Overview of Cleft Lip Repair
A cleft lip is a type of birth defect that occurs when a baby’s lip does not form properly during pregnancy. This is one of the most common physical birth defects. Sometimes, a cleft lip appears by itself. Other times, it happens along with other physical problems.
To help a baby with a cleft lip, a team of different types of doctors usually work together. This approach makes sure that the baby gets the best possible care from all angles. However, a surgery is usually necessary to properly fix a cleft lip. Over the years, doctors have come up with many different ways to perform this surgery.
There are strategies that doctors use both before and after the surgery to make sure the treatment is successful. The type of surgery that a doctor chooses can depend on a few things. Some of these factors include what the doctor is most comfortable with, how severe the cleft lip is, and whether the baby has other physical problems.
In this article, we’ll discuss the most common ways to surgically repair a cleft lip. We’ll also talk about the pros and cons of each method.
Anatomy and Physiology of Cleft Lip Repair
To understand the formation of a cleft lip, it’s crucial to grasp the stages of facial development in a fetus. Starting from the fourth week of embryonic development, facial structures start forming, which include maxillary prominences and nasal placodes. The maxillary prominences develop from neural crest cells and the nasal placodes are formed from surface ectoderm.
Around the fifth week, the nasal placodes form the nasal pits, constructing a ridge of tissue around them. During the sixth to seventh weeks, the maxillary prominences grow and merge with the medial nasal prominences to make the upper lip. The fusion of the nasal prominences forms the middle part of the upper lip, and the maxillary prominences form the sides of the upper lip. Further growth of the maxillary prominences leads to deeper fusion of the medial nasal prominences, which form the primary palate; the area of the front teeth and the roof of the mouth in front of the incisive foramen.
Any interruption during these sensitive stages of the upper lip’s formation can result in cleft lip deformity. It can be on one or both sides. Cleft lip damage varies in severity and can be classified as complete or incomplete based on the extent. Complete cleft lips involve a disruption in the entirety of the upper lip’s thickness, which typically includes a defect in the alveolus, the cavity in the jawbone where a tooth sits, because it’s part of the primary palate. An incomplete cleft lip involves only a segment of the upper lip’s height, having a continuous part between the two sections.
Ordinarily, the orbicularis oris muscle surrounds the lips creating a complete ring around the mouth. Patients with a cleft lip disorder have irregularities in this muscle that require correction for the lip and mouth to function properly. The orbicularis oris muscle’s configuration varies depending on the severity of the cleft. Establishing a proper connection across the cleft lip is necessary to accomplish a complete ring around the mouth.
Lastly, it’s worth noting that cleft lip deformity often brings along nasal deformities due to the abnormal connection and insertion of the orbicularis oris muscle. In unilateral cleft lips, the cartilage on the cleft side tends to have a short medial crus and a long lateral crus, causing the nose to tilt towards the non-impacted side. In bilateral cleft lips, a short medial crus and a lack of skin in the columella region (the tissue separating the nostrils) cause a broad nasal tip and laterally displaced nostrils.
Why do People Need Cleft Lip Repair
If a baby is born with a cleft lip, this means there is a split or opening in their lip. It’s recommended that this issue be fixed with surgery, unless there are specific reasons that make surgery unsafe or unsuitable.
When a Person Should Avoid Cleft Lip Repair
There are a few reasons why a doctor may delay repairing a cleft lip:
If a patient has other health problems that need to be investigated further, the cleft lip surgery might be delayed until those health problems are fully understood.
Also, some patients may not be able to tolerate general anesthesia, which puts you to sleep during surgery. In these instances, the cleft lip repair would be delayed until it’s safe to use anesthesia.
Lastly, if a patient has other health problems that need surgery more urgently, like issues with their heart, those surgeries will be performed before the cleft lip repair.
Equipment used for Cleft Lip Repair
The operation will need the following tools:
* A scalpel, which is a small and extremely sharp knife used for operations.
* Ophthalmic scissors, specialized scissors used for delicate eye surgeries.
* Tissue scissors, which are created to cut through body tissue.
* Mosquito clamps, these are small clamps used to hold or close off small blood vessels.
* Toothed pick-ups, these are used to grip the tissue and help the surgeon move the tissue aside or keep it in place.
* Non-toothed pick-ups, similar to the toothed pick-ups but these are used on delicate tissues to prevent damage.
* Double-pronged skin hooks, these are used to gently pull back the skin or other tissue to keep the operation area clear.
* A ruler for accurate measurements during the operation.
* A sterile marker, which is used to mark areas on the body before surgery.
Who is needed to perform Cleft Lip Repair?
For a surgery, you need several medical professionals, each with their own specific role:
1. The surgeon is the main doctor who performs the operation. They are trained and specialized in doing surgeries and they are the one who will directly work on your condition during the operation.
2. A surgeon’s assistant is there to help the surgeon during the operation. They provide an extra pair of trained hands to ensure everything goes smoothly.
3. An Operating room technician is a skilled individual who helps prepare the operating room, the medical instruments, and assists during the operation.
4. A registered nurse is there during the operation to care for your general needs. They will help make sure you’re comfortable and safe.
