Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5208_Библиотеки_им_академика_М_И_Перельмана
.pdf
21 Unilateral Cleft Lip Repair
283
C
1
ML
2
Fig. 21.3 Appearance of lip after making initial surgical incisions. (1) Non-cleft side of lip will
rotate down. (2) Cleft side of lip will advance forward. This is why it is called a rotation advancement procedure. Note that the rectangular defect at the base of columella will be lled by the “C
ap”. The “M ap” and the “L ap” will be used to close the nasal oor defect
5. Now inset the C-ap. With the noncleft side being rotated down, the 90-degree
back cut should open to create a rectangular defect. The C-ap is inset in this
defect, and the extra tip of the C-ap is trimmed.
6. Close the skin. Skin sutures should not provide any strength to the closure; there
should be no tension on the closure from the deep sutures. The skin sutures are
to align the skin and ensure that the skin on both sides of the repair is at the same
level. Either permanent sutures or dissolvable fast-gut sutures can be used.
t.me/Dr_Mouayyad_AlbtousH
284
A. Namin and R. F. Brown
Permanent sutures will likely require another brief anesthetic to remove (see
Figs.21.4, 21.5, and 21.6).
A dissolvable suture such as a 4-0 Monocryl or PDS can be used to straighten the
medial crura and reattach them to each other. The needle is passed from high on the
noncleft side medial crura to low on the opposite medial crura of the cleft side, and
L
M
C
Fig. 21.4 Appearance at the end of suturing. Note that the “C ap” has lled in the columellar
defect. This hides the incisions within the base of the columella and avoids the non-anatomic curving incision of the traditional Millard repair. Note that no incisions have been made along the nasal
ala on the cleft side which can create visible scars. The “M ap” and “L ap” are not seen from the
outside, but are reconstructing the anterior nasal oor which will prevent an anterior stula during
the cleft palate repair which can be very hard to repair
t.me/Dr_Mouayyad_AlbtousH
21 Unilateral Cleft Lip Repair
Fig. 21.5 Pre and post-op photos for left-sided unilateral cleft lip
285
Fig. 21.6 Pre and post-op photos for right-sided unilateral cleft lip
t.me/Dr_Mouayyad_AlbtousH
286
A. Namin and R. F. Brown
then back high on the cleft side and out high on the noncleft side and tied. If the
cleft-side ala needs to be elevated at the end of the procedure, then dome elevation
sutures can be placed. A Monocryl or PDS suture on a long, curved needle can then
be passed from underneath the lower lateral cartilage on the non-cleft side, up over
the tip, through the cleft-side lower lateral cartilage and into the cleft-side nostril.
Then go back in from underneath the cleft-side lower lateral cartilage, over the
domes, back through the upper cleft-side lower lateral cartilage and into the noncleft side nostril. Tie this suture, and it will help elevate the attened ala. This can
be repeated as needed. The angle of turning the needle blindly over the tip is difcult but worth learning to improve the symmetry of the nostrils.
Postoperative Management
Postoperative care includes routine incisional care of gently cleaning the incisions
with saline every 2–6hours, and then antibiotic ointment is applied to keep the incisions moist. It is important to show the parents how to clean the incision gently to
avoid damaging the repair. Feeding begins when the baby desires. If an infant, then
they can breastfeed, use a syringe or a soft-tipped bottle. Only breast milk or formula should be given. Paciers should not be used. If an older child, then very soft
or pureed food should be given. Forks, straws, and other utensils should be avoided.
Parents should strongly be encouraged to use arm splints/restraints for 2–3weeks
in younger patients so that they cannot reach the lip repair and damage it. Infants
should be placed to sleep on their backs to avoid the incision being rubbed against
anything while sleeping.
Infants are typically discharged on postoperative day 1. Older children could
potentially be performed as an outpatient depending on their health and
circumstances.
Three to four weeks after surgery, Vitamin E oil or other products could be used
to help improve scarring.
Postoperative nasal molding can be employed for up to 1year postoperatively to
improve the form of the lower lateral cartilage. Long-term follow-up into adolescence is important to assess aesthetic and functional results and identify patient
desires for revisional procedures to improve the aesthetic outcome.
References
1. Shkoukani MA, Chen M, Vong A.Cleft lip—a comprehensive review. Front Pediatr. 2013;1:53.
2. Jones MC. Prenatal diagnosis of cleft lip and palate: detection rates, accuracy of ultrasonography, associated anomalies, and strategies for counseling. Cleft Palate Craniofac
J. 2002;39(2):169–73.
3. Bhattacharya S, Khanna V, Kohli R.Cleft lip: the historical perspective. Indian J Plast Surg.
2009;42(Suppl):S4–8.
