the project with Smile Train
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18 November 2009
11 September 2009
Bilateral complete cleft lip and palate
preoperative 
intraoperative
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bilateral cleft lip repair
postaperative :bilateral cleft lip repairThe more recent technique aim to correct both the labial deformity and the nasal deformity in a single stage are gaining popularity by many surgeons. in this cases, surgical orthopedic treatment consists of molding the nasoalveolar process with progressivly modified splints, and achieving lengthening of the deficient and short columella tissue, leading to an improved nasal appearance with a single stage procedure .
Although insufficient space exists to describe all the commonly used techniques, the principles of bilateral lip repair are common among them, including creation of the philtrum from the prolabium and midline tubercle from the lateral vermilion. The technique described here is as described by Millard . A symmetric, bilateral complete cleft lip and palate with an adequate and moderately protruding prolabium and premaxilla is used as an example.
Although insufficient space exists to describe all the commonly used techniques, the principles of bilateral lip repair are common among them, including creation of the philtrum from the prolabium and midline tubercle from the lateral vermilion. The technique described here is as described by Millard . A symmetric, bilateral complete cleft lip and palate with an adequate and moderately protruding prolabium and premaxilla is used as an example.
Asymmetric, bilateral cleft lips and those with a rotated premaxilla can be treated with a one- or two-stage closure (using the lip adhesion as the first stage). For children with an extremely protruding premaxilla, surgical orthopedics required before definitive lip repair to move the premaxilla posteriorly.
As for the unilateral cleft lip repair, the initial step is to determine the lip landmarks . Point 1 is the midpoint of the vermilion cutaneous junction of the prolabium (the future low point of cupid's bow). From this point, both high points of the future cupid's bow (points 2 and 3) are measured 2.5 to 3 mm on each side of point 1. Two slightly curvilinear lines connect points 2 and 3 with points 4 and 5, which represent the junction of the prolabium with the columella. This delineates the new philtrum. Two lateral prolabial flaps are used at this time to construct the medial and inferior aspects of the nasal sill. Points 6 and 8 are marked at the white line attenuation of the vermilion cutaneous junction on the lateral lip elements. The distance from points 6 to 7 is designed to equal the distance from points 2 to 4; the distance from point 8 to 9 is equal to the distance from point 3 to point 5. A vermilion flap (6 to * and 8 to *) is created on each side, with the length of this flap approximating the length of point 1 to point 2 and point 1 to point 3.
After the lip landmarks and incisions are marked, the lip is infiltrated with local anesthetic containing epinephrine. The incisions are made, starting with the prolabium. The mid-prolabial flap (the future philtrum) and the two lateral prolabial flaps are incised, pedicled superiorly, and dissected free of the underlying premaxilla, along with a small vermilion flap (the e flap). The remaining vermilion of the prolabium is dissected and pedicled on the gingiva, inferiorly. The lateral lip incisions and lateral vermilion flaps are then made and extended to the alar crease. The alae are released from the underlying maxilla with dissection along the piriform aperture. Lateral gingivobuccal sulcus incisions are created for further relaxation, and the lateral lip is dissected from the underlying maxilla in the supraperiosteal plane, to allow adequate mobilization of the orbicularis oris muscle to the midline from each side.
The vermilion flap of the prolabium is sutured superiorly to mucosally line the anterior premaxilla . The lateral lip mucosa is sutured at the midline with 4.0 chromic suture; then, the orbicularis oris muscle is advanced medially and sutured at the midline with 4.0 Vicryl . The muscle is then secured to the anterior nasal spine with vicryl . The small vermilion flaps, which will form the central vermilion tubercle of the lip positioned inferior to the philtrum, are closed with chromic on the wet mucosa and 6.0 nylon sutures on the external aspect of the vermilion. The central prolabial skin flap is fitted into position between the lateral lip segments and secured into place with 6.0 nylon, creating the philtrum of the lip. The small e vermilion flap is tucked behind the lateral vermilion flaps to contribute to the creation of the central tubercle. The two lateral prolabial flaps are banked into the region just inferior to the nares and sutured into position to assist with nasal sill and floor reconstruction. These two banked flaps will ultimately be used to reconstruct the columella in a secondary procedure.
After the lip landmarks and incisions are marked, the lip is infiltrated with local anesthetic containing epinephrine. The incisions are made, starting with the prolabium. The mid-prolabial flap (the future philtrum) and the two lateral prolabial flaps are incised, pedicled superiorly, and dissected free of the underlying premaxilla, along with a small vermilion flap (the e flap). The remaining vermilion of the prolabium is dissected and pedicled on the gingiva, inferiorly. The lateral lip incisions and lateral vermilion flaps are then made and extended to the alar crease. The alae are released from the underlying maxilla with dissection along the piriform aperture. Lateral gingivobuccal sulcus incisions are created for further relaxation, and the lateral lip is dissected from the underlying maxilla in the supraperiosteal plane, to allow adequate mobilization of the orbicularis oris muscle to the midline from each side.
