Cleft - Lip repair

Considerations

• 2005: Unilateral Cleft Lip—Approach and Technique

• 2012: Unilateral Cleft Lip: Principles and Practice of Surgical Management

Preparation

• • Peri-operative antibiotic

  • Approach 

  • Equipment 

    • Methylene blue with 25 gauge needle and 3 ml syringe 

Procedure

Sample operative report

Findings:

*** complete cleft lip and palate

Performed primary cleft lip and associated cleft nasal deformity repair using *** modified Mohler technique

C, M, and L flaps preserved and utilized

*** mm philtral height

Caudal septum deflected to the ***, re-positioned to the *** of the anterior nasal spine

Tip rhinoplasty with *** dome suspension suture and *** lateral alar bolster suture

Dermaflex applied over skin suture

Size *** nostril retainer placed 

Procedure in Detail:

After obtaining informed consent patient was taken to the OR and placed in the supine position on the OR table. A timeout was performed per operating room policy with all members of the surgical team present. Patient was induced with general anesthesia and intubated without difficulty.

The patient was prepped and draped. The low point and high points of cupid's bow were chosen and this was approximately *** millimeters on each side of the trough. The philtral height on the normal side measured *** mm; The cleft side was marked to match this height in preparation for the reconstructed philtral ridge. These areas were marked with methylene blue tattoo.

The C, M and L flaps were then drawn, with a 90 degree back cut on the columellar incision to achieve height. The cleft vermillion was narrowed, so a small central back cut was planned to lengthen the height. This was matched on the lateral lip segment. The flaps were drawn, also, into the cleft nostril. The flaps were then incised, with the incisions carried into the sulcus on each side. Both sulci were then elevated over the periosteum, releasing both lip segments, taking care to preserve the infraorbital nerves. The cleft side had the C flap elevated in a superficial plane. The muscle was then divided off of the columella and this flap was developed. Undermining of the muscle and skin was performed. The lateral segment was then elevated, taken off of the pyriform aperture. Mucosal flaps were elevated and the skin was undermined.  The C flap was elevated all the way into the septum, allowing this flap to be turned medially to fill the defect at the base of the columella. The septal cartilage was noted to be deviated to the left into the nasal cavity, and the septal cartilage was freed and repositioned just past the maxillary crest to the right. Elevation of the skin envelope off the Left LLC was performed with tenotomy scissors.

The M flap was sewn down onto the alveolus to create increased lip sulcus. This was closed with 4-0 chromic. The muscle was then closed with 4-0 Maxon suture using buried vertical mattress sutures inferiorly and simple interrupted superiorly, closing it all the way from the vermillion muscle to its most superior extent up to the nose. Next, the nostril floor was then closed, placing the alar base in symmetric position and the nostril floor was closed with 4-0 chromic. A Left dome suspension was placed with 4-0 maxon, as was a lateral alar bolster suture on the Left. Next, 5-0 Biosyn was used to close the subcutaneous skin, closing the flaps together. The C flap was used to help close the back cut from the increased rotation. Several 6-0 fast sutures were placed in the skin.  Dermaflex skin glue was placed over the incision. Excess labial mucosa was removed and chromic was used to close the remaining lip.

0.25% Bupivicaine *** with 1:200,000 of Epinephrine was then injected via the oral commissures and infraorbital nerve regions. Size *** nostril retainers were placed in the nostrils. An OG was used to decompress the stomach. The patient was then awakened and extubated in the operating room, transported to the post anesthesia recovery room in stable condition.

Post-op

• • Disposition: Admit overnight and keep until swallowing well

    • No antibiotics

  • Wound care

    • Keep lip clean and dry

    • Keep nostril retainers in place for 1 week 

  • Activity: No-no's x 2 weeks if under age 5 

  • RTC 1 week and 3-4 weeks 

  • Diet: Clears advance to full liquid diet x 2 weeks as tolerated 

  • Feed at the corners of the mouth using a syringe and / or rubber catheter 

  • No sippy cup

  • No bottle x 2 weeks

• Pain control: Liquid Tylenol and Ibuprofen ATC

  • First 6 months, single steri-strip in parallel with the upper lip across the wound 

Pearls & Pitfalls

High-Yield

• • Key points to mark

  • What is the nasal deformity and why does it occur? 

    • The alar base is lateral, inferior, and medial on the cleft side and the caudal septum is deviated away from the cleft due to the insertion and pull of the orbicularis oris 

Links

• Mohler Unilateral Cleft Lip Repair: Surgical Tutorial for Professionals

• http://www.chop.edu/pages/bilateral-cleft-lip-repair-surgical-tutorial-professionals