f3rirish.loumd ofPiostk Surgery ( 1991), 44,48&494 Q t 991 The Trustees of British Association of Plastic Surgeons
Comprehensive treatment of bilateral cleft lip by multidisciplinary team approach T, Nakajima, Y. Yoshimura, Y. Nakanishi, M. Kuwahara and T. Oka deportment qf F~~~t~cand ~e~#~str~~ti~~ Surgery, and ~~~~rtrne~t health Unit:ersity Scram of Medicine, Japan
ofUric
Surgerv and ~rthadonti~s, F~j~ta
SUMMARY, Repair of bilateral cleft lip presents numerous problems, and in our opinion, it is better to begin treatment at the earliest age possrble. At Fujita Health University Hospital, we utilise a multidi~iplinary team approach to cleft lip. Nonsurgical correction of the nasal deformity using a nose retainer and preoperative orthodontics using a Kuwahara-modified Hotz’s palatal plate begins soon after birth. Surgical repair of the lip is done within the first 2 months of life, by the time the nose, alveolus and projecting prolabium are adequately reformed. A one-stage surgical procedure, including restoration of muscle union, labial sulcus construction and nasal correction is perfarmed. After lip repair, lip and tongue pressure are well balanced by the plate, and a good alig~ent of the alveolus can be achieved. A total of 27 cases of bilateral cleft lip were treated from August 19% to October 1990. In all cases, the postoperative course was uneventful, and no complications due to early surgery were encountered. -
method (Perko, 1979). A total of 27 cases have been treated in this way in a period of 4 years and 3 months.
Recently, surgical techniques for the repair of unilateral cleft lip have improved greatly, but in bilateral cleft lip repair there still remain numerous complicated and difficult problems such as the protruding premaxilla, tissue deficiency of prolabium, short columella, broad nasal tip, deviated septal cartilage and so on. In our opinion, it is best to initiate treatment as early as possible, because surgical scars become less visible following surgery on infants, bones and cartilages are soft and mouldable in infants making it easy to do non-surgicai correction, and normal oral function can be established ante structures have been repaired anatomically. Thus physical development is not disturbed, and psychological problems for the baby and its family are minimized. Consequently, in our institution, surgery for unilateral cleft lip is performed within 2 weeks of birth and within 2 months for bilateral clefts. The details of our treatment of unilateral cleft lip will be reported in another paper in the near future; in this paper, treatment of bilateral cleft lip is described. To facilitate the earliest possible surgical intervention, a multidisciplinary team composed of plastic surgeon, orthodontist, oral surgeon, otologist and paediatricia~ is involved. As soon after birth as possible, the cleft lip baby is transferred to the neonatal intensive care unit (NICU) and thorough examination of general condition is undertaken by the paediatrician. When the baby is healthy, orthopaedic treatment of the nose and alveolus is first commenced before surgery by the orthodontist and the plastic surgeon as detailed Iater. Surgery for bilateral cleft Iip is performed within 4-8 weeks after birth by the plastic surgeon. The oral surgeon performs the cleft palate repair at 12-l 8 months of age using Perko’s two-stage
Preoperative treatment A nose retainer is pulled up against a cotton bolster placed over the nose and sewn in place. This procedure can be carried out very quickly, making general anaesthesia unnecessary and thus safeguarding the newborn infant. The fixture is held in ptace initially by a suture for 2 weeks (Fig. 1A). By that time, the short columella and deviated cartilages have been corrected to some extent as the result of this splinting. The sutures fixing the retainer are removed and a longer retainer (Nakajima et al.. 1990; Shibata et al., 1991) replaces the initial one to continue nose correction until the time of surgery (Fig. 1B). Soon after the fixation of the nasal splint, a maxillary impression is taken by the orthodontist, and a palatal plate is made and applied. With a strip of adhesive tape fixed over the upper lip, the plate effectively corrects the alveolar alignment. Kuwahara, one of the authors, has modified the conventional Hotz’s pafatal plate (Hotz and Gnoinski, 1976) to increase its efficacy for use in early surgery. In her modified design, the plate itself is not inserted within the alveolar cleft, so that the inward development of the alveolus is not disturbed (Figs 2A, B). This palatal plate facilitates sucking in the cleft-palate baby, as well as helping the natural closure of the alveolar cleft. When the piate is applied in the neonatal period, the deviated and protruded premaxilla begins to move towards the desired position during the first week of application. After lip repair, lip and tongue pressure are well 486
Comprehensive P_.
