A Visual Guide for Cleft Surgeons [1st ed. 2023] 3031335201, 9783031335204

Citation preview

Marco Kesting Rainer Lutz Manuel Weber

A Visual Guide for Cleft Surgeons

123

A Visual Guide for Cleft Surgeons

Marco Kesting • Rainer Lutz • Manuel Weber

A Visual Guide for Cleft Surgeons

Marco Kesting Department of Oral and Cranio-Maxillofacial Surgery Erlangen University Hospital Erlangen, Germany

Rainer Lutz Department of Oral and Cranio-Maxillofacial Surgery Erlangen University Hospital Erlangen, Germany

Manuel Weber Department of Oral and Cranio-Maxillofacial Surgery Erlangen University Hospital Erlangen, Germany

ISBN 978-3-031-33520-4    ISBN 978-3-031-33521-1 (eBook) https://doi.org/10.1007/978-3-031-33521-1 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

Without being too pathetic: cleft lip and palate surgery has held an overwhelming fascination for me since my days as a student and made me embark on a long and rocky journey in surgical training and in my career. The fascination and passion helped me “survive” on the surgical cruise in stormy seas and look forward to learning this type of surgery. I am grateful to my surgical teacher Klaus Wolff for his generosity to show and teach me his patience and the appropriate techniques. I am very thankful to him for the chance to do a fellowship in Pretoria/ Tshwane, South Africa with Kurt Buetow in order to optimize my skills, which put me in a great position. Teaching these acquired skills and ideas at my alma mater in my Franconian home is a rewarding task, and it is a priviledge to care for the children with cleft formations who are entrusted to me by their parents. Together with my coworkers and surgical staff I have lived and developed the idea of cleft lip and palate treatment day by day following D. Ralph Millard’s principle “Semper investigans, nunquam perficiens”. What makes cleft surgery so fascinating? There is no craft, let alone surgical procedure, that is so sustainable and lasting for the appearance and the future development of a little patient. On the day of surgery, important foundations are cemented for what may be the next 95 years. The surgeon’s skill and focus become central to the child’s later aesthetics, functions and self-perception, as well as to his or her perception of others and social interaction. This may cause some pressure, but it is necessary for achieving excellent results. At times, this surgical burden may also be the cause of the occasional mystification of primary cleft surgery. With the fortunate circumstances described before, it has become a central concern of mine to pass on my idea and what I have learned as I have experienced it. It’s my “goal” to inspire junior surgeons for this fascinating aspect of surgery. However, there is hardly any literature that enables young, ambitious surgeons to get started in cleft surgery. The first choice is Millard’s bible “Cleft craft: The Evolution of its Surgery - Part I-III”. It contains a detailed description of surgical development, pros and cons of the techniques and important personal considerations. Although it is more than 40 years old, it remains a must for cleft surgeons for showing the basis of treatment in a unique manner on nearly 3000 pages. So - what is the goal of this book? What inspired my two most experienced colleagues and me to create this volume? The essential goal of this book is to demystify primary cleft surgery. Therefore, our aim was to present a basic and clear introduction to the most important techniques. This book is intended for prospective cleft surgeons, as well as students, residents, and specialists in co-treatment disciplines. In a concise manner, each chapter presents cleft-related anatomy, traditional surgical techniques, and current developments and modifications. As a special idea, we have developed special innovative, simple training models for the reader in teamwork. The training models enable the rookie surgeon to understand the techniques step by step. In addition, the ex vivo simulation models are readily available and provide the opportunity for haptic experience and surgical training of the procedures. To maintain its concise nature, the book deliberately omits descriptions of cleft formation and nonsurgical treatment. The reader will also forgive us, if we do not show all possible techniques and variations of cleft surgery for the reasons mentioned. We only want to show a walkable way to approach the highly complex and exciting topic. Erlangen, Germany January 2023

Marco Kesting v

Acknowledgments

First of all, we would like to thank the parents of the little patients who allowed us to publish the photos of their children. The work would not have been possible without the excellent support of Markus Kohler, who perfected the photos, and Katrin Foerster, who smoothed out the linguistic blur in the text. Special thanks go to Manuel Olmos and Jan Buerstner, who repeatedly provided ex vivo models and also helped to operate the models. In this context, a big “thank you” goes to Wolfgang Haertl and his coworkers, who provided us with pig snouts on call, and to Deniz Tasyuerek, who “invented” the application of lipstick on the model. We would like to thank Nicolai Oetter for his invaluable assistance with the literature review. Projects of this nature are born out of passionate discussions, stimulating conversations, and awe-inspiring incidents. The work is driven by emotions. For this, special thanks to Mayte Buchbender, Andreas Fichter, Christopher-Philipp Nobis, and Andrea Rau. Inspiration works forever: thanks to Michael Winklmair, Karl and Kitty Heitkamp, and Michael Mueck. The book would not have been produced in such an elegant form without input from Daniela Heller and Lee Klein from Springer. Special thanks to our families and friends for their angelic patience during the completion of the book!

