clinical aspects of cleft lip & palate reconstruction

Clinical Aspects of Cleft Lip/Palate Clinical Aspects of Cleft Lip/Palate ReconstructionReconstruction

ANJAN K DEBANJAN K DEB

Dept of Plastic surgery BIRDEMDept of Plastic surgery BIRDEM

OverviewOverview• Relevant Anatomy & PhysiologyRelevant Anatomy & Physiology

• Embryology of Facial CleftingEmbryology of Facial Clefting

• Classification/Epidemiology/Related SyndromesClassification/Epidemiology/Related Syndromes

• Principles of ManagementPrinciples of Management• Preoperatve Assessment/ OrthodonticsPreoperatve Assessment/ Orthodontics

– Indications/ContraindicationsIndications/Contraindications

• Time table of Procedures/EventsTime table of Procedures/Events

• Surgical TechniquesSurgical Techniques

– Millard / Tennison-RandallMillard / Tennison-Randall

– Wardill-Kilner/ Z-plastyWardill-Kilner/ Z-plasty

– Speech assessment/PharyngioplastySpeech assessment/Pharyngioplasty

– Alveolar bone graftAlveolar bone graft

• Post-op managementPost-op management

– Complications

– Follow up

Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction

Applied AnatomyApplied Anatomy

Normal LipNormal Lip

CENTRAL PHILTRUM

Lateral margins

Philtral columns

Inferior border

Cupids bow and tubercle

VERMILLION-CUTANEOUS BORDER

White roll

COMMISURE


Applied AnatomyApplied Anatomy• PHILTRAL ZONE

– Column/Dimple

• VERMILION– Cupid’s Bow/Apex

• SUB VEMILION• PERISTOMAL

– Wet & Dry Line

• COMMISURE• LATERAL • CENTRAL


• Glabella

• Root Or Nasion

• Dorsum Or Rhinon

• Ala (3)

• Columella (2)

• Tip (8)/ Infratip (1)

• Soft Triangle/Facet (4)

• Nasal Sill (5)

• Columella-philtral Angle (6)

• Alar –Facial Groove (7)


MUSCLES

Orbicularis oris (superficial and deep)

Levator labii superioris

Levator superioris alaeque

Levator anguli oris

Zygomaticus major et minor

Buccinator

Depressor labii inferioris

Depressor anguli oris

Mentalis

Disruption of the normal termination of the muscle fibers that cross the embryologic Disruption of the normal termination of the muscle fibers that cross the embryologic fault line of the maxillary and nasal processes, resulting in abnormal insertion & fault line of the maxillary and nasal processes, resulting in abnormal insertion & abnormal muscular forces between the normal equilibrium that exists with the abnormal muscular forces between the normal equilibrium that exists with the nasolabial and oral groups of musclesnasolabial and oral groups of muscles


MUSCLES OF LIP INNER VIEWMUSCLES OF LIP INNER VIEW

Applied AnatomyApplied AnatomyBLOOD SUPPLY LIPSBLOOD SUPPLY LIPSDORSAL NASALDORSAL NASAL

FACIALFACIAL

INF ALVEOLAR terminal brINF ALVEOLAR terminal br

INFERIOR LABIALINFERIOR LABIAL

SUPERIOR LABIALSUPERIOR LABIAL

INFRA ORBITALINFRA ORBITAL

MAXILLARYMAXILLARY

POST SUP ALVEOLARPOST SUP ALVEOLAR

BUCCALBUCCAL

Applied AnatomyApplied AnatomyBLOOD SUPPLY PALATEBLOOD SUPPLY PALATE

NASAL SEPTUMNASAL SEPTUM

TURBINATESTURBINATES SPHENOPALATINESPHENOPALATINE

GREATER PALATINEGREATER PALATINE

ANASTOMOSIS POSTERIOR SEPTAL & GR PALATINEANASTOMOSIS POSTERIOR SEPTAL & GR PALATINE

LESSER PALATINELESSER PALATINE


Normal PalateNormal Palate

Primary palatePrimary palate

Secondary palateSecondary palate

Soft palateSoft palate

Hard palateHard palate


• SUPERIOR CONSTRICTOR

» primary sphincter

• TENSOR VELI PALATINI

» tenses palate

• LEVATOR VELI PALATINI

» elevates palate

» dilates Eust Tube

• Salpingopharyngeus, palatopharyngeous, palatoglossus: minor contribution

Postero-superior view

PHARYNGEAL VIEWPHARYNGEAL VIEW

Muscle of velum 3D view

Embryology of CleftingEmbryology of Clefting

FACIAL DEVELOPMENT - 4FACIAL DEVELOPMENT - 4THTH - 10 - 10TH TH WEEK WEEK

Formed by the fusion ofFormed by the fusion of 55 prominences/processesprominences/processes

