In the name of

God

Cleft
Lip

Cleft
Palate

Dr. Sasan Dabiri

Otorhinolaryngologist Head & Neck
Surgeon
January 2011
Imam Hospital complex - Tehran

Cleft
Lip

Introduction

Cleft
Palate

Orofacial clefts are the most common

craniofacial birth defects
Cleft lip cleft palate is

epidemiologically & etiologically

distinct
from isolated cleft palate

Cleft
Lip

Yes
Yes
Male
25 %
1 in
1000

Differences
Differences
Ethnicity effect
Socioeconomic status
Gender preference
Syndromic rate
Incidence

Cleft
Palate

No
No
Female
50 %
1 in
2000

Concordance of cleft in monozygotic

twins is 50%

Cleft
Lip

Classification
Classification

Complete or Incomplete
entire vertical thickness of
upper lip
often associated with an
alveolar cleft

Cleft
Palate

Cleft
Lip

Classification

Complete or Incomplete
Unilateral or Bilateral

Cleft
Palate

Cleft
Lip

Classification

Cleft
Palate

Complete or Incomplete
Primary or( incisive foramen )
Secondary
Unilateral or bilateral

Cleft
Lip

Cleft
Palate

Team
Team work
work
Otolaryngolog
ist

Speech
pathologist

Plastic
surgeon

Psychologist

Maxillofacial
surgeon

Audiologist

Orthodontist

Nurse

Cleft
Lip

Otolaryngologi
st

Cleft
Palate

airway management
otologic care
evaluation of velopharyngeal insufficiency
facial reconstructive surgeon

Cleft
Lip

Feeding
Feeding

Cleft
Palate

The most immediate concern in the care,

other than the airway, is nutrition.
Early swallowing therapy is required
in infant with complete cleft palate
to ensure near-normal feeding

Cleft
Lip

Feeding
Feeding

Cleft
Palate

squeeze bottles with cross-cut nipples

Aerophagia
fail to gain weight
excessive aerophagia

Frequent
burping
Haberman
feeder
Palatal
obturator

Cleft
Lip

When
When to
to Treat
Treat

Cleft
Palate

Cleft lip : the rules of ten:

weight at least 10 pounds
Hb at least 10 g
WBC count less than 10,000/mm3
age more than 10 weeks

Cleft
Lip

When
When to
to Treat
Treat

Cleft
Palate

Cleft lip :
wide complete clefts with marked
premaxillary protrusion staged repair
lip adhesion performed at age 3 months
definitive repair performed at age 5 to 6
months

Cleft
Lip

When
When to
to Treat
Treat

Cleft
Palate

Cleft Palate

Speech outcome or Facial

growth
?This is a question
Proposed time is roughly 1
year old

Cleft
Lip

Surgery
surgery

Cleft
Palate

freshening and approximation of cleft edges

curved incisions to allow lengthening of lip
straight-line closure

numerous geometric repairs

produced scars that violated the philtrum)

Millard rotation-advancement technique

Cleft
Lip

Millard
metho
d:

Surgery
surgery

Cleft
Palate

Cleft
Lip

Surgery
surgery

Cleft
Palate

Millard Advantages:
scar along the natural philtral border
more flexible than geometric closures
complete muscular repair and primary cleft
rhinoplasty
minimizes the discarding of normal tissue

Millard Disadvantages:
extensive undermining
risk for nostril stenosis on the cleft side

Cleft
Lip

Surgery
surgery

Cleft
Palate

Rhinoplasty
primary rhinoplasty (at the time of lip repair)
intermediate rhinoplasty
correct any residual lower cartilaginous deformity
V-Y advancement flaps from upper lip lengthen columella
Y-V alar advancement to narrow alar base,
with fixation of base to nasal spine with permanent suture

Delayed rhinoplasty (after puberty)

correct any bony dorsal deformity or nasal obstruction

Cleft
Lip

Cleft
Palate

Surgery
surgery

Complications
Notch in the vermilion
Malalignment of Cupids bow (whistle
deformity)
Absence of median tubercle and part of
Cupids bow

Rx : Z-plasty

Cleft
Lip

Surgery
surgery

Cleft
Palate

Goals
Closure of oronasal communication
Correct speech pathology( velum)

mobility depends on six paired muscles

(normally insert on soft palate)

Cleft
Lip

Surgery
surgery

Cleft
Palate

Cleft
Lip

Surgery
surgery

Cleft
Palate

primary veloplasty (Schweckendiek)

Cleft
Lip

Surgery
surgery

Cleft
Palate

primary veloplasty (Schweckendiek)

bipedicled flap palatoplasty (Von
Langenbeck)

Cleft
Lip

Surgery
surgery

Cleft
Palate

primary veloplasty (Schweckendiek)

bipedicled flap palatoplasty (Von
Langenbeck)
V-Y pushback palatoplasty (Oxford)
unipedicled two-flap palatoplasty (Bardach)
double-opposing Z-plasty (Furlow)

Cleft
Lip

Surgery
surgery

Cleft
Palate

Cleft
Lip

Surgery
surgery

Cleft
Palate

primary veloplasty (Schweckendiek)

bipedicled flap palatoplasty (Von
Langenbeck)
V-Y pushback palatoplasty (Oxford)
unipedicled two-flap palatoplasty (Bardach)
double-opposing Z-plasty (Furlow)

Cleft
Lip

Surgery
surgery

Cleft
Palate

Cleft
Lip

Surgery
surgery

Cleft
Palate

primary veloplasty (Schweckendiek)

bipedicled flap palatoplasty (Von
Langenbeck)
V-Y pushback palatoplasty (Oxford)
unipedicled two-flap palatoplasty (Bardach)
double-opposing Z-plasty (Furlow)

Cleft
Lip

Surgery
surgery

Cleft
Palate

Cleft
Lip

Surgery
Surgery

Cleft
Palate

Complications
The most common : velopharyngeal
insufficiency
Oronasal fistula
Technical error
Severity of cleft

airway obstruction
Pressure of mouth gag during surgery

Cleft
Lip

Postoperative
Postoperative
Care
care

Cleft
Palate

Continuous pulse oximetry for first 24 to 48 hours

Intravenous hydration
Intr venous pain medications (+ acetaminophen
supp)
Arm splints (first 2 wks)
Clear liquids by syringe or cup on first day (1 to 2
wks)
Discouraging nipple feeding

Cleft
Lip

Otitis media

Cleft
Palate

Develops within the first months of life

Frequency decreases with increasing age
Due to abnormalities of cartilage and
muscles surrounding the eustachian tube

Cleft
Lip

Otitis media

Cleft
Palate

Abnormalities of cartilage and muscles

Hypoplasia of the lateral cartilage relative to the medial
cartilage
The curvature of the eustachian tube lumen
width and angulation of skull base with respect to
eustachian tube
Abnormal insertions of TVP and levator veli palatini muscles

Cleft
Lip

Otitis media

Cleft
Palate

Management
Tympanostomy tube insertion
Controversy : Type of VT
Controversy : Time of VT

Th

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