Labial sequels after uni- and bilateral cleft lip repair

Children born with labial-alveolar-velopalatine clefts must be managed by multidisciplinary teams in order to decrease the frequency and the importance of sequels, by implementing a true therapeutic strategy. It is indeed easier to avoid a secondary deformation than to correct it. Labial sequels are often associated to nasal sequels, and are managed in a single surgical intervention, with total revision of the cheilorhinoplasty. Some less important labial deformities can be corrected without total and simultaneous revision of the lip-nose complex. The goal of correction is functional and aesthetic, and the choice of the moment depends mainly on the psychological impact of the deformation for the child, and his motivation for reoperation.     

Sequels of labial-alveolar-velopalatine clefts observed in charity missions. Analysis and management

A lot of children with cleft lip and palate are not operated in the developing world, due to a lack of surgeons, hospitals, or simply because the condition is not considered as a priority. Charity missions give the opportunity to repair these malformations. Non-operated cleft lip and palate are the first problem, but our surgery may cause growth disturbances and sometimes a second operation is needed, more difficult than the first one in mission conditions. Repairing a cleft palate needs to be adapted to the type of cleft but also to the age of the child, a velopalatine pharyngoplasty can be performed in some cases.     

Nasal sequels of unilateral clefts: analysis and management

Usually, the nasal sequels of unilateral cleft patient are just considered as an esthetic problem to be addressed after the growth spurt of adolescence. This very narrow vision has led the cleft lip and palate treatment to a deadend. Actually, nasal sequels are the worst in terms of consequence on facial growth. 75% of complete unilateral cleft children are more oral than nasal breathers. Today, we know about the bad consequences of oral breathing on facial growth. It is not surprising to observe a high rate of small maxilla with cleft maxilla scars. In the fetus, the unilateral cleft nose deformities are well explained by the rupture of the facial envelope and the ventilatory dynamics of the amniotic fluid. Every step of the primary treatment threatens the nasal air way patency, whether when repairing lip and nose, suturing the hard palate that is the floor of the nose, or closing the alveolar cleft which controls the width of the piriform aperture. The functional and esthetic nasal sequels reflect the initial deformity, but are also the surgeon's skill and protocol choice. Before undertaking treatment, we must analyze the deformity at every level. Usually, the best option is to reopen the cleft completely to perform a combined revision of the lip, nose, and alveolar cleft after an adequate anterior maxillary expansion. If nasal breathing is necessary for an adequate facial growth, 25 years of experience showed us that it was very difficult to erase the cortical imprint of an early oral breathing pattern. So it is essential to establish a normal nasal breathing mode at the initial surgery. When the initial surgery is efficient and/or the secondary repair is successful, the final esthetic rhinoplasty, when indicated, is just performed for the sake of harmonization, with a classic internal approach and a few refinements.     

Medial cleft of the tongue, the lower lip and the mandible

INTRODUCTION: The oro-facial clefts are very frequent congenital malformations, with many clinical forms. We report an exceptional case of median cleft of the tongue, the lower lip and the mandible. CASE REPORT: Our patient was a new born, admitted in our unit for major facial malformation with swallowing disorder. The patient presented a particular form of cleft no 30 in Tessier's classification, which associated two hemi-tongues, two hemi-lower lips and two hemi-mandibles. Surgery was performed early because of the swallowing disorder. Cosmetic and functional results were positive, with 18 month follow-up. DISCUSSION: With a review of the literature, we describe this pathology, its embryologic origin, its different clinical forms and its treatment.     

A functional approach in the primary treatment of labial-alveolar-velopalatine clefts for a minimum of sequels