vii

Contents

1 Primary  Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty �����������   1 1.1 Relevant Anatomy of Lip and Nose���������������������������������������������������������������������   1 1.2 History and Development �����������������������������������������������������������������������������������   3 1.2.1 Ancient and Medieval Surgery—Needles and Pins���������������������������������   3 1.2.2 Triangular Techniques�����������������������������������������������������������������������������   4 1.2.3 Rotation-Advancement Technique�����������������������������������������������������������   5 1.2.4 Wave-Line Technique �����������������������������������������������������������������������������   5 1.2.5 Hybrid Techniques�����������������������������������������������������������������������������������   6 1.2.6 Incorporation of Valuable Modifications to the Basic Techniques ���������   6 1.3 Relevant Anatomy for Unilateral Cleft Lip Plasty�����������������������������������������������   7 1.3.1 Applied Anatomy�������������������������������������������������������������������������������������   7 1.3.2 Relevant Anatomy for Millard II Technique �������������������������������������������   7 1.3.3 Relevant Anatomy for Newly Developed Hybrid Technique�������������������   7 1.4 An ex vivo Model for Unilateral Lip Plasty���������������������������������������������������������  10 1.4.1 Development of the Model ���������������������������������������������������������������������  10 1.4.2 Simulation of a Millard II Lip Plasty on the Cleft Lip Model�����������������  10 1.5 Patient Cases �������������������������������������������������������������������������������������������������������  16 1.5.1 Technique of Millard II Lip Plasty in an Incomplete Unilateral Cleft Lip ���������������������������������������������������������������������������������  16 1.5.2 Newly Developed Hybrid Technique of Lip Plasty in a Broad Unilateral Cleft Lip ���������������������������������������������������������������  20 References���������������������������������������������������������������������������������������������������������������������  29 2 Primary  Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty�����������������  31 2.1 Relevant Anatomy of the Lip and Nose���������������������������������������������������������������  32 2.2 History and Development �����������������������������������������������������������������������������������  32 2.2.1 Ancient Surgery���������������������������������������������������������������������������������������  32 2.2.2 Development of Bilateral Cleft Surgery from the Fifteenth Century�����������������������������������������������������������������������������������������������������  32 2.3 Current Techniques ���������������������������������������������������������������������������������������������  33 2.3.1 Straight-Line Technique���������������������������������������������������������������������������  33 2.3.2 Quadrangular Flap Technique�����������������������������������������������������������������  34 2.3.3 Rotation-Advancement Techniques���������������������������������������������������������  34 2.4 Relevant Anatomy for Bilateral Cleft Lip Plasty�������������������������������������������������  35 2.4.1 Applied Anatomy�������������������������������������������������������������������������������������  35 2.4.2 Relevant Anatomy for Millard Technique�����������������������������������������������  35 2.5 An ex vivo Model for Bilateral Lip Plasty�����������������������������������������������������������  37 2.5.1 Development of the Model ���������������������������������������������������������������������  37 2.5.2 Simulation of a Millard Lip Plasty on the Bilateral Cleft Lip ex vivo Model���������������������������������������������������������������������������  40