Treatment
of Bilateral Cleft Lip by Multidisciplinary
Team Approach
487
~.~_______.__~
._.-.
.._ ^___-_
Fig. I
Figure I--- (A) Preoperative fixation of the nose retainer and bandage over the upper lip. (B) The long retainer of the nasal deformity (right). On the left is the conventional ready-made retainer.
is designed
for better correction
Fig. 2 Figure 2-- Ku~d~ra-modi~ed Hotz’s plate. (A) A set-up model (right) is made for production of the ideal aivcolar alignment. (B) Paiatal plate made to fit the set-up model. (C) Comparison of the maxillary models of 13-month-old patients who had the lip repaired eight weeks after birth by the same operative procedure. (right) used the palatal plate adequately.
One patient
(left) did not use the palatal
plate after her discharge
from hos,pital.
The other
British Journal of Plastic Surgery
488 balanced by the palatal plate, and better alignment the alveolus can be achieved (Fig. 2C).
of
Operative technique Figure 3 shows the basic design of our primary repair of bilateral complete cleft lip. It is a one-stage repair and is a combination of the straight-line method and small triangular flaps. A deep alveolar sulcus is produced according to the method described by DeHaan (1968). The columella can be elongated and a natural contour of the lip/columella angle is produced by Raps drawn at the base of the cleft margin of the prolabium. Flaps A and B are used to reconstruct the oral vestibule. Flap A is raised at the cleft margin of the prolabium and turned inwards to cover the gingival side of the oral vestibule (Fig. 4). Flap B is formed along the cleft margin of the lateral segment, and turned like a hinge so that it can be sutured in a zigzag fashion, joining with the opposite flap to form the lip side of the oral vestibule. The incision on the vermilion of flap B curves medially to make the tubercle of the upper lip. Prolabial vermilion is trimmed to use the portion with best colour match with the lateral vermilion. Suturing of the muscle layer is limited to the upper half of the lip so that tension is eliminated and a natural posture achieved (Fig. 5). Flaps A and B are fixed to the periosteum of the anterior nasal spine to form a deep labial sulcus (Fig. 6). The lateral wall of the nasal vestibule is incised along the piriform aperture. Modest subcutaneous undermining of the nose is then performed and the incised margin is sutured to slide the lateral wall upward. Flap C is created at the gingivolabial junction of the lateral cleft margin and rotated upward as a subcutaneous pedicle flap to cover the tissue defect of the lateral wall of the nasal vestibule (Fig. 7). To prevent dragging of this subcutaneous pedicle flap, through-and-through mattress sutures are inserted to fix the flap to the alar groove. Flap D, created at the base of the cleft margin of the prolabium, is rotated 90” and inserted into the base of the columella so that the columella can be elongated and natural contour of the columella/labiaf angle can be achieved (Fig. 8). When early surgery is performed, the cleft is usually wide. Therefore we insert tension-reducing buried sutures between the two alar bases using a 4-O monofilament synthetic absorbable stitch (Fig. 9). Laterally deviated alar cartilages are undermined subcutaneously through small incisions placed on the bilateral nostril rim and sutured together medially with absorbable sutures. Several sutures of absorbable monofilaments are added and buried through the stab incisions on the mucosal surface to fix the mucosa and covering skin (Fig. 10). In bilateral incomplete clefts, there is relative abundance of skin, making it possible to use the upper lip skin as a subcutaneous pedicle flap to be rotated into the lateral wall of the nasal vestibule (Figs 11 and 12).
In cases of asymmetric bilateral cleft, there is insufficient tissue on the complete cleft side. Therefore, the size and position of the Raps is changed according to the extent of the clefts and the tissue deficiency to achieve postoperative symmetry. As shown in Figures 13 and 14, flaps A and B which construct the oral vestibule differ in size between the complete and incomplete sides. Flap C, to be transposed into the lateral wall of the nasal vestibule, and flap D to elongate the columella, are raised only on the complete cleft side.
