Cleft Tips for Cleft Lips The unilateral cleft lip Andrew Wexler MD FACS Los Angeles ,CA

The following are some helpful pointers that I have picked over the last 20 years of operating on cleft lips both in the US and international mission trips. I aim these comments in particular to the repair of clefts in developing countries. Philosophy: While the anatomy of a cleft lip is the same in California as in Kenya the patients are not. On a mission trip the children have a greater potential for malnutrition, chronic illnesses (parasites, malaria, HIV), and often live in an environment where the risk of infection and minimal postoperative home care is great. While one wishes to help as many children as possible the selection criteria for surgery must be stricter then in a first world situation. The greatest incidence of complications on mission trips is from poor patient selection. While a robust child may be operated on at 6mo of age there are many teams that will not repair a child under the age of one. Interoperative and postoperative safety is paramount and should include the use of first world anesthesia techniques with end tidal co2 and, pulse oximetry. The use of narcotics may increase the incidence of postoperative respiratory depression and should be avoided if possible. From a surgical stand point consider the use of a heavier absorbable suture material for closure .For these patients a belt and suspenders approach is the wisest course. Lastly remember that this may be the only chance this child gets to attain a normal appearance. They may never be back again for a second operation, so dont forget to correct the nose as much as possible when repairing the lip and remember that a lip adhesion if used may well be the final repair for that child. From personal experience after hundreds of cleft repairs I have never required a lip adhesion on a unilateral or bilateral cleft.

The drawing above represents the standard markings for a Millard type advancement rotation cleft lip repair. M= Medial flap C= collumela flap L=lateral flap 1 and 2 are incisions inside the rim of the ala to help with cartilage mobilization and placement of the dome suture 3 is the rotation cut back incision 4 is an alar crease incision Procedural pointers: Incision 3 under collumela should extend to the contra lateral philtrum to insure adequate rotation and lip length. C may be used either to lengthen the ipsilateral collumela or for the nasal floor if needed M should be raised as a pedicle flap and inserted into a mucosal incision placed just below the sulcus of the medial lip segment mucosa. L maybe used for the nasal floor or discarded if not needed. The base of M and L should be place at maximum lip thickness before the vermillion starts to taper.

Obicularis

The drawing demonstrates the insertion of the M flap into the labial sulcus. The stippled structure is obicularis muscle. The use of this flap helps provide length to the mucosal side of the medial lip segment.

M flap

Release muscle

Completely release the obicularis muscle and its abnormal attachments to the base of the collumela on the medial side and the alar base on the lateral side. There is never a need to dissect and release muscle into the cheek. This maneuver will produce extensive swelling and often hematoma.

Mobilize nasal cartilages Using the alar incision dissect above the lower lateral cartilage to the dome separating the skin from the cartilage. . Use the medially placed rim incisions bilaterally to continue the dome dissection so that one can freely pass an instrument between the rim incisions.

Closure Lip closure is easiest from the inside out. Close the lip mucosa with 4-0 or 5-0 chromic. Be sure to align the wet mucosa dry mucosa junction. Next proceed with muscle closure. Be sure to close the most inferior portion of the muscle, which tends to pull away from the incision boarder. Failure to oppose the inferior obicularis muscle will result in a whistle deformity. Close muscle with 4-0 or 5-0 polygycolic suture. Dermal closure may be accomplished with 5-0 polygycolic suture. Skin closure with 5-0 chromic when on a surgical mission or 5-0 plain in a first world environment.

Obicularis

Wet vermillion

Key suture of advancement rotation bringing the advancement segment into the rotational defect.

Dome suture A 5-0 nylon suture is passed from the cleft side rim incision through the depressed segment of the lower lateral cartilage and across the dome to be retrieved through the contra lateral rim incision. The suture is then passed back through the cartilage and out the original side to then be tied. This suture will realign the nasal cartilages.

Before

After