FRONTONASAL x1FRONTONASAL x1

Lateral/medial nasal processesLateral/medial nasal processes

MAXILLARY x2

MANDIBULAR x2

Nose/Philtrum of upper lipNose/Philtrum of upper lip

Cheeks/Upper lip (Cheeks/Upper lip (-philtrum-philtrum))

Lower face (lower lip/chin)

Embryology of CleftingEmbryology of CleftingFACIAL DEVELOPMENTFACIAL DEVELOPMENT

Medial nasal processesMedial nasal processes migrate toward

each other and fuse

55thth -7 -7thth week week



• 7th -8th week– Inferior tips of medial nasal

processes expand laterally form the intermaxillary process

– Tips of maxillary swellings grow & meet the intermaxillary process and fuse

Failure of maxillary swellings to fuse with intermaxillary process = cleft lipFailure of maxillary swellings to fuse with intermaxillary process = cleft lip

FORMATION OF THE FORMATION OF THE PALATEPALATE

66thth -7 -7thth week weekAs nasal pits of lateral nasal As nasal pits of lateral nasal process invaginate and fuse, process invaginate and fuse, intermaxillary process extends intermaxillary process extends to form primary palateto form primary palate



88th th - 9- 9th th weekweekMedial walls Medial walls of of MAXILLARY PROCESSES MAXILLARY PROCESSES produce produce PALATINE SHELVESPALATINE SHELVESShelves grow downwards, Shelves grow downwards, parallel to lateral suface parallel to lateral suface of tongueof tongue

End of End of week 9week 9, , rotate rotate upward upward into a into a horizontal position and horizontal position and fuse with each fuse with each other other and and primary palate primary palate to to FORM FORM SECONDARY PALATESECONDARY PALATE Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction


Embryology of CleftingEmbryology of Clefting• MESODERM H&N derived from

– PARAXIAL MESODERMPARAXIAL MESODERM• Floor Of Brain CaseFloor Of Brain Case• Occipital & Parietal BonesOccipital & Parietal Bones• All Voluntary Muscle of H&NAll Voluntary Muscle of H&N• Dermis & CT of Dorsal HeadDermis & CT of Dorsal Head

– LATERAL PLATE MESODERMLATERAL PLATE MESODERM• Laryngeal Cartilages & CTLaryngeal Cartilages & CT

– NEURAL CREST CELLSNEURAL CREST CELLS(deficient in superoxide dismutase & catalase) (deficient in superoxide dismutase & catalase)

• Mid-facial & Pharyngeal Arch skeletonMid-facial & Pharyngeal Arch skeleton• Overlying Dermis & Soft TissuesOverlying Dermis & Soft Tissues• DentinDentin

– ECTODERMAL PLACODES• Neuron of Sensory Ganglia, V,VII,I X, X

CRANIO-FACIAL CLEFT• Tessier,s Classification

– Spoke wheel– Radiating from

orbit– Magic No- 14– Incidence:

1:150000

Cleft Lip & Palate VariantsCleft Lip & Palate VariantsGreat anatomic variation Great anatomic variation in types of clefts!in types of clefts!