4. Boo-Chai K.An ancient Chinese text on a cleft lip. Plast Reconstr Surg. 1966;38(2):89–91.
5. Perko M.The history of treatment of cleft lip and palate. Prog Pediatr Surg. 1986;20:238–51.
t.me/Dr_Mouayyad_AlbtousH
21 Unilateral Cleft Lip Repair
6. LeMESURIER AB. A method of cutting and suturing the lip in the treatment of complete
unilateral clefts. Plast Reconstr Surg (1946). 1949;4(1):1–12.
7. Randall P.A triangular ap operation for the primary repair of unilateral clefts of the lip. Plast
Reconstr Surg Transplant Bull. 1959;23(4):331–47.
8. Tennison CW.The repair of the unilateral cleft lip by the stencil method. Plast Reconstr Surg
(1946). 1952;9(2):115–20.
9. Stal S, Brown RH, Higuera S, Hollier LH, Byrd HS, Cutting CB, etal. Fifty years of the
Millard rotation-advancement: looking back and moving forward. Plast Reconstr Surg.
2009;123(4):1364–77.
10. Mohler LR.Unilateral cleft lip repair. Plast Reconstr Surg. 1987;80(4):511–7.
11. Fisher DM.Unilateral cleft lip repair: an anatomical subunit approximation technique. Plast
Reconstr Surg. 2005;116(1):61–71.
12. Yuzuriha S, Oh AK, Mulliken JB.Asymmetrical bilateral cleft lip: complete or incomplete and
contralateral lesser defect (minor-form, microform, or mini-microform). Plast Reconstr Surg.
2008;122(5):1494–504.
13. Mulliken JB, Wu JK, Padwa BL.Repair of bilateral cleft lip: review, revisions, and reections.
J Craniofac Surg. 2003;14(5):609–20.
14. Burt JD, Byrd HS. Cleft lip: unilateral primary deformities. Plast Reconstr Surg.
2000;105(3):1043–55; quiz 1056–7.
15. Mulliken JB, Pensler JM, Kozakewich HP. The anatomy of Cupid’s bow in normal and cleft
lip. Plast Reconstr Surg. 1993;92(3):395–403; discussion 404.
16. Jiri B, Jana V, Michal J, Jiri K, Dana H, Miroslav T, etal. Successful early neonatal repair of
cleft lip within rst 8 days of life. Int J Pediatr Otorhinolaryngol. 2012;76(11):1616–26.
17. Cutting C, Grayson B, Brecht L, Santiago P, Wood R, Kwon S.Presurgical columellar elongation and primary retrograde nasal reconstruction in one-stage bilateral cleft lip and nose repair.
Plast Reconstr Surg. 1998;101(3):630–9.
18. Salyer KE.Early and late treatment of unilateral cleft nasal deformity. Cleft Palate Craniofac
J. 1992;29(6):556–69.
19. Wilhelmsen HR, Musgrave RH. Complications of cleft lip surgery. Cleft Palate
J. 1966;3:223–31.
20. McHeik JN, Sfalli P, Bondonny JM, Levard G.Early repair for infants with cleft lip and nose.
Int J Pediatr Otorhinolaryngol. 2006;70(10):1785–90.
21. Salyer KE. Primary correction of the unilateral cleft lip nose: a 15-year experience. Plast
Reconstr Surg. 1986;77(4):558–68.
22. McComb H.Primary correction of unilateral cleft lip nasal deformity: a 10-year review. Plast
Reconstr Surg. 1985;75(6):791–9.
23. Chang C-S, Por YC, Liou EJ-W, Chang C-J, Chen PK-T, Noordhoff MS.Long-term comparison of four techniques for obtaining nasal symmetry in unilateral complete cleft lip patients: a
single surgeon’s experience. Plast Reconstr Surg. 2010;126(4):1276–84.
24. Lo L-J, Wong F-H, Mardini S, Chen Y-R, Noordhoff MS.Assessment of bilateral cleft lip nose
deformity: a comparison of results as judged by cleft surgeons and laypersons. Plast Reconstr
Surg. 2002;110(3):733–8; discussion 739–741.
25. Meijer R.Lip adhesion and its effect on the maxillofacial complex in complete unilateral clefts
of the lip and palate. Cleft Palate J. 1978;15(1):39–43.