Postoperative care At the end of the operation, a long nasal retainer (Shibata eta/., 1991) is inserted into the nostril and sutured to the nasal dorsum. One week after the operation, a modified Hotz’s palatal plate is applied again. Splinting of the nose is continued for 2 weeks or even longer if possible. After removal of the long retainer, a nostril retainer is used for about 2 months. At that time, depending on the nostril shape, the retainer may be augmented by mouldable silastic rubber to fit the individual shapeofthe nose (Nakajima et al., 1990).
Results In total, 23 bilateral clefts had their lip repaired within the first 2 months of life, receiving comprehensive treatment based on the protocol reported above. In all cases, the postoperative course was uneventful and, to date, no severe complications have occurred related to early surgery, thanks to careful preoperative screening by the paediatrician. Results are satisfactory with inconspicuous scars, deeply formed alveolar sulci and well developed orbicularis oris muscles. In most cases, postoperative nasal contour is also satisfactory. There have been a few patients who experienced mild recurrence of the nasal deformity, but in such cases, the deformity was much less than that seen in patients treated by conventional methods without any correction of the nose. If a slight deformity remains, it can easily be corrected with the modified reverse-U method (Nakajima et al., 1986) at 446 years of age. Good alignment of the alveolus is achieved with the modified Hotz’s palatal plate, which balances lip and tongue pressure (Fig. 17). Representative patients are presented (Figs 15-I 7).
Discussion Bilateral cleft lip repair remains one of the most challenging problems for plastic surgeons, demanding not only repair of the lip clefts, but also elongation of the columella, deepening of the labial sulcus and, of course, creation of functional lips (Nakajima and Yoshimura, 1990). To our knowledge, no report of a one-stage operation for simultaneous repair of the lip, nose, columella, muscle, labial sulcus and alveolus has appeared. Black
Comprehensive
Treatment
of Bilateral Cleft Lip by Multidisciplinary .~-.--
Fig. 3
Team Approach
Fig. 4
Fig. 5
PM : Premaxilla PL : Prolabium Fig. 6
Fig. 7
Fig. 8
Figure 3 Design of the incision for repair of bilateral complete cleft lip. Figure 4- Flaps covering the gingival surtace of the oral vestibule Figure 5.. Flaps 5 and B’ are hinged to form the labial side of the vestibule. Suturing of the muscle layer (striped) is limited to the upper half’ of the lip. Figure d-Sagittal section of the premaxiIia showing the formation of the oral vestibule. PM, pr~rna~l~la~ PL, pr~~~ab~urn. Figure “- Flap C has a subcutaneous pedicle which is rotated to add to the nasal lining. Figure &--Flap I3 is rotated911’ to elongate the coiumelln and for-m an adequate columella labial angle
British Journal of Plastic Surgery
490
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Figure 9-Tension-reducing sutures to be tightened and buried. Figure l&Buried sutures to ensure nasal correction. Dark shadow indicates stab incision, light shadow indicates alar cartilage. Figure 11-Design for bilateral incomplete cleft lip repair. Figure 12-Resulting suture line following bilateral complete and incomplete cleft lip repair. Figure KG-Design for asymmetric bilateral cleft lip. Figure 14---Resulting suture line following asymmetrical repair.
C’omtxehensive
Treatment
of Bilateral
Cleft
LiD bv ~uitidis~iD]in~ry
Team
Approach
491
Fig. 15 Figure 15 --(A) Frontal view before treatment of a patient with bilateral complete cleft lip and palate. (B) Lateral view betore treatment of a patient uith bilateral complete cleft lip and palate. (Ct Frontal view slier 6 weeks of preoperative correction. (D) Frontal view 3: years after birth. (It:) Profle 3$ years after birth.
British Journal of Plastic Surgery
492
Fig.16
Figure &-Patient with bilateral compXete cleft lip and palate. (A) Frontal view 5 days after birth before commencing preoperative correction. (B) Profile. (C) Frontal view 3 years postoperatively. (II) Profile 3 years postoperatively.
and Scheflan (1984) and Garcia-Velasco and Nahtis (1988) have reported similar one-stage methods, but these. do not incorporate nasal reconstruction. The method reported here includes all these in a single stage, The nasal repair invades the nose minimally, so there is little fear of postoperative growth disturbance of the nose. The flaps made at the base of the columella
are useful not only to elongate the columeIla but also to make a natural contour of the columella labia1 angle. Together with transposition of the subcutaneous flaps to the lateral wall of the nasal vestibule, the alar cartilages become free from their lateral attachment and mobile enough to be sutured together medially. Nasal cartilages soon after birth are so soft and
Comprehensive -_~._--.__
Treatment of Bilateral Cleft Lip by ~~ult~~isciplin~ry
3 days after birth
Team Approach
1 year 4 months old Fig.
