This document discusses cleft lip and palate, including the embryology, classification systems, prenatal diagnosis methods, and surgical techniques for repair. It provides details on various lip repair procedures like Millard's rotation-advancement, Mohler's, and Cutting's techniques. Presurgical infant orthopedics methods like nasoalveolar molding are also summarized. The document aims to comprehensively cover the magnitude, causes, evaluation, and management of cleft lip and palate.

1. Associate Professor of Plastic Surgery
Institute of Post Graduate Medical Education &
Research, Kolkata

2. Magnitude of the Problem
 Incidence of CLP: 1 in 1000
 Isolated cleft palate: 0.5 in 1000
 Estimated recurrence risk: 4% (17% if also 1 parent affected, 9% if two children
affected)
 M > F in CLP, reverse in CP, L side more common in CLP
 Recurrence risk for 1st, 2nd, 3rd degree relatives: 3.5%, 0.8%, 0.6%

3. Embryology

4. Embryology

5. Embryology

6. Palate Formation

7. Prenatal Diagnosis: 3D USG

8. Prenatal Diagnosis: 3D USG

9. Prenatal Diagnosis: Fetal MRI

10. Nagpur Classification (Dr. C.
Balakrishnan 1975)

11. Indian Classification (Abbreviated)

12. Complete Table of Indian
Classification

13. Classify

14. Classify

15. Classify

16. Prenatal Ultrasound Classification

17. Yuzuriha & Mulliken Classification
 MINOR: notched vermilion-cutaneous jn > 3mm above Cupid’s bow peak
 MICROFORM: notch < 3mm
 MINI-MICROFORM: disrupted vermilion-cutaneous jn without elevation of Cupid’s
bow peak

18. Orbicularis Oris
 2 parts
 Pars superficialis: divided into upper and lower (forms the philtral columns)
bundles, involved in lip retraction
 Pars marginalis: sphincteric action

19. Abnormality in Orbicularis Oris
 Pars superficialis (cleft side): redirects superiorly to attach to nasal ala and
periosteum of piriform rim – lateral displacement of nostril, inferior and lateral
displacement of bony piriform rim
 Pars superficialis (medial side): inserts into the cleft edge perpendicularly
 Pars marginalis (cleft side): attaches to ipsilateral alar base, pulls on LLC, leading to
collapsed, concave deformity
 Pars marginalis (medial side): attaches to caudal septum, displaces it ipsilaterally

20. Orbicularis Anatomy in Cleft Lip

21. Cleft Nasal Deformity
 Lower dome.
 Crimped lateral crura.
 Lateral crura tipped caudally.
 Bifid tip.
 Obtuse columella nostril angle.

22. Cleft Nasal Deformity
 Depressed bony floor.
 Horizontal nostril angle.
 Missing nostril sill.
 Caudal septum deviation to normal side.

23. Cleft Nasal Deformity

24. Management

25. Presurgical Infant Orthopedics
 Alveolar Molding: External Taping +/- Dental Plating +/- Nasal elevator
 Nasoalveolar Molding: Liou & Grayson Methods
 Latham technique
 Lip Adhesion
 Not effective after 3 months
 Nasal conformer for incomplete clefts (for nasal correction only)*

26. Alveolar Molding: External Taping

27. Dental Plate

28. Lip Taping + Nasal Elevator

29. Nasoalveolar Molding: Pretreatment

30. Nasoalveolar Molding: Treatment

31. Nasoalveolar Molding: Result

32. Nasoalveolar Molding (NAM)
 Liou’s Method: nasal & alveolar molding done simultaneously, dental plate fixed
with adhesive.
 Grayson’s Method: nasal projection added only when the alveolar cleft is <6 mm,
held in place with Micropore & orthodontic elastics, 2 molding bulbs on top of
nasal projection (nasal dome & nostril rim), no dental adhesive.
 Figueroa’s Technique: similar to Liou but rubber bands are attached to dental plate
for premaxillary retraction, soft resin ball attached for nasolabial angle.
 Spring Device: Reduces number of visits to 4.

33. Liou’s Device

34. Figueroa’s Device

35. Grayson’s Device

36. NAM with a Spring Device

37. Latham’s Technique
 Uses a fixed appliance inserted under anesthesia.
 Aggressive and forceful movement of segments.
 Takes 3-5 weeks to approximate alveolus.

38. Latham’s Pin Retained Appliance

39. Evaluation of a Cleft Lip patient

40. Repair
 Lip adhesion: Optional
 Definitive Repair

41. Lip Adhesion (Johanson)
 Makes a complete cleft incomplete for later repair.
 Advantages: facilitates definitive closure, molding of maxillary segments, facilitates
feeding, elongation of short lip.
 Timing: usually around 3-4 weeks (before 2-3 months).
 Used in combination with a maxillary guidance plate.

42. Lip Adhesion
 Indications: cleft > 10 mm wide with vertical length discrepancy of 4-5 mm,
protruding premaxilla with complete cleft of primary palate, older children with
wide clefts.
 Principles: closure of mucosa with rectangular flaps, skin apposition and nostril
floor closure without muscle dissection.
 Problem: dehiscence.

