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.