ix

x

Contents

2.6 Patient Cases �������������������������������������������������������������������������������������������������������  44 2.6.1 Technique of Millard Lip Plasty in a Complete Symmetrical Bilateral Cleft Lip �����������������������������������������������������������������������������������  44 2.6.2 Technique of Millard Lip Plasty in an Incomplete Asymmetric Bilateral Cleft Lip �����������������������������������������������������������������������������������  52 References���������������������������������������������������������������������������������������������������������������������  60 3 Primary  Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty���������������������������������������������������������������������������������������������  61 3.1 History and Development �����������������������������������������������������������������������������������  61 3.2 Current Concepts�������������������������������������������������������������������������������������������������  64 3.3 Relevant Anatomy for Palatoplasty���������������������������������������������������������������������  64 3.4 Technique of Palatoplasty in Isolated Cleft Palates���������������������������������������������  66 3.4.1 One-Stage Repair in a Moderately Wide Cleft of the Hard and Soft Palate: Bardach Two-Flap Palatoplasty with Intravelar Veloplasty—Case 1���������������������������������������������������������������������������������   67 3.4.2 One-Stage Repair in a Wide Cleft of the Hard and Soft Palate (Pierre-­­Robin-­­Patient): Bardach Two-Flap Palatoplasty with Intravelar Veloplasty and Pichler’s Vomerine Plasty—Case 2�����������������������������������������������������������������������������������������   70 3.5 Technique of Palatoplasty in Bilateral Cleft Lip and Palate �������������������������������  80 3.5.1 One-Stage Repair: Bardach Two-Flap Palatoplasty with Intravelar Veloplasty and Pichler’s Vomerine Plasty—Case 3�����������������������������������������������������������������������������������������   80 References���������������������������������������������������������������������������������������������������������������������  89 4 Surgery  of the Alveolar Cleft: Secondary Bone Grafting of Alveolar Clefts���������������������������������������������������������������������������������������������������������  91 4.1 History and Development �����������������������������������������������������������������������������������  91 4.1.1 Primary and Tertiary Osteoplasty �����������������������������������������������������������  91 4.1.2 The Way to Secondary Osteoplasty���������������������������������������������������������  92 4.2 Patient Case���������������������������������������������������������������������������������������������������������  93 4.2.1 Secondary Bone Grafting of Alveolar Cleft���������������������������������������������  93 References���������������������������������������������������������������������������������������������������������������������  97 5 Surgery  of the Transverse Facial Cleft/Congenital Macrostomia: Lip and Commissuroplasty in the Transverse Facial Cleft�������������������������������������  99 5.1 Basic Technique���������������������������������������������������������������������������������������������������  99 5.2 Recommended Procedures Depending on the Extent of the Cleft����������������������� 100 5.3 History and Development of the Techniques������������������������������������������������������� 100 5.4 Case Report��������������������������������������������������������������������������������������������������������� 101 5.4.1 Technique of Lip Plasty and Commissuroplasty in a Transverse Cleft Lip������������������������������������������������������������������������� 101 References��������������������������������������������������������������������������������������������������������������������� 105

1

Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

Unilateral cleft lip repair is usually performed between 3 and 5 months of age. Goals of the unilateral cheiloplasty procedure are: Create an intact orbicularis oris muscle. Create a harmonic and symmetric philtrum/upper lip. Correct the lack of vertical length on the cleft side. Correct nasal deformity. Produce preferably invisible scars (Marcus et al. 2017). Numerous surgical techniques for unilateral cleft lip closure are available. Basically, four variations for lip lengthening can be distinguished: V-shaped techniques, primary closure. Triangular flap techniques. Rotation flap techniques. Wave-line lengthening. V-shaped closures for complete unilateral lip clefts are often associated with postoperative “whistle deformities” (Marcus et al. 2017). Therefore, the technique is nowadays obsolete for complete unilateral lip clefts, but might still be useful for minor cleft lip deformities. Triangular flap techniques leave unflattering scars diametrically opposed to the natural skin tension lines, especially in the area of the philtrum. On the other hand, the triangular techniques allow precise measurement of the incisions, which has great advantages for the regular extension of the philtrum edge on the cleft side (Marcus et al. 2017). In a survey of American cleft surgeons, 84% currently use the rotation-advancement technique to close unilat-

eral cleft lips, while 9% prefer triangular flap techniques (Campbell et  al. 2010). Wave-like lengthening was mainly applied by several German cleft surgeons (Pfeifer 1970a; Pfeifer 1970b; Höltje and Ehmann 1973). Hybrid procedures with rotation-­advancement and wave-like elements were recently introduced (Reddy et al. 2009; Gosla Reddy et  al. 2010; Gosla-Reddy et  al. 2011; Madaree 2019). In the following, the relevant anatomical basics for unilateral cleft closure are highlighted before a brief outline of the essential techniques is given. The historical development in particular is discussed, as it reflects the considerations and conclusions of the leading cleft surgeons. The constant development of the techniques, the fine-tuning on modifications and improvements are thus taken into account. Understanding of the techniques and tissue handling will be trained through the presentation of a specially designed ex vivo model for unilateral cleft lips. To round off the chapter, the techniques referred to by the author are presented step by step using patient examples.

1.1 Relevant Anatomy of Lip and Nose Learning the constructive surgical techniques requires anatomical knowledge of the nose and upper lip region. In the following illustrations, the relevant structures are pointed out (Figs. 1.1, 1.2, and 1.3). In addition, the anatomical surgical landmarks required for the construction are described (Fig. 1.4).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. Kesting et al., A Visual Guide for Cleft Surgeons, https://doi.org/10.1007/978-3-031-33521-1_1

1

2 Fig. 1.1  Anatomy of labial and nasal structures I. (a) Schematic drawing of columella (red dotted), right and left philtral column (in yellow), cupid’s bow (in black), dry vermilion (in light pink), and wet vermilion (in dark pink). (b) Clinical appearance in a non-cleft patient with color-coded highlighting of the structures. (corresponding to 1.1a)

