In the name of God

1. In the name of God

2. Cleft Palate Cleft Lip Dr. SasanDabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran

3. Cleft Lip Cleft Palate Introduction Orofacial clefts are the most common craniofacial birth defects Cleft lip ± cleft palate is epidemiologically & etiologically distinct from isolated cleft palate

4. Cleft Lip Cleft Palate Differences Differences Concordance of cleft in monozygotic twins is 50%

5. Cleft Lip Cleft Palate Classification Classification • Complete or Incomplete • entire vertical thickness of upper lip • often associated with an alveolar cleft

6. Cleft Lip Cleft Palate Classification Classification • Complete or Incomplete • Unilateral or Bilateral

7. Cleft Lip Cleft Palate Classification Classification • Complete or Incomplete • (incisive foramen) Primary or Secondary • Unilateral or bilateral

8. Cleft Lip Cleft Palate Team work Team work Otolaryngologist Speech pathologist Plastic surgeon Psychologist Maxillofacial surgeon Audiologist Orthodontist Nurse

9. Cleft Lip Cleft Palate Otolaryngologist airway management otologic care evaluation of velopharyngealinsufficiency facial reconstructive surgeon

10. Cleft Lip Cleft Palate Feeding Feeding The most immediate concern in the care, other than the airway, is nutrition. Early swallowing therapy is required in infant with complete cleft palate to ensure near-normal feeding

11. Cleft Lip Cleft Palate Feeding Feeding • squeeze bottles with cross-cut nipples • Aerophagia • fail to gain weight • excessive aerophagia • Frequent burping • Haberman feeder Palatal obturator

12. Cleft Lip Cleft Palate When to Treat When to Treat • Cleft lip : the rules of ten: • weight at least 10 pounds • Hb at least 10 g • WBC count less than 10,000/mm3 • age more than 10 weeks

13. Cleft Lip Cleft Palate When to Treat When to Treat • Cleft lip : • wide complete clefts with marked premaxillary protrusion  staged repair • lip adhesion performed at age 3 months • definitive repair performed at age 5 to 6 months

14. Cleft Lip Cleft Palate When to Treat When to Treat • Cleft Palate Speech outcome or Facial growth This is a question? • Proposed time is roughly 1 year old

15. Cleft Lip Cleft Palate surgery Surgery • freshening and approximation of cleft edges • curved incisions to allow lengthening of lip • straight-line closure • numerous geometric repairs • produced scars that violated the philtrum) • Millard rotation-advancement technique

16. Cleft Lip Cleft Palate surgery Surgery • Millard method:

17. Cleft Lip Cleft Palate surgery Surgery • Millard Advantages: • scar along the natural philtral border • more flexible than geometric closures • complete muscular repair and primary cleft rhinoplasty • minimizes the discarding of normal tissue • Millard Disadvantages: • extensive undermining • risk for nostril stenosis on the cleft side

18. Cleft Lip Cleft Palate surgery Surgery • Rhinoplasty • primary rhinoplasty (at the time of lip repair) • intermediate rhinoplasty • correct any residual lower cartilaginous deformity • V-Y advancement flaps from upper lip lengthen columella • Y-V alar advancement to narrow alar base, with fixation of base to nasal spine with permanent suture • Delayed rhinoplasty (after puberty) • correct any bony dorsal deformity or nasal obstruction

19. Cleft Lip Cleft Palate surgery Surgery • Complications • Notch in the vermilion • Malalignment of Cupid’s bow (whistle deformity) • Absence of median tubercle and part of Cupid’s bow Rx : Z-plastyc

20. Cleft Lip Cleft Palate surgery Surgery • Goals • Closure of oronasal communication • (velum) Correct speech pathology • mobility depends on six paired muscles (normally insert on soft palate)

21. Cleft Lip Cleft Palate surgery Surgery

22. Cleft Lip Cleft Palate surgery Surgery • primary veloplasty (Schweckendiek)

23. Cleft Lip Cleft Palate surgery Surgery • primary veloplasty (Schweckendiek) • bipedicled flap palatoplasty (Von Langenbeck)

24. Cleft Lip Cleft Palate surgery Surgery • primary veloplasty (Schweckendiek) • bipedicled flap palatoplasty (Von Langenbeck) • V-Y pushback palatoplasty (Oxford) • unipedicled two-flap palatoplasty (Bardach) • double-opposing Z-plasty (Furlow)

25. Cleft Lip Cleft Palate surgery Surgery

26. Cleft Lip Cleft Palate surgery Surgery • primary veloplasty (Schweckendiek) • bipedicled flap palatoplasty (Von Langenbeck) • V-Y pushback palatoplasty (Oxford) • unipedicledtwo-flap palatoplasty (Bardach) • double-opposing Z-plasty (Furlow)

27. Cleft Lip Cleft Palate surgery Surgery

28. Cleft Lip Cleft Palate surgery Surgery • primary veloplasty (Schweckendiek) • bipedicled flap palatoplasty (Von Langenbeck) • V-Y pushback palatoplasty (Oxford) • unipedicledtwo-flap palatoplasty (Bardach) • double-opposing Z-plasty (Furlow)

29. Cleft Lip Cleft Palate surgery Surgery

30. Cleft Lip Cleft Palate Surgery Surgery • Complications • The most common : velopharyngeal insufficiency • Oronasalfistula • Technical error • Severity of cleft • airway obstruction • Pressure of mouth gag during surgery

31. Cleft Lip Cleft Palate Postoperative care Postoperative Care Continuous pulse oximetry for first 24 to 48 hours Intravenous hydration Intr venous pain medications (+ acetaminophen supp) Arm splints (first 2 wks) Clear liquids by syringe or cup on first day (1 to 2 wks) Discouraging nipple feeding

32. Cleft Lip Cleft Palate Otitis media • Develops within the first months of life • Frequency decreases with increasing age • Due to abnormalities of cartilage and muscles surrounding the eustachiantube

33. Cleft Lip Cleft Palate Otitis media • Abnormalities of cartilage and muscles • Hypoplasia of the lateral cartilage relative to the medial cartilage • The curvature of the eustachian tube lumen • width and angulation of skull base with respect to eustachian tube • Abnormal insertions of TVP and levatorvelipalatinimuscles

34. Cleft Lip Cleft Palate Otitis media • Management • Tympanostomy tube insertion • Controversy : Type of VT • Controversy : Time of VT

35. Thanks for your attention