Is the poor potential of growth an ineluctable consequence of mesodermal deficiency? Should we agree with the idea that all protocols are equivalent? Actually, these opinions reflect the empiricism of previous generations. We must now become rational and develop a project without compromise to achieve good functions at primary surgery. 'The normal structures are present on either side of the cleft, only modified by the fact of the cleft...' Victor Veau's hypothesis is the conclusion of rigorous anatomical and embryological research. Our current knowledge of the pathological anatomy allows for a better restoration of the normal anatomy. Anatomy is nothing if it is not functional. Every thing should be done to control the healing process to allow the best expression and interaction of the various functions, especially for those concerning nasal ventilation and masticatory efficiency. To correct the deformity, the cleft surgeon must perform a wide subperiosteal and subperichondrial elevation and must learn the skills of this accurate work to preserve the integrity of very fragile structures. The primary treatment must take into account a rational and uncompromising selection of the age of the first operation, of the successive procedures, and their chronology to benefit from the growth spurt of the maxilla, and to avoid the worse scars resulting from secondary epithelialization. Finally, if nasal breathing is the most important function concerning facial growth, it is essential to restore this normal function at the time of the first operation. The oral breathing pattern set at the time of the first operation leaves a cortical imprint that is very difficult to erase, even after clearing the nasal airways. The results of the functional approach we have used in the last decade are particularly consistent and very convincing. In this ambitious and demanding program, the patient comes first; we decrease the burden for him and his family, and give them the benefit of a good social life before school age.     

Management of bilateral cleft lip and nasal deformity

PURPOSE OF REVIEW: Management of bilateral cleft lip and nasal deformity can be a challenging task. This paper provides an overview of bilateral cleft lip and nasal deformity with an updated review of current management issues in the literature. RECENT FINDINGS: The Centers for Disease Control and Prevention recently reported that orofacial clefts are now the most common birth defect. While this statistic may be disheartening, the increased prevalence brings the problem to light at the forefront of the medical community, thus gaining more support and resources. Many techniques have been described for repair of bilateral cleft lip and nasal deformity. A recent advancement in presurgical orthopedics is the use of nasoalveolar molding to narrow wide clefts. SUMMARY: Surgical management of bilateral cleft lip and nasal deformity poses a challenge to the skill and judgment of the cleft surgeon. Although techniques continue to evolve over the decades, the basic principles of cleft surgery remain the same. The main principles are to achieve an appropriate philtral size and shape, to position the cartilages in a more optimal position, and to attain muscular continuity and symmetry for optimal appearance and function. Thus, while keeping the basic principles in mind, management of bilateral cleft lip and nasal deformity becomes a valuable and rewarding experience for the surgeon, patient and caregiver.     

Maxillary sequelae in cleft patients. Causes of maxillary hypoplasia and possible prevention

Maxillary hypoplasia is frequently observed in cleft patients. Although maxillary retrusion can be a syndromic outcome, the growth failure is also a consequence of the primary surgery of the palate, alveolar cleft, or lip. In this article the authors analyze the impact of primary surgery on the maxillary growth failure and discuss on how to prevent this complication.     

Prolabial lengthening by Turkish tulip method in bilateral cleft lip repair

OBJECTIVE: In bilateral cleft lip, there is a characteristic deformity called cleft lip nose characterized by short columella and prolabium with a pressed nose. Although lots of surgical techniques were described for columella lengthening and correction of the nose deformity, no technical method was suggested for prolabium lengthening. STUDY DESIGN: In this paper we propose a simultaneous bilateral cleft lip repair and lengthening of the prolabium, and describe a new technique called "Turkish tulip" for this aim. PATIENTS AND METHOD: Eleven patients (6 males and 5 females) with bilateral cleft lip were treated using this method. Patients' ages ranged from 3 months to 17 years at the time of operation. Five patients had incomplete and six had complete bilateral cleft lips. The patients were evaluated in terms of functional and aesthetic results in postoperative period. RESULTS.: The average follow-up time was 8 months (ranged from 4 months to 15 months). There were no postoperative complications. The prolabium was lengthened adequately in all patients. No notch and whistle deformity was seen in our series. The patient or parent satisfaction was good or perfect in all cases. CONCLUSIONS: To avoid the disadvantage of the long time course required to correct the nose deformity and to lengthen the prolabium, we propose the "Turkish tulip" technique with the primary repair of bilateral cleft lips simultaneously. With this technique it is possible to lengthen the columello-prolabial complex with cleft lip repair in the same session without any intervention to any part of the nose including the columella. As a preliminary study, according to the early results, this new technique seems to have good cosmetic outcomes.     