ANATOMIC CLASSIFICATION ANATOMIC CLASSIFICATION basedbased on: on:

1) LOCATION1) LOCATION

2) COMPLETENESS 2) COMPLETENESS (Incomplete/Complete)(Incomplete/Complete)

3) EXTENT3) EXTENT

Since lip, alveolus, and hard palate differ in embryologic Since lip, alveolus, and hard palate differ in embryologic origin, origin,

4) ANY COMBINATION CAN OCCUR4) ANY COMBINATION CAN OCCUR


Cleft Lip & Palate VariantsCleft Lip & Palate Variants

CLEFLIP & PRIMARY PALATECLEFLIP & PRIMARY PALATE

CLEFT OF PRIMARY & SECONDARY PALATECLEFT OF PRIMARY & SECONDARY PALATE

CLEFT OF SECONDARY PALATECLEFT OF SECONDARY PALATE

Veau Classification CLCPVeau Classification CLCP

• 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

• Iowa Classification - a variation of Veau Classification

Iowa Classification CLCPIowa Classification CLCP

Group IGroup I

Clefts of lip onlyClefts of lip only

Group IIGroup II

Clefts of palate only (Clefts of palate only (22oo))

Group IIIGroup III

Clefts of lip, Clefts of lip, alveolus, palatealveolus, palate

Group IVGroup IV

Clefts of lip and Clefts of lip and alveolus alveolus (primary (primary cleft palate and cleft palate and lip)lip)

Group VGroup V

MiscellaneousMiscellaneous

Striped Y Modified Kernahan’sStriped Y Modified Kernahan’s1 & 5 1 & 5 - - FLOOR OF NOSE FLOOR OF NOSE on right & on right & left sidesleft sides

2 & 6 2 & 6 - - LIPLIP

3 & 7 3 & 7 - - ALVEOLAR RIDGESALVEOLAR RIDGES

4 & 8 4 & 8 -- PREMAXILLA PREMAXILLA to incisive to incisive foramenforamen

9 & 10 9 & 10 - Each half of the - Each half of the HARD HARD PALATEPALATE

11 11 - - SOFT PALATESOFT PALATE

12 12 - Congenital - Congenital VELOPHARYNGEAL VELOPHARYNGEAL INCOMPETENCEINCOMPETENCE without obvious without obvious cleftsclefts

13 13 - - PROTRUSION PROTRUSION of premaxillaof premaxilla

KERNAHANSKERNAHANS


Isolated INCOMPLETEIsolated INCOMPLETE

Intact skin/muscle between the lip and noseIntact skin/muscle between the lip and nose

Less distortion brought on by abnormal muscle pullLess distortion brought on by abnormal muscle pull

Bilateral/UnilateralBilateral/Unilateral

CLEFT LIPCLEFT LIPExpressed in structures Expressed in structures anterior to incisive foramenanterior to incisive foramen

- prepalatal alveolus, maxilla, lip, nasal structures- prepalatal alveolus, maxilla, lip, nasal structures

GAPING CLEFT of alveolus/lip structures to GAPING CLEFT of alveolus/lip structures to MERE ‘SCAR’ (MERE ‘SCAR’ (forme frusteforme fruste))

DEFICIENCY IN DEFICIENCY IN SKINSKIN, , MUSCLES, MUCOUS MUSCLES, MUCOUS MEMBRANESMEMBRANES, MAXILLARY/NASAL , MAXILLARY/NASAL BONESBONES, NASAL , NASAL CARTILAGESCARTILAGES

ISOLATED COMPLETE ISOLATED COMPLETE Bilateral/UnilateralBilateral/Unilateral

Cleft runs entire length of lip to floor of noseCleft runs entire length of lip to floor of nose

Abnormal muscle pull distorts nose extensively Abnormal muscle pull distorts nose extensively and creates wide clefts between the lip and creates wide clefts between the lip segmentssegments


Ipsilateral Lower Lat Cart Ipsilateral Lower Lat Cart flattenedflattenedrotated downwardrotated downward

Bifid tipBifid tipShort columellaShort columellaFlattened alaFlattened alaCleft of alveolusCleft of alveolus



ISOLATED CLEFT PALATEISOLATED CLEFT PALATE

COMPLETE/INCOMPLETE/SUBMUCOUSCOMPLETE/INCOMPLETE/SUBMUCOUS

Soft PalateSoft Palate

cleft can extend into the hard palate to cleft can extend into the hard palate to any extentany extent

Hard PalateHard Palate

Primary PalatePrimary Palate

Secondary PalateSecondary Palate


Cleft Lip & Palate VariantsCleft Lip & Palate VariantsCOMBINED CLEFTS COMBINED CLEFTS

Complete lip &/palate Unilateral Complete lip &/palate Unilateral

Cleft Lip & Palate VariantsCleft Lip & Palate VariantsComplete lip &/palate BilateralComplete lip &/palate Bilateral