Figure 17 Patlent wrth asymmetrical bilateral cleft lip and palate. year\ ;tftt:r wrgcq CC) Follow-up maxillary models of this patient.
amenable to moulding that they respond well to the nonsur,gical correction. Nasal splinting with a long retainer commenced soon after birth and continued for 2 months after surgery can also correct the deviated nasal septum, which is most commonly seen in the asymmetrical cleft cases, within a short time. We believe it is also possible to apply a nose retainer designed to suit the shape of the Caucasian nose. With the help of the Kuwahara-modified Hotz’s palatal plate, babies treated in our hospital can be fed by the same nipples used for normal babies or the mother’s nipple. Due to the reconstructed deep oral vestibule, it is easy to apply the palatal plate. With reconstructed continuity of the orbicularis oris muscle into a sling, oral feeding commenced as early in life as possible facilitates a natural development of all the facial elements, not only the orbicularis oris muscle. The plate we use is designed to balance the increased lip pressure after lip repair and the intraoral pressure exerted by the tongue, therefore making it possible to gain ideal alveolar alignment. If the plate is not used,
3 years old
17
(A) Preoperatlvc
vie,.
Surgery was performed
5 weeks attcr birth. (B) 7
early closure of the lip cleft results in collapse of the alveolar arch, as shown in Figure :!C. ‘Therefore, it can be said that this plate is an important adjunct to the early surgery. It is also important in the preoperative treatment that the plate be applied as early as possible after birth, and after surgery the shape of the plate should be changed frequently according to the alveolar shape and growth of the patieni:.
References Black, P. W. and Scheflan, M. (19841, Bikitt’rdl ‘cleft lip repair: “Putting it all together“. Annuls of Plustic Srqq~. 12. I 1X. DeHaan,C. R. (1968). Initial repair of cleft lip. In Stark. R. B. (Ed), Clcri Palate. ,4 ~~lti~~~cipli~~~ .$pprow’h rjew York. Hoeber Med. Div., Harper and Row, p. 1X. Garcia-Velasco, M. and Nahtis, R. A. (1988). Surgical repax of the bilateral cleft of the primary palate. Ann& ~~/~Pkwtic~Surpyv. 20. 76.
494
British
Hotz, M. M. and Gnoinski, W. (1976). Comprehensive care of cleft lip and palate children at Zurich University: A preliminary report. American Journal of Orthodontics, 70.48 I. Nakajiia, T., Yoshimura, Y. and Kami, T. (1986). Refinement of the “reverse-U” incision for the repair of cleft lip nose deformity. British Journul ofPlastic Surgery, 39, 345, Nakajima, T., Yoshimura, Y. and Sakakibara, A. (1990). Augmentation of nostril splint for retaining the corrected contour of the cleft lip nose. Plastic and Reconstructive Surgery, 85, 182. Nakajiia, T. and Yoshimara, Y. (1990). Secondary correction of bilateral cleft lip nose deformity. JournafofCranio-Ma.rilio-Facial Surgery, 18.63. Perko, M. A. (1979). Two-stage closureof cleft palate. MaxiNo-Facial Surgery. 34, 179.
Journal of
Shibata, K., Nakajima, T., Yoshimura, Y., Sakakibara, A. and Aoki, T. (1991). Use of long retainer for post-operative correction of cleft lip nose. Japanese Journal of Plastic and Reconstructive Surgery, 34. 179.
Journal
of Plastic
Surgery
The Authors Tatsuo Nakajima, MD, Professor and Chief, Department of Plastic and Reconstructive Surgery Yohko Your, MD, Associate Professor, Department of Plastic and Reconstructive Surgery Yuji Nakanishi, MD, Instructor. Department of Plastic and Reconstructive Surgery Miyoko Kuwahara, DMD, Associate Professor, Department ofOral Surgery and Orthodontics Toro Oka, DDS, MD, Professor and Chief, Department of Oral Surgery and Orthodontics School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukake. Toyoake, Aichi 470-I 1, Japan. Requests
for reprints
to Professor
Nakajima.