Specificity of prosthetic dental rehabilitation in cleft lip and palate sequels

The same techniques are used for dental rehabilitation in cleft patients and non-cleft patients. The clinical state for cleft edentulous patients ranges from one missing tooth to maxillary loss. For cleft patients, several surgical procedures may have been performed to close the cleft lip and/or palate, so the patient will not always agree to a new surgical procedure for preprosthetic management. The main difference to take into account is the dental occlusion stability. If previous management of the cleft patient did not provide normal occlusion, dental rehabilitation is the alternative. We describe implant-supported prosthesis; implant stabilized prosthesis, bridge, and maxillofacial prosthesis.     

Rhinoplasty in unilateral cleft lip nasal deformity

An operation is described for correction of unilateral cleft lip nasal deformity which has had considerable uniformity of success and is applicable to both mild and severe degrees of deformity. Our proposed repair technique is performed through an external rhinoplasty approach and depends on repositioning of the displaced and deformed cartilages together with the reinforcement of the structural support of the nose by using multiple cartilage grafts. This surgical technique was used in 18 consecutive adult patients with unilateral cleft lip nasal deformity and yielded consistently good long-term functional and cosmetic results.     

单侧唇裂修复术改善鼻部畸形

目的探讨单侧唇裂修复手术对鼻部畸形的治疗影响。方法我院2002年至2006年收治单侧唇裂186例,回顾分析其手术方式与鼻唇部修复情况。结果单侧唇裂修复术后,鼻畸形35例,其中Millard法修复术后鼻畸形12例（12/77,15.6%）;Tennison法修复16例（16/56,28.6%）,上旋转下三角瓣法修复7例（7/53,13.2%）。结论对于单侧唇裂,选择适宜的手术方式,可同期修复鼻部畸形,减少患者痛苦。     

Lip adhesion in bilateral cleft lip

Surgical correction of bilateral cleft lip deformities remains one of the most challenging areas in facial plastic surgery. This is particularly true with asymmetrical, incomplete-complete clefts; and with symmetrical, complete clefts with marked protrusion of the premaxilla. Although the lip adhesion procedure has been used with success in certain unilateral clefts, its possible role in the bilateral deformity is less well defined and accepted. The purpose of this report is to propose that lip adhesion has advantages in certain bilateral deformities and to describe a technique for one-stage bilateral adhesions.     

Treatment outcome after neonatal cleft lip repair in 5-year-old children with unilateral cleft lip and palate

IntroductionThe aim of this study was to assess speech outcomes and dental arch relationship of 5-year-old Czech patients with unilateral cleft lip and palate (UCLP) who have undergone neonatal cleft lip repair and one-stage palatal closure.Methods and materialsTwenty-three patients with UCLP, born between 2009 and 2010, were included in the study. Three universal speech parameters (hypernasality, articulation and speech intelligibility) have been devised for speech recordings evaluation. Outcomes of dental arch relationship were evaluated by applying the GOSLON Yardstick and subsequently compared with the GOSLON outcome of other cleft centers.ResultsModerate hypernasality was present in most cases, the mean value for articulation and speech intelligibility was 2.07 and 1.93, respectively. The Kappa values for inter-examiner agreement for all the three speech outcomes ranged from 0.786 to 0.808. Sixty-three percent of patients were scored GOSLON 1 and 2, 26% GOSLON 3, and 10% GOSLON 4. GOSLON mean score was 2.35. Interrater agreement was very good, represented by kappa value of 0.867.ConclusionThe treatment protocol, involving neonatal cleft lip repair and one-stage palatal repair performed up to the first year of UCLP patient's life, has shown good speech outcomes and produced very good treatment results in regard to maxillary growth, comparable with other cleft centers.     

Maxillary sequels in labial-alveolar-velopalatine clefts. Role of distraction osteogenesis

A high rate of cleft patients present with maxillary hypoplasia. Most of the growth defects concern the anteroposterior axis of the maxilla. Before bone lengthening by distraction osteogenesis, orthognathic surgery was the only alternative treatment for maxillary hypoplasia. Several studies showed the lack of stability after conventional surgery. In this article reviewing the literature concerning all bone lengthening procedures, the authors discuss published data on maxillary distraction osteogenesis by external and internal devices. Indications of distraction in growing children as an interceptive step are discussed.