43. Lip Adhesion

44. Lip Adhesion

45. Dehiscence

46. Problems with Lip Adhesion
 Precludes use of L-flap so nasal floor reconstruction is poor.
 Scar from the surgery interferes with a superior result in subsequent lip surgery.

47. Things to Solve
 Skin discontinuity with lack of tissues on the cleft side.
 Absent philtral column on cleft side.
 Abnormal muscle attachment with discontinuity.
 Nostril floor defect with alar malposition.
 Abnormal architecture of nasal cartilages and bones with bony deficiency.
 Mucosal hypoplasia on cleft side with discontinuity.
 White roll deficiency.
 Lack of convexity in Cupid’s bow transition with lateral part of lip.

48. Principles of Repair
 Creation of philtral column on cleft side.
 Cupid’s bow.
 Augmentation of vermilion on cleft side.
 Closure of nasal floor.
 Nasal cartilage.
 Mucosal closure.

49. Types of Lip Repair
 Upper Lip Flaps: Millard, Mohler, Cutting (Extended Mohler).
 Middle Lip Flaps: LeMesurier, Pool.
 Lower Lip Flaps: Tennison-Randall, Fisher.

50. Procedures

51. Rose Thompson Repair

52. Mirault Repair

53. Le Mesurier Procedure

54. Balakrishnan’s Triple Wedge
Technique

55. Pool Repair

56. Millard’s Repair: Markings

57. Rotation Advancement Repair

58. Flaps in Millard’s Rotation
Advancement
 Rotation flap
 Advancement flap
 C-flap (Millard I vs Millard II)
 M-flap
 L-flap

59. Markings

60. Markings

61. Marking Incisions with WSR Flap

62. Adequacy of Rotation

63. Muscle Layer Dissection

64. Medial Crural Dissection

65. Septal Dissection & Vomer Flap

66. L Flap & T flap

67. Lateral Lip Dissection

68. Alar Base Release

69. Vestibular Fat Pad Removal

70. OM and WSR Flaps

71. Nasal Floor Closure I

72. Nasal Floor Closure II

73. Muscle Reconstruction

74. Philtral Column Creation
 Skin Incision
 Muscle Reconstruction
 Subdermal suture placement (philtral dimple)
 Soft tissue laxity

75. WSR Flap Insertion

76. Triangular Vermilion Flap

77. Semi Open Rhinoplasty

78. Crural & Alar Sutures

79. Final Skin Closure

80. Randall-Tennison-Sawhney Repair

81. Randall-Tennison- Sawhney Repair: Skin
markings

82. Basket Weave Muscle Repair

83. Tennison: Completed Repair

84. Mohler’s Repair

85. Mohler’s Repair

86. Mohler’s Repair

87. Mohler’s Repair: Advantages
 Symmetric philtral column (especially in upper 1/3).
 Advancement flap has to travel less by 2-3 mm.
 Lengthening of short columella on cleft side.
 Asymmetric Z-plasty rather than rotation-advancement.
 Prevents micronostril as seen with Millard.

88. Cutting’s Repair (Extended Mohler)

89. Cutting’s Repair
 Apex of back cut is 1.5 – 2 mm superior to columellar base.
 Traverses 4/7 across columella.
 Angled back cut.
 L-flap pedicled on lateral nasal wall (not on alveolus) – less oronasal fistula.
 Fibrofat is not removed from intercartilaginous area.

90. Cutting’s Repair: Nasal Floor Closure

91. Final Appearance

92. Fischer’s Technique

93. Fisher’s Technique

94. Fisher’s Technique: Marking

95. Fisher’s Technique: Design

96. Fisher’s Technique: Advantages
 Rotation is minimized so also tension in repair.
 Utilizes primarily the Rose-Thompson effect.
 Nasal incisions confined to nostril sill.
 Minimal scarring at the base of the nose.
 Cutaneous scars positioned across anatomical subunits.
 Accentuation of lip pout.
 Lateral lip transverse length is not compromised.

97. Nasal dissection
 Access through nostril base.
 Rim incisions.
 Infracartilaginous incision.

98. Components of Nasal Dissection
 Dissection of nasal soft tissue envelope from LLC.
 Repositioning and resuspension of LLC to ULC and opposite LLC.
 Transdermal alar suspension technique.
 Straightening and fixation of deviated anterocaudal septum.

99. Incomplete Cleft Lip
 Dissection should be similar to complete clefts.
 Complete mobilization of alar base and cephalic repositioning.
 Local flap used for correction of nasal floor deficiency.

100. Incomplete Cleft Lip: Markings

101. Postoperative Care
 Feeding.
 Cleaning of suture lines.
 Antibiotics.
 Nostril splint.
 Stitch removal.
 Silicone dressing.
 Botox.

102. Fetal Surgery

103. Fetal Surgery

104. Fetal Surgery: Current Status
 Not proved to be comprehensively beneficial and safe.
 Some experimental models have shown shortened lips after birth.
 Not recommended at present.

105. The search for the ideal cleft lip surgery goes on and on………..