Paper received 5 February 1991. Accepted 19 April 199 1after revision.
Comprehensive treatment of bilateral cleft lip by multidisciplinary team approach T, Nakajima, Y. Yoshimura, Y. Nakanishi, M. Kuwahara and T. Oka deportment qf F~~~t~cand ~e~#~str~~ti~~ Surgery, and ~~~~rtrne~t health Unit:ersity Scram of Medicine, Japan
ofUric
Surgerv and ~rthadonti~s, F~j~ta
SUMMARY, Repair of bilateral cleft lip presents numerous problems, and in our opinion, it is better to begin treatment at the earliest age possrble. At Fujita Health University Hospital, we utilise a multidi~iplinary team approach to cleft lip. Nonsurgical correction of the nasal deformity using a nose retainer and preoperative orthodontics using a Kuwahara-modified Hotz’s palatal plate begins soon after birth. Surgical repair of the lip is done within the first 2 months of life, by the time the nose, alveolus and projecting prolabium are adequately reformed. A one-stage surgical procedure, including restoration of muscle union, labial sulcus construction and nasal correction is perfarmed. After lip repair, lip and tongue pressure are well balanced by the plate, and a good alig~ent of the alveolus can be achieved. A total of 27 cases of bilateral cleft lip were treated from August 19% to October 1990. In all cases, the postoperative course was uneventful, and no complications due to early surgery were encountered. -
method (Perko, 1979). A total of 27 cases have been treated in this way in a period of 4 years and 3 months.
Recently, surgical techniques for the repair of unilateral cleft lip have improved greatly, but in bilateral cleft lip repair there still remain numerous complicated and difficult problems such as the protruding premaxilla, tissue deficiency of prolabium, short columella, broad nasal tip, deviated septal cartilage and so on. In our opinion, it is best to initiate treatment as early as possible, because surgical scars become less visible following surgery on infants, bones and cartilages are soft and mouldable in infants making it easy to do non-surgicai correction, and normal oral function can be established ante structures have been repaired anatomically. Thus physical development is not disturbed, and psychological problems for the baby and its family are minimized. Consequently, in our institution, surgery for unilateral cleft lip is performed within 2 weeks of birth and within 2 months for bilateral clefts. The details of our treatment of unilateral cleft lip will be reported in another paper in the near future; in this paper, treatment of bilateral cleft lip is described. To facilitate the earliest possible surgical intervention, a multidisciplinary team composed of plastic surgeon, orthodontist, oral surgeon, otologist and paediatricia~ is involved. As soon after birth as possible, the cleft lip baby is transferred to the neonatal intensive care unit (NICU) and thorough examination of general condition is undertaken by the paediatrician. When the baby is healthy, orthopaedic treatment of the nose and alveolus is first commenced before surgery by the orthodontist and the plastic surgeon as detailed Iater. Surgery for bilateral cleft Iip is performed within 4-8 weeks after birth by the plastic surgeon. The oral surgeon performs the cleft palate repair at 12-l 8 months of age using Perko’s two-stage
Preoperative treatment A nose retainer is pulled up against a cotton bolster placed over the nose and sewn in place. This procedure can be carried out very quickly, making general anaesthesia unnecessary and thus safeguarding the newborn infant. The fixture is held in ptace initially by a suture for 2 weeks (Fig. 1A). By that time, the short columella and deviated cartilages have been corrected to some extent as the result of this splinting. The sutures fixing the retainer are removed and a longer retainer (Nakajima et al.. 1990; Shibata et al., 1991) replaces the initial one to continue nose correction until the time of surgery (Fig. 1B). Soon after the fixation of the nasal splint, a maxillary impression is taken by the orthodontist, and a palatal plate is made and applied. With a strip of adhesive tape fixed over the upper lip, the plate effectively corrects the alveolar alignment. Kuwahara, one of the authors, has modified the conventional Hotz’s pafatal plate (Hotz and Gnoinski, 1976) to increase its efficacy for use in early surgery. In her modified design, the plate itself is not inserted within the alveolar cleft, so that the inward development of the alveolus is not disturbed (Figs 2A, B). This palatal plate facilitates sucking in the cleft-palate baby, as well as helping the natural closure of the alveolar cleft. When the piate is applied in the neonatal period, the deviated and protruded premaxilla begins to move towards the desired position during the first week of application. After lip repair, lip and tongue pressure are well 486
Comprehensive P_.