5. An anesthesiologist is a doctor who specializes in providing anesthesia, the medicine that helps you sleep and not feel any pain during the operation.
6. An anesthetist, similar to an anesthesiologist, is a specialist who is also trained to give anesthesia, ensuring you’re asleep and painless during the surgery.
Each of these professionals work as a team to take care of you during your surgery, and to make sure you are safe and the operation goes well.
Preparing for Cleft Lip Repair
While some experts suggest that a baby’s cleft lip could be surgically corrected as soon as two days after birth, it is more commonly done when the baby is around 10 weeks old, weighs about 10 lbs., and has a hemoglobin level of 10 g/dL. This is known as the rule of 10s. Operating at this time allows doctors to check the baby for other birth defects, and allows the baby to grow, which provides more tissue to help with the repair during surgery.
Before the main surgery, there are techniques that can be used to prepare for the operation. These are especially helpful when the cleft lip is quite wide. These techniques include tape adhesion and using orthopedic devices. The aim of these pre-surgery techniques is to narrow the cleft lip to reduce tension after the surgery and improve the final result.
Tape adhesion involves sticking steri strips across the cleft lip to bring it together. On the other hand, orthopedic devices, also called nasoalveolar molding, involve the baby wearing a special device made by an orthodontist. This device brings the upper jaw closer together and narrows the cleft lip. Over time, the device is adjusted to make the cleft lip the right width for the upcoming surgery.
How is Cleft Lip Repair performed
In simple terms, the two most commonly performed surgical procedures to address a unilateral cleft lip are the ‘rotation-advancement technique’ and the ‘triangular flap technique’.
The ‘rotation-advancement technique’, also referred to as the Millard technique, was first described by a surgeon called Millard. The procedure forms a rotating strip, almost like a flap, on the closer part of the cleft, while another strip is advanced from the cleft’s farther side. This technique helps to recreate the ‘philtrum’, the dent in the middle of the upper lip, on the cleft side. It also allows the surgeon to work on the tip of the nose and make intraoperative adjustments, or changes during the operation. However, the drawbacks include potential narrowing of the nostrils and difficulty in closing a wide cleft. This technique can also be more challenging for less experienced surgeons as it requires good professional judgment during the surgery.
The ‘triangular flap technique’, otherwise known as the Tennison-Randall technique, was first introduced by a surgeon named Tennison. The method creates a triangular strip which originates from the cleft side and is inserted on an incision performed on the non-cleft side. This technique is more straightforward, allowing even inexperienced surgeons to perform the procedure more easily. Also, this flap lets wider clefts to be repaired. Though, its downsides mainly concern cosmetic outcomes such as failure to create a philtrum on the cleft side, a scar that crosses cosmetic units, and inability to access nasal cartilages during repair and inability to modify repair once surgery has started.
Before the surgery, certain significant anatomical landmarks should be identified and marked. These include the peak of the upper lip curve on both non-cleft and cleft sides and the midpoint between these two points, the midpoint of the columella (the tissue separating the nasal passages), and the base of this on both sides, the base of nasal ala (nostril) on both sides, and the corner of the mouth on both sides. Once these landmarks are identified, other points necessary for a successful surgery can be decided.
After the surgery, it’s essential to maintain cleanliness of the incisions with hydrogen peroxide and apply antibiotic ointment. To prevent the patient from accidentally touching the surgical wound, elbow splints are used for three weeks along with arm restraints used during the first week after the operation. Feeding can be done by a bulb syringe for these three weeks. Sutures are typically removed after the first week following the surgery. Doctors recommend antibiotic prophylaxis, preventive treatment, with a penicillin antibiotic for five days post-surgery.
In Millard’s technique, those anatomical landmarks are used to guide making the incisions according to the lines marked before the surgery. A curvilinear or rounded incision is made from the cleft side’s upper lip curve peak to the base of the columella. Another incision is made along the border of the upper lip of the lateral or farther cleft margin, extending upwards towards the nasal floor. After making these incisions, the procedure involves rotating the flap from the closer side of the cleft and extending the flap from the farther side for closure. If necessary, additional rotation can be employed to close the defect. Throughout the process, careful handling of the tissues and solid professional judgment are required.
Possible Complications of Cleft Lip Repair
There can be some issues related to surgery that fixes appearance defects, such as the surgical wound splitting open, or problems with how the scar heals. More issues can happen if the appearance problems with the lip and nose aren’t fully fixed in the first surgery. This includes problems like uneven lip coloring, misalignment of the lip’s lining, misalignment of the lip muscle, too short or too long lip, too short or crooked nose stem, nose holes placed horizontally, abnormal nose hole sizes, and disturbance in the placement of the outer lower nose.
Avoiding stress on the stitch line after surgery and taking care of the surgical wound can lessen the risk of the surgery wound separating. Marking the line of the lips carefully and making sure it’s aligned during surgery can also avoid a lop-sided appearance. Dissecting and stitching the lip muscle carefully can also prevent misalignment of this muscle. Therefore, the best way to avoid these issues is to prevent them from happening in the first place with careful surgery techniques.
