Treatment of Complete Bilateral Cleft Lip-Nasal Deformity

ABSTRACT

The modern technique of presurgical orthopedics and nasoalveolar molding produces a better skeletal foundation and nasal shape for the repair of the bilateral cleft lip-nasal deformity. The general principles are as follows: (1) preserve the presurgical columellar length; (2) keep the width of the central lip segment narrow without compromising the blood supply; (3) advance the columella prolabium complex superiorly to allow reconstruction of the orbicularis oris muscle behind the prolabium; (4) release the alar cartilage attachment from the pyriform rim and provide additional coverage of this soft tissue deficiency with the use of inferior turbinate flaps; (5) release and reposition the lower lateral cartilage; (6) adequately dissect above the maxillary periosteum; (7) reconstruct the nasal floor by local mucosal flaps; (8) reconstruct the prolabial buccal sulcus with tissue from the prolabium; (9) reconstruct the orbicularis muscle sphincter and attach it to the anterior nasal spine; (10) reconstruct a new Cupid's bow, central vermilion, and lip tubercle with tissue from the lateral lips; (11) balance the height of both lateral lips without any incision around the ala; and (12) maintain the presurgical nasolabial angle. The residual nasal deformity remains a problem that needs further improvement. The long-term result in Chang Gung Craniofacial Center suggests overcorrection of columella height before, during, and after lip repair.