Treatment
of Bilateral Cleft Lip by Multidisciplinary
Team Approach
487
~.~_______.__~
._.-.
.._ ^___-_
Fig. I
Figure I--- (A) Preoperative fixation of the nose retainer and bandage over the upper lip. (B) The long retainer of the nasal deformity (right). On the left is the conventional ready-made retainer.
is designed
for better correction
Fig. 2 Figure 2-- Ku~d~ra-modi~ed Hotz’s plate. (A) A set-up model (right) is made for production of the ideal aivcolar alignment. (B) Paiatal plate made to fit the set-up model. (C) Comparison of the maxillary models of 13-month-old patients who had the lip repaired eight weeks after birth by the same operative procedure. (right) used the palatal plate adequately.
One patient
(left) did not use the palatal
plate after her discharge
from hos,pital.
The other
British Journal of Plastic Surgery
488 balanced by the palatal plate, and better alignment the alveolus can be achieved (Fig. 2C).
of
Operative technique Figure 3 shows the basic design of our primary repair of bilateral complete cleft lip. It is a one-stage repair and is a combination of the straight-line method and small triangular flaps. A deep alveolar sulcus is produced according to the method described by DeHaan (1968). The columella can be elongated and a natural contour of the lip/columella angle is produced by Raps drawn at the base of the cleft margin of the prolabium. Flaps A and B are used to reconstruct the oral vestibule. Flap A is raised at the cleft margin of the prolabium and turned inwards to cover the gingival side of the oral vestibule (Fig. 4). Flap B is formed along the cleft margin of the lateral segment, and turned like a hinge so that it can be sutured in a zigzag fashion, joining with the opposite flap to form the lip side of the oral vestibule. The incision on the vermilion of flap B curves medially to make the tubercle of the upper lip. Prolabial vermilion is trimmed to use the portion with best colour match with the lateral vermilion. Suturing of the muscle layer is limited to the upper half of the lip so that tension is eliminated and a natural posture achieved (Fig. 5). Flaps A and B are fixed to the periosteum of the anterior nasal spine to form a deep labial sulcus (Fig. 6). The lateral wall of the nasal vestibule is incised along the piriform aperture. Modest subcutaneous undermining of the nose is then performed and the incised margin is sutured to slide the lateral wall upward. Flap C is created at the gingivolabial junction of the lateral cleft margin and rotated upward as a subcutaneous pedicle flap to cover the tissue defect of the lateral wall of the nasal vestibule (Fig. 7). To prevent dragging of this subcutaneous pedicle flap, through-and-through mattress sutures are inserted to fix the flap to the alar groove. Flap D, created at the base of the cleft margin of the prolabium, is rotated 90” and inserted into the base of the columella so that the columella can be elongated and natural contour of the columella/labiaf angle can be achieved (Fig. 8). When early surgery is performed, the cleft is usually wide. Therefore we insert tension-reducing buried sutures between the two alar bases using a 4-O monofilament synthetic absorbable stitch (Fig. 9). Laterally deviated alar cartilages are undermined subcutaneously through small incisions placed on the bilateral nostril rim and sutured together medially with absorbable sutures. Several sutures of absorbable monofilaments are added and buried through the stab incisions on the mucosal surface to fix the mucosa and covering skin (Fig. 10). In bilateral incomplete clefts, there is relative abundance of skin, making it possible to use the upper lip skin as a subcutaneous pedicle flap to be rotated into the lateral wall of the nasal vestibule (Figs 11 and 12).
In cases of asymmetric bilateral cleft, there is insufficient tissue on the complete cleft side. Therefore, the size and position of the Raps is changed according to the extent of the clefts and the tissue deficiency to achieve postoperative symmetry. As shown in Figures 13 and 14, flaps A and B which construct the oral vestibule differ in size between the complete and incomplete sides. Flap C, to be transposed into the lateral wall of the nasal vestibule, and flap D to elongate the columella, are raised only on the complete cleft side.
Postoperative care At the end of the operation, a long nasal retainer (Shibata eta/., 1991) is inserted into the nostril and sutured to the nasal dorsum. One week after the operation, a modified Hotz’s palatal plate is applied again. Splinting of the nose is continued for 2 weeks or even longer if possible. After removal of the long retainer, a nostril retainer is used for about 2 months. At that time, depending on the nostril shape, the retainer may be augmented by mouldable silastic rubber to fit the individual shapeofthe nose (Nakajima et al., 1990).