PROTRUDED PEMAXILLAPROTRUDED PEMAXILLA

EpidemiologyEpidemiology• Isolated CLEFT PALATE genetically distinct

from isolated CLEFT LIP OR CLAP– same among all ethnic groups (1:2000, M:F 1:2)

– More assoc with Syndrome

• Isolated CL or CLAP– different among ethnic groups

• American Indians: 3.6:1000 (M:F 2:1)

• Asians 3:1000 (M:F 2:1)

• African American 0.3:1000 (M:F 2:1)

• 20% CL (18% unilateral, 2% bilateral) 20% CL (18% unilateral, 2% bilateral)

• 50% CL and CP (38% unilateral, 12% bilateral) 50% CL and CP (38% unilateral, 12% bilateral)

• 30 % CP alone30 % CP alone

EpidemiologyEpidemiology

• GENETICS (Clustering in families)

FAMILY MAKEUP RISK OF CLEFT LIP / PALATE

RISK OF CLEFT PALATE

ONE AFFECTED SIBLING OR PARENT

1 IN 25 (4%) 2.5%

TWO AFFECTED SIBLING

1 IN 11 (9%) 1%

ONE SIBLING AND ONE PARENT

1 IN 6 (16%) 15%

EpidemiologyEpidemiology• SYNDROMIC CLAP

– associated with more than 300 malformations• CHROMOSOMAL

– Trisomy 13, 18, 21 & Deletion 22q11 (Velocardiofacial Syndrome)

• NON MENDELIAN– PIERRE ROBIN, Goldenhar

• MENDELIAN– Corlin’s, Dysplasia-Clefting, Treacher-Collins, Van der Woude (AD)

– Smith-Lemli-Opitz (AR)

– Oto-Palato-digital, Oto-Palato-Facial (XL)

• UNKNOWN– DeLarge , Kabuki

• TERATOGENIC– Fetal Alcohol, Phenytoin, Valproate

• NONSYNDROMIC CLAP• diagnosis of exclusion

• OVERALL INCIDENCE OF ASSOCIATED ANOMALIES (e.g. OVERALL INCIDENCE OF ASSOCIATED ANOMALIES (e.g. CARDIACCARDIAC) = 30% ) = 30%

EpidemiologyEpidemiology

• RISK FACTORS– PARENTAL AGE: >30yrs– VIRAL INFECTIONS: Rubella– TERATOGENS: Alcohol, Steroids,

Anticonvulsants, Retinoic acid derivatives

Principles of ManagementPrinciples of Management

• Multidisciplinary Approach

• These are not merely surgical problems– Requires team approach throughout life

• neonatal period

• toddler

• grade school

• adolescence

• young adulthood


MULTIDISCIPLINARY APPROACHMULTIDISCIPLINARY APPROACHBeyond lip repair are other issues:Beyond lip repair are other issues:

Hearing (Otolaryngologists)Hearing (Otolaryngologists)Speech (Speech Pathologists / Therapist) Speech (Speech Pathologists / Therapist)

Dental (Periodontologist/Orthodontist / Prosthodontist/)Dental (Periodontologist/Orthodontist / Prosthodontist/)

Maxillofacial Surgeons/Maxillofacial Surgeons/

Psychosocial (Psychologist/ Psychiatrist/ Social Worker) Psychosocial (Psychologist/ Psychiatrist/ Social Worker) Geneticist Geneticist

Integration with team-based approachIntegration with team-based approach

Each case is assessed independently by those involved and a global treatment plan Each case is assessed independently by those involved and a global treatment plan is instituted based on present need in his/her developmentis instituted based on present need in his/her development

Cleft Lip and PalateCleft Lip and Palate

Nutrition (Nutritionist )Nutrition (Nutritionist )


ASSESSMENTASSESSMENTAIMAIM: RESTORING NORMAL MORPHOLOGIC FORM AND FUNCTION: RESTORING NORMAL MORPHOLOGIC FORM AND FUNCTION

Important for Important for normal dentition, mastication, speech, hearing, normal dentition, mastication, speech, hearing, andand breathing breathing

