Cleft lip and palate surgery

Cleft lip surgery

Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or continues into the nose (complete cleft). Cleft lip can occur as one sided (unilateral cleft lip) or two sided (bilateral cleft lip).

Partial unilateral cleft		Complete unilateral cleft		Bilateral cleft

A mild form of a cleft lip is a microform cleft. A microform cleft can appear as small as a little dent in the red part of the lip or look like a scar from the lip up to the nostril. In some cases muscle tissue in the lip underneath the scar is affected and might require reconstructive surgery. It is advised to have newborn infants with a microform cleft checked with a craniofacial team as soon as possible to determine the severeness of the cleft.

In general, patients with clefts have a deficiency of tissue and not merely a displacement of normal tissue.

Surgical Anatomy

Before describing some of the characteristics of a cleft lip and its repair, it helps to be familiar with some of the common landmarks and anatomy of a normal lip. Cupid’s bow is central to the upper lip, with its peaks delineating the philtrum between the philtral columns.

Normal lip anatomy.

The demarcation between mucosa and skin of the lip is called the vermilion border. The mucosa or vermilion of the lip is further divided into dry and wet sections. The protuberant vermilion in the midline is referred to as the tubercle. The two nostrils (nares) are separated by the columnella externally and the septum internally.

Below the surface, the orbicularis oris muscle encircles the oral aperture, creating a sphincter. The fibers decussate in the midline creating the philtrum. In the cleft lip, the orbicularis muscle inserts into the nasal alar base.

Lip musculature. A) Normal musculature with fiber decussation to form the philtral columns. B) Cleft musculature with abnormal muscle insertions into the base of the nose.

Cleft lip surgery

Cleft lip often requires only one reconstructive surgery, especially if the cleft is unilateral. Cleft lips are repaired at about 2-3 months of age. It is carried out under full anesthetic.

Bilateral cleft lips may be repaired in two surgeries, about a month apart, which usually requires a short hospital stay.

The basic goal of cleft lip, alveolus, and palate repair, whether for the unilateral or bilateral anomaly, is to restore normal anatomy. The objectives of surgical repair of the cleft lip are two-fold: restore aesthetic ‘normal’ landmarks and reconstruct a functional orbicularis oris. There are many variations in the technique of cleft lip repair.

The repair involves making incisions and bringing the pieces of lip together to form a full lip. There are a number of different techniques from which the surgeon can choose depending on the nature of the cleft. Two of the most common approaches are the rotation-advancement and the triangular flap repair.

The rotation-advancement (Millard)
Unilateral Cleft Lip Surgery

The rotation-advancement repair, pioneered by D. Ralph Millar, creates two opposing and interdigitating flaps. The medial side of the cleft lip is rotated downward from the columella in order to lower the ’peak’ level to that of the normal side, and the lateral lip is advanced toward the midline into the defect at the base of the columella. A major advantage of the rotation-advancement repair is the placement of scars along the natural anatomic features of the philtral columns and nasal sill.

Cutting design for the unilateral cleft lip surgery according to Millard.		Final flap positioning after cutting for the unilateral cleft lip surgery according to Millard.

Before unilateral cleft lip surgery according to Millard.	After unilateral cleft lip surgery according to Millard.

The triangular flap (Tennison-Randall)
Unilateral Cleft Lip Surgery

The triangular flap repair, developed by Tennison and others, uses a triangular flap from the lateral lip, inserted into a notch in the medial side of the cleft, just above the vermilion border, crossing the philtral column as it meets Cupid’s peak. This ‘triangle’ adds length to the shorter cleft side of the lip. While this techniques provides excellent lip length, it comes at the expense of a less natural appearing scar across the columnella.

Cutting design for the unilateral cleft lip surgery according to Tennsion-Randall.		Final flap positioning after cutting for the unilateral cleft lip surgery according to Tennison-Randall.

Before Cleft lip surgery according to Tennison-Randall.		After Cleft lip surgery according to Tennison-Randall.

Bilateral Cleft (Millard)

In a bilateral complete cleft lip, both sides of the abnormal orbicularis muscle must be brought together across the prolabial segment. If it appears that either side of the cleft is too wide to close, with risk of muscle dehiscence due to too much tension, a ‘lip adhesion’ can be done, bridging the defect by reapproximating skin only. This allows the short soft tissues to stretch while often ‘molding’ the protuberant premaxilla into a more anatomical position and a narrower defect for later definitive closure. The most common repair is based on Millard’s design.

Cutting design for the unilateral cleft lip surgery according to Millard.		Final flap positioning after cutting for the unilateral cleft lip surgery according to Tennison-Randall.

Bilateral cleft before		Bilateral cleft after

The appearance of the protruding premaxilla is very worrying to the parents or other non-medical person who cannot see how the defect can possibly be rectified. The whole emphasis in repairing the lip is on the muscle repair, in order to mould the distorted premaxilla back into its proper position.

The premaxilla in a baby with cleft palate is rotated forward because the gums are divided or cleft and the normal restraining action of the muscle in the lip is broken. The emphasis is on the muscle repair at the time so that the premaxilla is gently moved back into position by the repaired lip.

What about the cleft nose?

Traditionally, the initial cleft nose repair was done as a secondary procedure when the child was older and nose growth had reached its final development. Recently, the trend has been to fix the nose primarily along with the lip. At the time of the lip repair, the alar cartilages can be freed from their abnormal configuration and repositioned to reshape the nasal tip and nostril, restoring better symmetry at an earlier age. A nasal stent may also be used to reshape the nostrils. As the child grows, septoplasty and further revisions may be required to achieve more tip projection and columellar length.

After The Surgery For Cleft Lip 


• During the surgery, and for a short time after surgery, your child will have an intravenous catheter (IV) to provide fluids until he/she is able to drink by mouth.
  
  
• Your child's upper lip and nose will have stitches where the cleft lip was repaired. It is normal to have swelling, bruising, and blood around these stitches.
  
  
• For a day or two, your child will feel mild pain, which can be relieved with a non-aspirin pain medication. A prescription medication may also be given for use at home.
  
  
• The stitches will be removed after approximately one week.
  
  
• The scar will gradually fade, but it will never completely disappear.
  
  

Book for surgeons about Cleft lip surgery

In July 2008 Bart van de Ven, Joel Defrancq and Ellen Defrancq published the book "Cleft Lip Surgery, a Practical Guide".