Results In total, 23 bilateral clefts had their lip repaired within the first 2 months of life, receiving comprehensive treatment based on the protocol reported above. In all cases, the postoperative course was uneventful and, to date, no severe complications have occurred related to early surgery, thanks to careful preoperative screening by the paediatrician. Results are satisfactory with inconspicuous scars, deeply formed alveolar sulci and well developed orbicularis oris muscles. In most cases, postoperative nasal contour is also satisfactory. There have been a few patients who experienced mild recurrence of the nasal deformity, but in such cases, the deformity was much less than that seen in patients treated by conventional methods without any correction of the nose. If a slight deformity remains, it can easily be corrected with the modified reverse-U method (Nakajima et al., 1986) at 446 years of age. Good alignment of the alveolus is achieved with the modified Hotz’s palatal plate, which balances lip and tongue pressure (Fig. 17). Representative patients are presented (Figs 15-I 7).
Discussion Bilateral cleft lip repair remains one of the most challenging problems for plastic surgeons, demanding not only repair of the lip clefts, but also elongation of the columella, deepening of the labial sulcus and, of course, creation of functional lips (Nakajima and Yoshimura, 1990). To our knowledge, no report of a one-stage operation for simultaneous repair of the lip, nose, columella, muscle, labial sulcus and alveolus has appeared. Black
Comprehensive
Treatment
of Bilateral Cleft Lip by Multidisciplinary .~-.--
Fig. 3
Team Approach
Fig. 4
Fig. 5
PM : Premaxilla PL : Prolabium Fig. 6
Fig. 7
Fig. 8
Figure 3 Design of the incision for repair of bilateral complete cleft lip. Figure 4- Flaps covering the gingival surtace of the oral vestibule Figure 5.. Flaps 5 and B’ are hinged to form the labial side of the vestibule. Suturing of the muscle layer (striped) is limited to the upper half’ of the lip. Figure d-Sagittal section of the premaxiIia showing the formation of the oral vestibule. PM, pr~rna~l~la~ PL, pr~~~ab~urn. Figure “- Flap C has a subcutaneous pedicle which is rotated to add to the nasal lining. Figure &--Flap I3 is rotated911’ to elongate the coiumelln and for-m an adequate columella labial angle
British Journal of Plastic Surgery
490
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Figure 9-Tension-reducing sutures to be tightened and buried. Figure l&Buried sutures to ensure nasal correction. Dark shadow indicates stab incision, light shadow indicates alar cartilage. Figure 11-Design for bilateral incomplete cleft lip repair. Figure 12-Resulting suture line following bilateral complete and incomplete cleft lip repair. Figure KG-Design for asymmetric bilateral cleft lip. Figure 14---Resulting suture line following asymmetrical repair.
C’omtxehensive
Treatment
of Bilateral
Cleft
LiD bv ~uitidis~iD]in~ry
Team
Approach
491
Fig. 15 Figure 15 --(A) Frontal view before treatment of a patient with bilateral complete cleft lip and palate. (B) Lateral view betore treatment of a patient uith bilateral complete cleft lip and palate. (Ct Frontal view slier 6 weeks of preoperative correction. (D) Frontal view 3: years after birth. (It:) Profle 3$ years after birth.
British Journal of Plastic Surgery
492
Fig.16
Figure &-Patient with bilateral compXete cleft lip and palate. (A) Frontal view 5 days after birth before commencing preoperative correction. (B) Profile. (C) Frontal view 3 years postoperatively. (II) Profile 3 years postoperatively.
and Scheflan (1984) and Garcia-Velasco and Nahtis (1988) have reported similar one-stage methods, but these. do not incorporate nasal reconstruction. The method reported here includes all these in a single stage, The nasal repair invades the nose minimally, so there is little fear of postoperative growth disturbance of the nose. The flaps made at the base of the columella
are useful not only to elongate the columeIla but also to make a natural contour of the columella labia1 angle. Together with transposition of the subcutaneous flaps to the lateral wall of the nasal vestibule, the alar cartilages become free from their lateral attachment and mobile enough to be sutured together medially. Nasal cartilages soon after birth are so soft and
Comprehensive -_~._--.__
Treatment of Bilateral Cleft Lip by ~~ult~~isciplin~ry
3 days after birth
Team Approach
1 year 4 months old Fig.