CONTRAINDICATIONSCONTRAINDICATIONS: MALNUTRITION, ANEMIA RESPIRATORY : MALNUTRITION, ANEMIA RESPIRATORY INFECTION or other conditions that render infant INFECTION or other conditions that render infant UNABLE TO TOLERATE UNABLE TO TOLERATE GENERAL ANESTHESIA Airway obstruction, Acute otitis mediaGENERAL ANESTHESIA Airway obstruction, Acute otitis media

Work-upWork-up(1) Thorough (1) Thorough PE PE to uncover any to uncover any ASSOCIATED ANOMALIESASSOCIATED ANOMALIES

Additional work-up determined by physical findings that suggest involvement Additional work-up determined by physical findings that suggest involvement of of other organ other organ systemssystems

(2) (2) WEIGHT, ORAL INTAKE, GROWTH/DEVELOPMENT WEIGHT, ORAL INTAKE, GROWTH/DEVELOPMENT

are of primary concern and must be followed closelyare of primary concern and must be followed closely (3) Routine lab studies generally not required; Hgb level before surgery(3) Routine lab studies generally not required; Hgb level before surgery

The Neonatal Period

• Pediatrician:– directs care

– establishes feeding• complete clefts

preclude feeding – breast feeding not

possible

– a soft, large bottle with large hole is required

– a palatal prosthesis may be required

• Feeding bottle large hole

The Neonatal Period

• Presurgical Orthodontics (Baby Plates)

– Moulds palate into more anatomically correct position

– decreases tension

– may improve facial growth

– Grayson, presurgical nasal alveolar moulding (PSNAM)

• c

The Neonatal Period

The Neonatal Period

• Surgical Repair– Cleft Lip

• In US - “THE RULE OF TENS” - 10 wks, 10 lbs, Hgb 10gm%

• Lip adhesion vs baby plates

– Cleft Palate• Varies from 6-18 Months - most around 10 mo

• Early repair may lead to MIDFACE RETRUSION

• Early repair improves SPEECH

Different institutions = different practiceDifferent institutions = different practice

Management Schedule

Palatal obturatorPalatal obturator

Repair cleft lipRepair cleft lip

Repair of Palate Repair of Palate

Repair of Hard palateRepair of Hard palate

Tympanotomy tubeTympanotomy tube

Speech therapy/pharyngoplastySpeech therapy/pharyngoplasty

Bone graftingBone grafting

OrthodonticsOrthodontics Jaw surgeryJaw surgery

Surgical Principles

• Release the muscles Release the muscles from abnormal from abnormal insertionsinsertions

• Repair them in Repair them in anatomical positionanatomical position

• Lengthen medial side Lengthen medial side of cleft so that it of cleft so that it attains normal attains normal anatomical lengthanatomical length

Surgical ManagementSurgical ManagementUnilateral Complete Cleft LipUnilateral Complete Cleft Lip

GOALS GOALS

• SYMMETRY: Nostrils, SYMMETRY: Nostrils, Nasal Sill, and Alar BasesNasal Sill, and Alar Bases

• WELL DEFINED WELL DEFINED PHILTRUM: Dimple and PHILTRUM: Dimple and Columns Columns

• CUPID’S BOW: Natural CUPID’S BOW: Natural appearingappearing

• FUNCTION: Good muscle FUNCTION: Good muscle repairrepair

SURGICAL PRINCIPLESSURGICAL PRINCIPLES

• Lengthen medial side of Lengthen medial side of cleft so that it equals the cleft so that it equals the vertical dimensions of non-vertical dimensions of non-cleft sidecleft side

• Flap designs:Flap designs:– Triangular (Tennison-Triangular (Tennison-

Randall)Randall)

– QuadrangularQuadrangular

– Rotation-advancement Rotation-advancement (Millard)(Millard)

• MuscleRepair:MuscleRepair:

Surgical ManagementSurgical ManagementUnilateral Complete Cleft LipUnilateral Complete Cleft Lip

TENNISON-RANDALLTENNISON-RANDALL

Millard TechniqueMillard Technique• Cleft Lip Repair• Unilateral

• Rotation(a &c)-advancement (b)flap developed by Millard

– Medial flap(a) Medial flap(a) rotates rotates downward to achieve necessary downward to achieve necessary lengtheninglengthening

– Lateral flap (b) Lateral flap (b) advances into advances into the defect produced by downward the defect produced by downward displacement of medial flapdisplacement of medial flap