The vermilion flap of the prolabium is sutured superiorly to mucosally line the anterior premaxilla . The lateral lip mucosa is sutured at the midline with 4.0 chromic suture; then, the orbicularis oris muscle is advanced medially and sutured at the midline with 4.0 Vicryl . The muscle is then secured to the anterior nasal spine with vicryl . The small vermilion flaps, which will form the central vermilion tubercle of the lip positioned inferior to the philtrum, are closed with chromic on the wet mucosa and 6.0 nylon sutures on the external aspect of the vermilion. The central prolabial skin flap is fitted into position between the lateral lip segments and secured into place with 6.0 nylon, creating the philtrum of the lip. The small e vermilion flap is tucked behind the lateral vermilion flaps to contribute to the creation of the central tubercle. The two lateral prolabial flaps are banked into the region just inferior to the nares and sutured into position to assist with nasal sill and floor reconstruction. These two banked flaps will ultimately be used to reconstruct the columella in a secondary procedure.
11 May 2009
unilateral cleft lip repair
preoperative 
intraoperative
postoperative
Unilateral Cleft Lip Repair
The rotational advancement method can be used for the entire spectrum of unilateral cleft lips. The technique is described for a complete cleft lip. The following section summarizes the principal steps of the technique.
The landmarks of the lip are marked with a vital dye as follows:
Point 1: The base of the nasal ala on the normal noncleft side
Point 2: The high point of the Cupid's bow on the noncleft side
Point 3: The midpoint of the cupid's bow
Point 4: The high point of the cupid's bow on the cleft side, determined by measuring the distance between points 2 and 3
Point 5: The peak of the cupid's bow on the lateral cleft segment, usually placed where the white roll (vermilional cutaneous junction) begins to attenuate
Point 6: The superior extent of the advancement flap. The distance between points 5 and 6 should be equal to the height of the lip in the noncleft side. Final determination of point 6 may have to wait until the rotation incision is completed in some cases.
Point 7: Located along the alar crease so that the distance between points 5 and 7 equals the distance between points 1 and 2
Point 8: The superior extent of the rotation incision, which can be extended to point 9, if necessary, and should not cross the philtral column on the noncleft side
Point 9: The extent of the area back cut incision (if needed). This may be necessary to achieve adequate downward rotation of the medial lip segment.
The distance between points 1 and 2 represents the height of the lip on the noncleft side and should equal the ultimate height of the lip on the cleft side; this measurement is also useful as a guide in determining the length of the curvilinear incision between points 4 and 8. The position of this incision can be facilitated with the use of a curved 26-gauge wire to mark an incision that begins at point 4 and ascends along the vermilional cutaneous junction and then swings across the lip to where the columella meets the lip at point 8. It is important that this line not extend or cross into the normal philtral column.
After marking and infiltration of a small amount of local anesthetic containing epinephrine, the skin incisions are scored and incised, beginning with the rotation flap. Completion of the rotation incision allows point 4 to drop down to a position symmetric with point 2; if the rotation still is not sufficient, a small backcut to point 9 can be made to achieve satisfactory rotation. A small triangular flap of tissue remains attached to the columella (Millard C flap), and this flap is later used to lengthen the shortened columella of the cleft side as well as to construct the medial aspect of the nasal sill. Final delineation of point 6 is now possible and is determined after adequate downward rotation of point 4. If additional height is needed, point 6 can be adjusted slightly into the nasal vestibule (avoid nasal vibrissae hairs) or point 5 can be moved 1 to 2 mm lateral toward the oral commissure.
The medial and lateral lip flaps are freed by sharp dissection from the underlying maxilla in a supraperiosteal plane to allow for a tensionless closure. Laterally, this is performed with a high gingivobuccal sulcus incision. Dissection is completed subcutaneously around the nasal ala, intercartilaginous region, and piriform aperture, as needed, to release tension and to allow for the nasal ala to be positioned independently of the lip.
Primary nasal reconstruction (if desired) is initiated by undermining the skin overlying the columella, nasal dome, and lower lateral cartilages. The skin lining the vestibule is elevated off the lateral crus of the lower lateral cartilage. This allows it to be actively repositioned within the skin pocket.
Depending on the individual case, the C flap can be advanced on itself, thus lengthening the cleft side of the columella or used for the reconstruction of the medial portion of the nasal sill. In many cases, it is used for construction of both columella and nasal sill.
The orbicularis oris muscles are dissected about 1 to 2 mm from their attachment to skin and mucosa, and then are approximated with interrupted 4.0 Vicryl sutures. After placement of each stitch, overall symmetry and rotation of the lip is evaluated. With inadequate rotation or
insufficient length of the lateral segment, adjustments need to be made.
