate

Lower lip cleft (cleft 30)

CONFIDENCE LIKE ART NEVER COMES FROM HAVING ALL THE ANWERS, BUT IT COMES FROM BEING OPEN TO ALL QUESTIONS !