26. Pool R, Farnworth TK.Preoperative lip taping in the cleft lip. Ann Plast Surg. 1994;32(3):243–9.
27. Grayson BH, Garnkle JS.Early cleft management: the case for nasoalveolar molding. Am J
Orthod Dentofacial Orthop. 2014;145(2):134–42.
28. Matsuo K, Hirose T, Otagiri T, Norose N.Repair of cleft lip with nonsurgical correction of
nasal deformity in the early neonatal period. Plast Reconstr Surg. 1989;83(1):25–31.
29. Chang C-S, Wallace CG, Pai BC-J, Chiu Y-T, Hsieh Y-J, Chen I-J, et al. Comparison of two
nasoalveolar molding techniques in unilateral complete cleft lip patients: a randomized, prospective, single-blind trial to compare nasal outcomes. Plast Reconstr Surg. 2014;134(2):
275–82.
287
t.me/Dr_Mouayyad_AlbtousH
288
30. Liou EJ-W, Subramanian M, Chen PKT, Huang CS.The progressive changes of nasal symmetry and growth after nasoalveolar molding: a three-year follow-up study. Plast Reconstr
Surg. 2004;114(4):858–64.
31. Zheng J, He H, Kuang W, Yuan W. Novel three-dimensional coordinate system to analyze
alveolar molding effects of pre-surgical nasoalveolar molding on infants with non-syndromic
unilateral cleft lip and palate. J Craniofac Surg. 2020;31(3):653–7.
32. Lee CTH, Garnkle JS, Warren SM, Brecht LE, Cutting CB, Grayson BH.Nasoalveolar molding improves appearance of children with bilateral cleft lip-cleft palate. Plast Reconstr Surg.
2008;122(4):1131–7.
A. Namin and R. F. Brown
t.me/Dr_Mouayyad_AlbtousH
Cleft Palate Repair
22
AdrianA.Ong, RyanF.Brown, andFiyinSokoya
Introduction
Cleft lip and/or palate is a common congenital malformation within the head and
neck; the incidence of isolated cleft palate is ~1:2500 [1]. These orofacial clefts are
most often an isolated nding but can be associated with syndromes or other comorbidities in 30–50% of cases [2]. Untreated, these patients may experience otologic
diseases, speech and language problems, difculty with oral feeding, velopharyngeal dysfunction, and psychosocial issues. Many surgical techniques have been
developed and rened to address the various types of cleft palate, and surgical intervention is often tailored to the individual patient. Ultimately, the goal of cleft palate
repair is to restore separation between the nasal and oral cavities to allow for oral
feeding and improve verbal communication. Determining candidacy and the timing
of repair for return to normal feeding, speech, and Eustachian tube function is then
balanced with the impact of surgical intervention on maxillary growth [3].
Anatomy
Understanding the normal anatomy of the palate is important to the repair of palatal
clefts, which helps to separate the oral and nasal cavities (Fig.22.1). The incisive
foramen is an important landmark, and divides the primary palate consisting of the
A. A. Ong
Fort Worth, TX, USA
R. F. Brown
Department of Head and Neck Surgery/Facial Plastic and Reconstructive Surgery,
Denver, CO, USA
F. Sokoya (*)
Wellstar Health Systems, Atlanta, GA, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_22
t.me/Dr_Mouayyad_AlbtousH
289
290
Palatine foramen
Fig. 22.1 Normal
anatomy of the palate
A. A. Ong et al.
Dental arch
Premaxilla
Incisive foramen
Palatine process
of maxilla
Palatine bone
Posterior nasal
spine
Hamulus
Tensor palatini
muscle
Levator palatini
muscle
premaxilla anteriorly from the secondary palate consisting of the remainder of the
hard palate and soft palate posteriorly.
The soft palate plays a key role in speech and swallowing function. The levator
veli palatini muscle is the most signicant structure within the soft palate. It is a
paired muscle, which forms a sling from its origin at the base of the temporal bone
to the midline. Together with its contralateral component, they elevate the soft palate to the posterior pharyngeal wall. In addition, the palatopharyngeus muscle aids
in the elevation and posterior movement of the soft palate. The tensor veli palatini
muscle originates from the medial pterygoid and inserts onto the palatine aponeurosis. It assists the levator veli palatini muscle in the elevation of the palate and helps
maintain the normal function of the Eustachian tube. Finally, the uvularis muscle is
a small muscle that originates from the palatine aponeurosis and inserts into the
mucosa of the uvula. It shortens the uvula; however, it does not appear to play a
signicant role in speech.