The primary nasal reconstruction follows the muscular closure. The lower lateral cartilage is repositioned and fixed into place with through-and-through 4.0 nylon sutures tied over Teflon pledgets securing the dome of the cartilage to the contralateral side and to the upper lateral cartilages. The lip skin and mucosa are closed with 7.0 nylon or 6.0 chromic sutures, matching the vermilional cutaneous junction precisely. Final adjustment of the vermilion is completed to create a tubercle, and any tendency toward vermilion notching is corrected by creating a Z-plasty, with transposition of a mucosal flap from the fuller side to the more deficient side to balance the lip. Nylon sutures are removed at 5 to 7 days on an outpatient basis with sedation. Nasal bolsters can remain is place for 10 to 14 days.
intraoperative
postoperative
Unilateral Cleft Lip RepairThe rotational advancement method can be used for the entire spectrum of unilateral cleft lips. The technique is described for a complete cleft lip. The following section summarizes the principal steps of the technique.
The landmarks of the lip are marked with a vital dye as follows:
Point 1: The base of the nasal ala on the normal noncleft side
Point 2: The high point of the Cupid's bow on the noncleft side
Point 3: The midpoint of the cupid's bow
Point 4: The high point of the cupid's bow on the cleft side, determined by measuring the distance between points 2 and 3
Point 5: The peak of the cupid's bow on the lateral cleft segment, usually placed where the white roll (vermilional cutaneous junction) begins to attenuate
Point 6: The superior extent of the advancement flap. The distance between points 5 and 6 should be equal to the height of the lip in the noncleft side. Final determination of point 6 may have to wait until the rotation incision is completed in some cases.
Point 7: Located along the alar crease so that the distance between points 5 and 7 equals the distance between points 1 and 2
Point 8: The superior extent of the rotation incision, which can be extended to point 9, if necessary, and should not cross the philtral column on the noncleft side
Point 9: The extent of the area back cut incision (if needed). This may be necessary to achieve adequate downward rotation of the medial lip segment.
The distance between points 1 and 2 represents the height of the lip on the noncleft side and should equal the ultimate height of the lip on the cleft side; this measurement is also useful as a guide in determining the length of the curvilinear incision between points 4 and 8. The position of this incision can be facilitated with the use of a curved 26-gauge wire to mark an incision that begins at point 4 and ascends along the vermilional cutaneous junction and then swings across the lip to where the columella meets the lip at point 8. It is important that this line not extend or cross into the normal philtral column.
After marking and infiltration of a small amount of local anesthetic containing epinephrine, the skin incisions are scored and incised, beginning with the rotation flap. Completion of the rotation incision allows point 4 to drop down to a position symmetric with point 2; if the rotation still is not sufficient, a small backcut to point 9 can be made to achieve satisfactory rotation. A small triangular flap of tissue remains attached to the columella (Millard C flap), and this flap is later used to lengthen the shortened columella of the cleft side as well as to construct the medial aspect of the nasal sill. Final delineation of point 6 is now possible and is determined after adequate downward rotation of point 4. If additional height is needed, point 6 can be adjusted slightly into the nasal vestibule (avoid nasal vibrissae hairs) or point 5 can be moved 1 to 2 mm lateral toward the oral commissure.
The medial and lateral lip flaps are freed by sharp dissection from the underlying maxilla in a supraperiosteal plane to allow for a tensionless closure. Laterally, this is performed with a high gingivobuccal sulcus incision. Dissection is completed subcutaneously around the nasal ala, intercartilaginous region, and piriform aperture, as needed, to release tension and to allow for the nasal ala to be positioned independently of the lip.
Primary nasal reconstruction (if desired) is initiated by undermining the skin overlying the columella, nasal dome, and lower lateral cartilages. The skin lining the vestibule is elevated off the lateral crus of the lower lateral cartilage. This allows it to be actively repositioned within the skin pocket.
Depending on the individual case, the C flap can be advanced on itself, thus lengthening the cleft side of the columella or used for the reconstruction of the medial portion of the nasal sill. In many cases, it is used for construction of both columella and nasal sill.
The orbicularis oris muscles are dissected about 1 to 2 mm from their attachment to skin and mucosa, and then are approximated with interrupted 4.0 Vicryl sutures. After placement of each stitch, overall symmetry and rotation of the lip is evaluated. With inadequate rotation or
insufficient length of the lateral segment, adjustments need to be made.
The primary nasal reconstruction follows the muscular closure. The lower lateral cartilage is repositioned and fixed into place with through-and-through 4.0 nylon sutures tied over Teflon pledgets securing the dome of the cartilage to the contralateral side and to the upper lateral cartilages. The lip skin and mucosa are closed with 7.0 nylon or 6.0 chromic sutures, matching the vermilional cutaneous junction precisely. Final adjustment of the vermilion is completed to create a tubercle, and any tendency toward vermilion notching is corrected by creating a Z-plasty, with transposition of a mucosal flap from the fuller side to the more deficient side to balance the lip. Nylon sutures are removed at 5 to 7 days on an outpatient basis with sedation. Nasal bolsters can remain is place for 10 to 14 days.
10 May 2009
postoperative CT
postoperative video
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