KEYWORDS

Bilateral cleft lip - nasoalveolar molding - long-term result

REFERENCES

• 1 Cronin T D. Lengthening columella by use of skin from nasal floor and alae.  Plast Reconstr Surg. 1958;  21 417-426
• 2 Millard D RJ. Closure of bilateral cleft lip and elongation of columella by two operations in infancy.  Plast Reconstr Surg. 1971;  47 324-331
• 3 McComb H. Primary repair of the bilateral cleft lip nose: a 15-year review and a new treatment plan.  Plast Reconstr Surg. 1990;  86 882-893
• 4 McComb . Primary repair of the bilateral cleft lip nose: a 4-year review.  Plast Reconstr Surg. 1994;  94 37-50
• 5 Millard Jr D R, Latham R, Xu H, Spiro S, Morovic C. Cleft lip and palate treated by presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion (POPLA) compared with previous lip adhesion method: a preliminary study of serial dental casts.  Plast Reconstr Surg. 1999;  103 1630-1644
• 6 Noordhoff M S. Bilateral cleft lip and nasal repair. In: Cohen MS Masters of Surgery. Vol. 1 St. Louis; Little Brown 1994: 566-580
• 7 Mulliken J B. Principles and techniques of bilateral complete cleft lip repair.  Plast Reconstr Surg. 1985;  75 477-487
• 8 Tolhurst D E. Primary columella lengthening and lip adhesion.  Br J Plast Surg. 1985;  38 89-92
• 9 Salyer K E. Primary bilateral cleft lip/nose repair: Salyer's technique. In: Salyer KE, Bardach J Atlas of Craniofacial and Cleft Surgery. Vol. 1 Philadelphia; Lippincott-Raven 1999: 543-567
• 10 Hamamoto J. Bilateral cleft lip repairs: the Manchester method and presurgical orthodontic treatment.  Cong Anom. 1984;  24 421-428
• 11 Noordhoff M S. Primary elongation of the columella in bilateral cleft lip and palate with a prolabial island pedicle flap. Paper presented at: 6th International Congress on Cleft Palate and related Craniofacial Anomalies, Jerusalem 1989
• 12 Mulliken J B. Correction of the bilateral cleft lip nasal deformity: evolution of a surgical concept.  Cleft Palate Craniofac J. 1992;  29 540-545
• 13 Mulliken J B. Bilateral complete cleft lip and nasal deformity: an anthropometric analysis of staged to synchronous repair.  Plast Reconstr Surg. 1995;  96 9-26
• 14 Trott J A, Mohan N. A preliminary report on one stage open tip rhinoplasty at the time of lip repair in bilateral cleft lip and palate: the Alor Setar experience.  Br J Plast Surg. 1993;  46 215-222
• 15 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;  101 630-639
• 16 Kernahan D A. On cleft lip and palate classification.  Plast Reconstr Surg. 1973;  51 578
• 17 Noordhoff M S. Multidisciplinary management of cleft lip and palate in Taiwan. In: Bardach J, Morris HL Multidisciplinary Management of Cleft Lip and Palate. Vol. 1 Philadelphia, PA; Saunders 1990
• 18 Schendel S A, Pearl R M, De Armond S J. Pathophysiology of cleft lip muscles following the initial surgical repair.  Plast Reconstr Surg. 1991;  88 197-200
• 19 Schendel S A, Pearl R M, De Armond S J. Pathophysiology of cleft lip muscle.  Plast Reconstr Surg. 1989;  83 777-784
• 20 Stark R B. Development of the face.  Surg Gynecol Obstet. 1973;  137 403-408
• 21 Stark R B, Ehrman N A. The development of the center of the face with particular reference to surgical correction of bilateral cleft lip.  Plast Reconstr Surg. 1958;  21 177-192
• 22 Stark R B. The pathogenesis of harelip and cleft palate.  Plast Reconstr Surg. 1954;  13 20-39
• 23 Noordhoff M S. Asymmetric bilateral cleft lip repair: Noordhoff's technique. In: Salyer KE, Bardach J Atlas of Craniofacial and Cleft Surgery. Vol. 2 Philadelphia; Lippincott-Raven 1999: 568-593
• 24 Noordhoff M S, Huang C S, Lo L J. Median facial dysplasia in unilateral and bilateral cleft lip and palate: a subgroup of median cerebrofacial malformations.  Plast Reconstr Surg. 1993;  91 996-1007
• 25 Noordhoff M S, Chen P KT, Liou E JW, Lin W Y. Recent advances in the treatment of the complete bilateral cleft lip-nasal deformity. In: Habal MB, Himel HN, Lineaweaver WC et al Key Issues in Plastic Cosmetic Surgery. Vol. 17 Basel, Switzerland; Karger 2001: 51-71
• 26 Huang C S, Cheng H C, Chen Y R, Noordhoff M S. Maxillary dental arch affected by different sleep position in unilateral cleft lip and palate infants.  Cleft Palate Craniofac J. 1994;  31 179-184
• 27 Matsuo K, Hirose T, Otagiri T, Norose N. Repair of cleft lip with nonsurgical correction of nasal deformity in the early neonate period.  Plast Reconstr Surg. 1989;  83 25-31
• 28 Grayson B H, Cutting C, Wood R. Preoperative columella lengthening in bilateral cleft lip and palate.  Plast Reconstr Surg. 1993;  92 1422-1423
• 29 Figueroa A. Orthodontics in cleft lip and palate management. In: Mathes SJ, Hentz UR Plastic Surgery. 2nd ed. Philadelphia, PA; Saunders 271-310
• 30 Liou E JW, Subramanian M, Chen P KT. The progressive change of columella length and nasal growth after nasoalveolar molding in bilateral cleft patients: a three years follow up study. Submitted for publication. 
• 31 Noordhoff M S. Bilateral cleft lip reconstruction.  Plast Reconstr Surg. 1986;  78 45-54
• 32 Lin W Y, Grayson B H, Figueroa A A, Liou E, Cutting C B. The effect of presurgical molding of the nasal cartilages before lip repair in patients with unilateral cleft lip and palate-an intercenter report. Presented at the 4th Asian Pacific Cleft Lip & Palate Conference, Fukuoka, Japan, Sept. 28 1999
• 33 Millard Jr D R, Latham R A. Improved primary surgical and dental treatment of clefts.  Plast Reconstr Surg. 1990;  86 856-871
• 34 Santiago P E, Grayson B H, Cutting C B, Gianoutsos M P, Brecht L E, Kwon S M. Reduced need for alveolar bone grafting by presurgical orthopedics and primary gingivoperiosteoplasty.  Cleft Palate Craniofac J. 1998;  35 77-80
• 35 Lee S T. A new approach to bilateral cleft lip repair.  Ann Acad Med Singapore. 1983;  12 347-352
• 36 Pigott R W. Aesthetic considerations related to repair of the bilateral cleft lip nasal deformity.  Br J Plast Surg. 1988;  41 593-607
• 37 Nakajima T, Ogata H, Sakuma H. Long-term outcome of simultaneous repair of bilateral cleft lip and nose (a 15 year experience).  Br J Plast Surg. 2003;  56 205-217
• 38 Wu W T. The oriental nose: an anatomical basis for surgery.  Ann Acad Med Singapore. 1992;  21 176-189
• 39 Tajima S, Maruyama M. Reverse-U incision for secondary repair of cleft lip nose.  Plast Reconstr Surg. 1977;  60 256-261
• 40 Friede H, Lilja J, Johanson B. Lip-nose morphology and symmetry in unilateral cleft lip and palate patients following a two-stage lip closure.  Scand J Plast Reconstr Surg. 1980;  14 55-64
• 41 Shah J S. Stenosis of the nostrils: a case report, following smallpox.  Plast Reconstr Surg. 1967;  39 57-58
• 42 Nakajima T, Yoshimura Y. Secondary correction of bilateral cleft lip nose deformity.  J Craniomaxillofac Surg. 1990;  18 63-67
• 43 Chen K T, Noordhoff M S. Open tip rhinoplasty.  Ann Plast Surg. 1992;  28 119-130
• 44 Lemon J C, Martin J W, Wesley P J, Kin G E. Use of nonconductive tubing for nasal stent fabrication.  J Prosthet Dent. 1994;  71 301-302
• 45 Walter C. Nasal deformities in cleft lip cases.  Facial Plast Surg. 1995;  11 169-183
• 46 Yeow V KL, Chen P KT, Chen Y R, Noordhoff M S. The use of nasal splints in the primary management of unilateral cleft nasal deformity.  Plast Reconstr Surg. 1999;  103 1347-1354
• 47 Delaire J. Theoretical principles and technique of functional closure of the lip and nasal aperture.  J Maxillofac Surg. 1978;  6 109-116
• 48 Manchester W M. The repair of the bilateral cleft lip and palate.  Br J Surg. 1965;  52 878-882
• 49 Manchester W M. The repair of double cleft lip as part of an integrated program.  Plast Reconstr Surg. 1970;  45 207-216
• 50 Nagase T, Januszkiewicz J S, Keall H J, de Geus J J. The effect of muscle repair on postoperative facial skeletal growth in children with bilateral cleft lip and palate.  Scand J Plast Reconstr Surg Hand Surg. 1998;  32 395-405
• 51 Mulliken J B, Pensler J M, Kozakewich H P. The anatomy of Cupid's bow in normal and cleft lip.  Plast Reconstr Surg. 1993;  92 395-404
• 52 Noordhoff M S. Reconstruction of vermilion in unilateral and bilateral cleft lips.  Plast Reconstr Surg. 1984;  73 52-61
• 53 Noordhoff M S. Operative Syllabus on the Surgical Technique for the Unilateral Cleft Lip-Nasal Deformity. Taiwan; Noordhoff Craniofacial Foundation 1997
• 54 Liou E JW, Subramanian M, Chen P KT, Huang C S. The progressive change of nasal symmetry and growth after nasoalveolar molding: a three-years follow-up study.  Plast Reconstr Surg. 2004;  114 858-864