The blood supply of the palate consists of the greater and lesser palatine arteries,
which are distal branches of the maxillary artery. The greater palatine arteries are
especially important as these contribute the main blood supply to the aps used during cleft palate repair.
Clefts of the palate can consist of a combination of bony and soft-tissue abnormalities. Clefts of the secondary palate are typically midline, while clefts of the
primary palate are asymmetric. In clefts of the secondary palate, the velar musculature is affected, with the levator veli palatini muscle oriented in a longitudinal direction with an anomalous insertion onto the bony cleft margin.
The most popular classication system for cleft palate is the Veau classication
(Fig.22.2), which describes cleft palates in four groups: Group I, defect of the soft
palate only; Group II, defect involving both the hard and soft palate; Group III,
t.me/Dr_Mouayyad_AlbtousH
ab
cd
22 Cleft Palate Repair
Fig. 22.2 Veau
classication. (a)
Incomplete cleft involving
the soft palate only; (b)
cleft involving the hard and
soft palate; (c) complete
unilateral cleft involving
the lip and palate; (d)
complete bilateral cleft
291
defect involving the hard and soft palate and alveolus; and Group IV, bilateral complete cleft palate [4]. This classication can provide a framework for the appropriate
type of repair.
Indications/Contraindications
Nearly all patients will benet from the repair of the cleft palate, and the question is
not if but when. Repair of the cleft palate may have an effect on craniofacial skeletal
growth, but this should be balanced with the development of proper speech and
language [5]. The American Cleft Palate-Craniofacial Association currently recommends that the palate be closed by age of 18months and preferably earlier when
possible [6]. At most institutions, the cleft palate is repaired at 10–12months of
age [7, 8].
As many patients may have an associated syndrome and/or comorbidities, contraindications to cleft palate repair are related to those conditions and not the cleft
palate itself. Life-threatening comorbidities, such as complex congenital heart disease, may require specialized care involving pediatric cardiology and pediatric
anesthesiology to determine the safety of general anesthesia. In addition, surgery on
patients with severe neurodevelopmental delay who are nonverbal and
t.me/Dr_Mouayyad_AlbtousH
292
A. A. Ong et al.
gastrostomy- tube dependent should be balanced with prognostic factors that portend improvement or worsening of their neurodevelopmental delay. In the immediate preoperative period, patients who have recently had an upper respiratory illness
or hospitalization may benet from postponing surgical intervention to decrease
perioperative risks.
Preoperative Planning
As stated earlier, patients with cleft palates may have signicant comorbid conditions and preoperative assessment by the primary care provider with or without
cardiology involvement is an important step before proceeding with surgical intervention. Any recent upper respiratory illnesses or hospitalizations are identied, as
these may affect the timing of surgery.
Patients undergoing cleft palate repair are orotracheally intubated, and this may
be challenging in patients with craniofacial anomalies. Cleft surgeons should communicate with anesthesia colleagues prior to induction, and discuss any signicant
physical examination or exible laryngoscopy ndings to maximize intubation success. An oral RAE endotracheal tube, which has a preformed bend, can be used to
direct the circuit away from the surgical eld.
Depending on the comorbid conditions of the patient, arrangements may be
made for a bed in the intensive care unit, if close monitoring is required
postoperatively.
Caregiver education is initiated during the preoperative visit to avoid any postoperative pitfalls. This is especially important for diet maintenance with options
including squeeze bottles with tubing, traditional cups, syringe with tubings or
spoon feeding with the goal of minimizing negative pressure in the oral cavity during feeding in the postoperative period [9].
Instruments/Equipment Set
A head pad (either donut or horseshoe) is used to stabilize the patient’s head and
minimize movement throughout the duration of the case. A shoulder roll can also be
placed if there are no contraindications to further cervical extension. Having the
head and neck extended provides an easier view of the anterior palate, which can
facilitate repair. The Dingman mouth retractor is commonly used during cleft palate
repair. The teeth hooks can be adjusted during the case depending on the portion of
the palate that requires exposure, and the lateral cheek retractors provide additional
visualization. The use of a surgical headlight and loupe magnication are important
for improved intraoperative visualization.
Periosteal elevation of the palatal aps can be facilitated with a Joseph elevator
or a #9 periosteal elevator. If additional pedicle length is required, the greater palatine artery can be carefully osteotomized. The authors nd that a curved or 90-degree
Beaver blade can help remove the fascia around the vascular pedicle if added
t.me/Dr_Mouayyad_AlbtousH
Соседние файлы в папке Библиотека им академика М.И. Перельмана