– Small pennant-shaped Small pennant-shaped medial flap (c)medial flap (c)c an be used to c an be used to restore nostril sill or lengthen the restore nostril sill or lengthen the columellacolumella

3 Flaps a,b & c

Millard TechniqueMillard Technique• ADVANTAGES

– ““Cut as you go” technique Cut as you go” technique

– Preserves’ cupid’s bow and Preserves’ cupid’s bow and philtral dimplephiltral dimple

– Scar placed in anatomical position along philtral column

– Tension of closure under the Tension of closure under the alar base; reduces flair and alar base; reduces flair and promotes better molding of the promotes better molding of the underlying alveolar processesunderlying alveolar processes

Millard TechniqueMillard Technique

• COMPLICATIONS– Tightness at white roll/

cupids bow– Peaking of vermillion– Notching of stomal

margin– Residual nasal

deformity– Tension?/ dehisence?/

HTS?/infection?– scar stretching

Bilateral Cleft Lip Repair

• MILLARD’S ADAPTATION:– Philtral from central

prolabium

– Prolab paring banked for collumelar lengthening

– Prolabial white roll & vermillion discarded

– Cupids bow tubercle from lateral lip segments


• MODIFIED MANCHESTER– Preserves white roll

vermillion of prolabium

– Philtral flap cut to desired width

– Prolabial paring used for nasal floor

– Lateral muscle are sutured to prolabial sub cut tissues


• BLACK’S METHOD

Post-op ManagementPost-op Management

1) FEEDINGS administered with catheter tip syringe 1) FEEDINGS administered with catheter tip syringe fitted with small red rubber catheter for the first 10 days fitted with small red rubber catheter for the first 10 days post-oppost-op

2) AVOID SUCKING Nipples are avoided to minimize 2) AVOID SUCKING Nipples are avoided to minimize strain on the muscle/skin suturesstrain on the muscle/skin sutures

3) ARM RESTRAINT Velcro arm restraints to 3) ARM RESTRAINT Velcro arm restraints to protect repair from flailing hands/fingersprotect repair from flailing hands/fingers

4) SUTURE LINE CARE: PRN cleansing with half 4) SUTURE LINE CARE: PRN cleansing with half strength peroxide followed with polymixin B-bacitracin strength peroxide followed with polymixin B-bacitracin ointmentointment

Cleft LipCleft Lip



Scar contractureScar contracture

ErythemaErythema

FirmnessFirmness

Inform the parents of:Inform the parents of:

Avoid placing in direct sunlight until the scar fully maturesAvoid placing in direct sunlight until the scar fully matures


ComplicationsComplicationsPost-op ManagementPost-op Management

• AestheticAesthetic– vermilion-cutaneous vermilion-cutaneous

mismatchmismatch– vermilion notchingvermilion notching– Whistle deformityWhistle deformity– tight appearing lateral lip tight appearing lateral lip

segementsegement– lateral muscle buldgelateral muscle buldge– laterally displaced alalaterally displaced ala– constricted appearing constricted appearing

nostrilnostril

• OtherOther– dehiscencedehiscence

– excessive scar excessive scar formationformation


Surgical ManagementSurgical ManagementCleft PalateCleft Palate

Goal: Production of a competent velopharyngeal sphincterGoal: Production of a competent velopharyngeal sphincter

Two most common repairs:Two most common repairs:

1) V-Y (Veau-Wardill-Kilner)*1) V-Y (Veau-Wardill-Kilner)*

2) von Langenbeck2) von Langenbeck

Main difference: V-Y repair involves Main difference: V-Y repair involves elongation of the palateelongation of the palate, while , while von Langenbeck does notvon Langenbeck does not


Wardill-KilnerWardill-Kilner1) Incisions made along free margins of cleft and extend 1) Incisions made along free margins of cleft and extend anteriorly to apexanteriorly to apex

2) Dissection continued posteriorly along oral side of 2) Dissection continued posteriorly along oral side of alveolar ridge to retromolar trigonealveolar ridge to retromolar trigone


Wardill-KilnerWardill-Kilner3) Mucoperiosteal flaps are elevated from 3) Mucoperiosteal flaps are elevated from nasal/oral surfaces of bony palatenasal/oral surfaces of bony palate

