Cleft Lip and Palate Repair

Embryology & Classification - Cleft Genesis

• Embryology: Failed mesenchymal fusion of facial prominences.
  • Lip (CL): Medial nasal & maxillary prominences. Failure by 4-7 weeks.
  • Palate (CP): Palatal shelves (from maxillary prominences). Failure by 6-12 weeks.
    • Primary palate: Anterior to incisive foramen.
    • Secondary palate: Posterior to incisive foramen.
• Classification:
  • Types: Cleft Lip (CL), Cleft Palate (CP), Cleft Lip & Palate (CLP).
  • Extent: Unilateral/Bilateral, Complete/Incomplete.
  • Systems: LAHSHAL, Veau.

⭐ CL/P more common in males; isolated CP more in females. 📌 M>F (CL/P), F>M (CP).

Cleft Lip Repair - Lip Architects

• Timing: Rule of 10s: 10 weeks age, 10 pounds weight, 10 g/dL Hb.
• Techniques Overview:
  • Millard (Rotation-Advancement): Most popular; adaptable. Preserves Cupid's bow point C.
  • Tennison-Randall (Triangular Flap): Z-plasty principle; good for wide clefts. Lengthens lip.
  • Rose-Thompson (Straight Line): For incomplete/microform clefts.
• Surgical Goals:
  • Restore orbicularis oris muscle continuity.
  • Achieve lip symmetry & Cupid’s bow definition.
  • Create a natural philtrum.
  • Symmetrical nostril floor & alar base.

⭐ The Millard technique, a rotation-advancement flap, is favored for its ability to recreate the philtral dimple and Cupid's bow effectively for unilateral clefts.

Cleft Palate Repair - Palatal Reconstruction

• Timing: Typically 9-18 months; balances speech development & facial growth.
• Goals:
  • Separate oral & nasal cavities.
  • Achieve normal velopharyngeal function for speech.
  • Minimize impact on maxillary growth.
• Key Surgical Principle:
  • Intravelar veloplasty: Dissection & retropositioning of levator veli palatini muscles to create a functional sling.
• Common Techniques:
  • Von Langenbeck: Bipedicle mucoperiosteal flaps.
  • Wardill-Kilner (V-Y pushback): Lengthens soft palate.
  • Furlow Double Opposing Z-plasty: Lengthens palate & reconstructs levator sling.

⭐ Furlow Z-plasty is often favored for its superior levator muscle reconstruction, crucial for optimal speech outcomes and reducing Velopharyngeal Insufficiency (VPI) risk.

Associated Issues & Teamwork - Holistic Care

• Associated Problems
  • Speech: VPI (hypernasality), articulation issues.
  • Hearing: OME common (Eustachian tube dysfunction); audiology vital.
  • Dental: Malocclusion, tooth anomalies; orthodontics.
  • Feeding: Early difficulties; specialized aids.
  • Psychosocial: Support for child/family.
• MDT Approach
  • Crucial for staged, comprehensive care.
  • Core Team: Surgeon, Orthodontist, SLP, Audiologist, ENT.
  • Supporting Team: Pediatrician, Psychologist.

⭐ Otitis Media with Effusion (OME) affects ~90% of cleft palate infants, mandating early hearing screening & management.

Complications & Long-Term - Potential Pitfalls

• Early:
  • Lip: Bleeding, infection, dehiscence, flap necrosis. Airway (Pierre Robin).
  • Palate: Bleeding, airway obstruction, dehiscence. Oronasal fistula (common).
• Long-Term:
  • Speech: Velopharyngeal Insufficiency (VPI) → hypernasality, nasal emission. Therapy/surgery.

    ⭐ VPI is the most frequent long-term issue after palate repair, causing hypernasal speech.

  • Dental: Malocclusion, crossbite. Alveolar Bone Grafting (ABG) at 8-10 yrs.
  • Hearing: Otitis Media with Effusion (OME) → grommets.
  • Growth: Maxillary hypoplasia → orthognathic surgery.
  • Nasal Deformity: Secondary rhinoplasty.
  • Fistula: Persistent oronasal fistula.

High‑Yield Points - ⚡ Biggest Takeaways

• Cleft lip repair is typically performed at 3 months (Rule of 10s); Millard rotation-advancement flap is most common for unilateral cases.
• Cleft palate repair is usually done between 9-18 months to optimize speech development; common techniques include Von Langenbeck and Furlow Z-plasty.
• Veau classification is used for cleft palate. Presurgical orthopedics like NAM can improve outcomes.
• Velopharyngeal insufficiency (VPI) is a key complication post-palate repair, leading to hypernasal speech.
• Associated syndromes include Pierre Robin sequence (micrognathia, glossoptosis, cleft palate) and Van der Woude syndrome (lip pits).
• Simonart's band (a soft tissue bridge) may be present in incomplete cleft lips.