Figure 17 Patlent wrth asymmetrical bilateral cleft lip and palate. year\ ;tftt:r wrgcq CC) Follow-up maxillary models of this patient.
amenable to moulding that they respond well to the nonsur,gical correction. Nasal splinting with a long retainer commenced soon after birth and continued for 2 months after surgery can also correct the deviated nasal septum, which is most commonly seen in the asymmetrical cleft cases, within a short time. We believe it is also possible to apply a nose retainer designed to suit the shape of the Caucasian nose. With the help of the Kuwahara-modified Hotz’s palatal plate, babies treated in our hospital can be fed by the same nipples used for normal babies or the mother’s nipple. Due to the reconstructed deep oral vestibule, it is easy to apply the palatal plate. With reconstructed continuity of the orbicularis oris muscle into a sling, oral feeding commenced as early in life as possible facilitates a natural development of all the facial elements, not only the orbicularis oris muscle. The plate we use is designed to balance the increased lip pressure after lip repair and the intraoral pressure exerted by the tongue, therefore making it possible to gain ideal alveolar alignment. If the plate is not used,
3 years old
17
(A) Preoperatlvc
vie,.
Surgery was performed
5 weeks attcr birth. (B) 7
early closure of the lip cleft results in collapse of the alveolar arch, as shown in Figure :!C. ‘Therefore, it can be said that this plate is an important adjunct to the early surgery. It is also important in the preoperative treatment that the plate be applied as early as possible after birth, and after surgery the shape of the plate should be changed frequently according to the alveolar shape and growth of the patieni:.
References Black, P. W. and Scheflan, M. (19841, Bikitt’rdl ‘cleft lip repair: “Putting it all together“. Annuls of Plustic Srqq~. 12. I 1X. DeHaan,C. R. (1968). Initial repair of cleft lip. In Stark. R. B. (Ed), Clcri Palate. ,4 ~~lti~~~cipli~~~ .$pprow’h rjew York. Hoeber Med. Div., Harper and Row, p. 1X. Garcia-Velasco, M. and Nahtis, R. A. (1988). Surgical repax of the bilateral cleft of the primary palate. Ann& ~~/~Pkwtic~Surpyv. 20. 76.
494
British
Hotz, M. M. and Gnoinski, W. (1976). Comprehensive care of cleft lip and palate children at Zurich University: A preliminary report. American Journal of Orthodontics, 70.48 I. Nakajiia, T., Yoshimura, Y. and Kami, T. (1986). Refinement of the “reverse-U” incision for the repair of cleft lip nose deformity. British Journul ofPlastic Surgery, 39, 345, Nakajima, T., Yoshimura, Y. and Sakakibara, A. (1990). Augmentation of nostril splint for retaining the corrected contour of the cleft lip nose. Plastic and Reconstructive Surgery, 85, 182. Nakajiia, T. and Yoshimara, Y. (1990). Secondary correction of bilateral cleft lip nose deformity. JournafofCranio-Ma.rilio-Facial Surgery, 18.63. Perko, M. A. (1979). Two-stage closureof cleft palate. MaxiNo-Facial Surgery. 34, 179.
Journal of
Shibata, K., Nakajima, T., Yoshimura, Y., Sakakibara, A. and Aoki, T. (1991). Use of long retainer for post-operative correction of cleft lip nose. Japanese Journal of Plastic and Reconstructive Surgery, 34. 179.
Journal
of Plastic
Surgery
The Authors Tatsuo Nakajima, MD, Professor and Chief, Department of Plastic and Reconstructive Surgery Yohko Your, MD, Associate Professor, Department of Plastic and Reconstructive Surgery Yuji Nakanishi, MD, Instructor. Department of Plastic and Reconstructive Surgery Miyoko Kuwahara, DMD, Associate Professor, Department ofOral Surgery and Orthodontics Toro Oka, DDS, MD, Professor and Chief, Department of Oral Surgery and Orthodontics School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukake. Toyoake, Aichi 470-I 1, Japan. Requests
for reprints
to Professor
Nakajima.
Paper received 5 February 1991. Accepted 19 April 199 1after revision.
