Cleft Lip and Palate

Cleft Lip and PalateDr. Faisal Ameer MS, MCh, MRCSEdInternational Scholar for 2015, Plastic Surgery Foundation of ASPS/ASMSInternational Member of American Society of Plastic SurgeonsMember of Royal College of Surgeons EdinburghAssociate Professor Plastic SurgeryLLRM Medical CollegeMeerut, U.P. India+91 9557721163www.plasticsurgicraft.com

ObjectivesRecap of embryologyRelevant Anatomy and PathophysiologyClassificationCounseling of parentsBasic repair techniques

IntroductionFacial clefting is the second most common congenital deformity (after clubfoot).Affects 1in 1000 birthsProblems are cosmetic, dental, speech, swallowing, hearing, facial growth, emotional

PathophysiologyComplex mechanism of swallowing, hearing, speech and breathing are impairedFeeding difficulty in neonate. (Cleft makes creation of negative pressure difficult)Eustachian tube dysfunctionSecondary defect of tooth development. Psychological problem.

GeneticsNon-syndromic inheritance is multifactorialCleft Lip, With or Without Cleft Palate:One Parent-2%One Sibling- 4% Two Siblings- 9%One Parent + One Sibling- 15%Cleft Palate:One Parent- 7%One Sibling- 2% Two Siblings- 1%One Parent + One Sibling- 17%

Antenatal diagnosis

EpidemiologyCleft Lip +/- Palate- M:F 2:1Cleft Palate - F:M 2:1Cleft Lip +/- Palate- Native Americans > Oriental and Caucasians > BlacksCleft Palate- Same among ethnic groupsEnvironmental: Ethanol, Rubella virus, Thalidomide, Aminopterin B

Embryology

ClassificationNagpur classificationGroup I cleft lip onlyGroup Ia cleft lip + cleft alveolus Group II cleft palate onlyGroup III cleft lip + cleft alveolus + cleft palate

Joaquin Rafael Phoenix13

Anatomy

PhiltrumPhiltral RidgesCupids BowPhiltral DimpleCommisureWhite rollTubercle

History & Examination Cosmetic disfigurement (cleft lip)Feeding problems in cleft palateSuckling difficultiesNasal regurgitationEar diseaseRespiratory infectionsMalnutrition and failure to thrive (wt. for age)Other congenital anomalies digits, cardiac, craniofacial syndromes etc.

Pre operative evaluationHistory Physical examination Laboratory dataHb%Syndromes Xray mandible, Cardiac workup

Investigations Blood OPG (for canine tooth eruption)Occlusal viewSpeech evaluationNasendoscopyLateral/Frontal videofluroscopyFlowmeteryCephalometry lateral / AP

Management

Care of the newborn

Lip Repair

Timing of Cleft Lip RepairAt three months of age Larger anatomical parts Safer anesthesia

Rule of 1010 weeks 10 grams10 pounds10k WBC

Millard Lip Reapir

Randall-Tenisson Lip Reapir

Veau Lip Reapir

Palate Repair

Timing of Cleft Palate repairEarly repair (< 24 mts) speech and hearing improvedDelayed closure (>4y) less retardation of mid facial growthOptimal time Soft palate 3 6 mtsHard palate 15-18 mts

VWK Palate Reapir

Intervelar Veloplasty

Furlows Palate Reapir

Surgical Complications

EarlyAirway compromiseBleeding LateFistulaReduced movement of the soft palatePersistent VPIUnder developed facial skeleton

ConclusionsEmbryology and Anatomy extremely important.Counseling and communicationMeticulous technique and tissue respectEasy to learnCleft team

Thank youTeamwork is the key !