4) Dissection of the greater palatine vessels from 4) Dissection of the greater palatine vessels from the foramen lengthens the pediclethe foramen lengthens the pedicle

5) Tensor veli palatini muscle is elevated off the 5) Tensor veli palatini muscle is elevated off the hamulus to aid in relaxing the midline closurehamulus to aid in relaxing the midline closure


Wardill-KilnerWardill-Kilner

6) Nasal mucosa freed from bony palate 6) Nasal mucosa freed from bony palate and closed to either side, or if necessary and closed to either side, or if necessary closed by using vomer flapsclosed by using vomer flaps

7) Muscle and oral mucosa closed in a 7) Muscle and oral mucosa closed in a second single layer in a horizontal fashionsecond single layer in a horizontal fashion


Wardill-KilnerWardill-Kilner8) Anteriorly, the oral mucoperiosteal flaps are 8) Anteriorly, the oral mucoperiosteal flaps are attached to the third flap (mucosa overlying the attached to the third flap (mucosa overlying the primary palateprimary palate

9) Posteriorly, the palate is closed in 3 layers9) Posteriorly, the palate is closed in 3 layersNasal mucosaNasal mucosaLevator muscleLevator muscleOral mucosaOral mucosa



• Cleft PalateCleft Palate– Immediate concerns: Immediate concerns:

• AIRWAY MANAGEMENT: Change in nasal/oral airway AIRWAY MANAGEMENT: Change in nasal/oral airway dynamicsdynamics

• ANALGESIA: Risk of over-sedation and subsequent ANALGESIA: Risk of over-sedation and subsequent airway compromiseairway compromise

• ARM RESTRAINTS to prevent placing fingers in mouthARM RESTRAINTS to prevent placing fingers in mouth

• DIET restricted to liquids, soft foods (x3wks): bottles DIET restricted to liquids, soft foods (x3wks): bottles avoidedavoided

Acetominophen, Codeine sufficient: cont’d for 7-10 daysAcetominophen, Codeine sufficient: cont’d for 7-10 days



• Airway obstructionAirway obstruction

• Intraoperative bleeding/ AspirationIntraoperative bleeding/ Aspiration

• Palatal fistula/ DehisencePalatal fistula/ Dehisence

• Midface abnormalities (early interventions)Midface abnormalities (early interventions)

COMPLICATIONSCOMPLICATIONS


Cleft Palate ClinicsCleft Palate Clinics

Through a protocol of sequential, regular evaluations by a Through a protocol of sequential, regular evaluations by a team composed of plastic surgeon, speech pathologist, team composed of plastic surgeon, speech pathologist, orthodontist, and audiologist, great strides have been made in orthodontist, and audiologist, great strides have been made in improving all aspects of care of the child with cleft palateimproving all aspects of care of the child with cleft palate


The Toddler Years

• Priority: Speech

• VELOPHARYNGEAL DYSFUNCTION– A. VELOPHARYNGEAL MISLEARNING

“i.e. Phoneme Specific Nasal Air Emission”– B. VELOPHARYNGEAL INCOMPTENCY

i.e.“apraxia”, neurological deficit– C. VELOPHARYNGEAL INSUFFICENCY

i.e. Anatomical deficit

The Toddler Years

• Priority: Speech– “CLEFT ERRORS OF SPEECH” in 30%

• PRIMARY DEFECTS - due to VPD (hypernasality)– consonants are most difficult sounds (plosives)

• SECONDARY DEFECTS - due to attempted correction

– Glottic Stops, Nasal Grimace

– VELOPHARYNGEAL DYSFUNCTION• diagnosed by fiberoptic laryngoscopy or BaSw

• surgical repair after failed speech therapy - usually around age 4

VELOPHARYNGEAL DYSFUNCTION

• SIGNS AND SYMPTOMS– History of NASAL REGURGITATION post

cleft palate repair– History of need for multiple placement of PE

tubes– Nasal GRIMACE– HOARSE Vocal Quality – Decreased INTELLIGIBILITY

clinical aspects of cleft lip & palate reconstruction

Health & Medicine

nasal sill

normal equilibrium

normal termination

alar facial groove

abnormal insertion fault

d view

muscle fibers

columellaphiltral angle