Fig. 1.2  Anatomy of labial and nasal structures II. (a) Schematic drawing of the structures. (b) Clinical appearance of the structures in a non-cleft patient

Fig. 1.3  Schematic drawing of the relevant perioral and perinasal musculature: zygomatic muscle (in gray), levator angularis oris muscle (light beige), levator labii superioris alaeque nasi muscle (green), risorius muscle (brown), depressor anguli oris muscle (dark beige), orbicularis oris muscle (yellow) and modiolus (white)

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

a

b

a

b

1.2 History and Development Fig. 1.4  Anatomic landmarks for cleft lip repair. (a) Schematic drawing with relevant landmarks; most cranial point of columella is indicated by red dot, superior points of left and right philtral column are indicated by green dots, left and right peak of cupid’s bow are indicated by dark blue dots, central most inferior point of cupid’s bow is marked by light blue dot. (b) Clinical appearance in a non-cleft patient with corresponding color-coded landmarks as in 1.3a

3

a

1.2 History and Development In order to understand current treatment concepts of unilateral cleft lip surgery, a presentation of the century-long historical development is indispensable. Advantages and disadvantages of old and innovative techniques show the tightrope walk of cleft surgery. Millard’s guiding principle “Semper investigans, nunquam perficiens” thus becomes clear (Millard 1976). The crystallization of the best possible technique can only be achieved by a multitude of elaborate preliminary considerations. In the process, the experiences of important pioneers of cleft surgery are combined with own routine and practice. Anecdotally, the most important milestones of unilateral lip repair are presented below.

1.2.1 Ancient and Medieval Surgery— Needles and Pins 390 B.C. The first documented unilateral cleft closure was reported in ancient China. Eighteen-year-old Wei Yang-Chi, a farmer’s son born with a cleft lip, strongly desired correction of his malformation. Therefore, Wei took all the rice he could carry to his Governor. The Governor was so amazed that he called one of his surgeons to operate on Wei. The surgeon did a briefing in the form of an in-depth consultation session and informed Wei that he has to keep his mouth closed for 100 days after surgery. Wei remained calm and answered that 100 days are nothing compared to the relief of his condition: for a successful correction he would stay silent for half of his lifetime (Millard 1976; Burt and Byrd 2000; Wong and Wu 1932; Randall and Jackson 2016).

b

Medieval Period and sixteenth Century Johan or Jehan Yperman (born around 1260  in Ypern in today’s Belgium) was probably the first one who described cleft repair. The Flemish surgeon excised the cleft margins with a scalpel. Further he pierced the two cleft parts with a triangular needle, which is for its part fixed with a figure-ofeight thread around it (Millard 1976; Prioreschi 1996; Vrebos 1982). The German knight and surgeon Heinrich von Pfalzpaint (born around 1400 in Pfalzpaint near Ingolstadt, died around 1464) sold his castle and went on a journey to learn techniques from the medieval surgeons in Southern Germany, France, and Italy. He described Tagliacozzis Rhinoplasty in his book “Bündtarznei” (1460) more than 100 years before Tagliacozzi did it. Moreover, the book—which is written in an obscure old-German idiom—presents a technique for cleft lip closure, which describes for the first time full-­ thickness closure of the lip including the muscles (“szo stich im ducrh die hawth vnnd tieff in das fleyss, also dastu fleisch gnug mith dem hefftenn nimst, das es genaw inn der dicke des fleisch mitten heraussergehe. Des gleiche vff der ander seytten entiegenn.”) (von Pfolsprundt 1868; Richter 2003; Greig et al. 2015). Ambroise Paré (born in 1510  in Bourg-Hersent near Laval, died in 1590  in Paris) was the most famous French barber surgeon and served king Henry II, Francis II, Charles IX, and Henry III. He learnt his skills on the European battlefields. Paré contributed to surgical amputation and developed artificial limbs as the iron hand. He is also considered as the founder of maggot therapy for wound healing. Paré was the first one to illustrate cleft surgery. Needles and pins and a figure-of-eight wraparound thread are evident in his pictures (Fig. 1.5) (Williams and Williams 2004).

4

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

Fig. 1.5  Parés needles and pins and figure-of-eight wraparound thread

Fig. 1.7  Incisions for unilateral lip plasty after Mirault

Fig. 1.6  Incision for unilateral lip plasty after Malgaigne

Fig. 1.8  Incisions for unilateral lip repair after Tennison-Randall

1843 Straight line or primary closure of unilateral cleft lips resulted in contractures and shortness of the cleft side, called “whistling deformity” (Marcus et  al. 2017). To overcome this Joseph Malgaigne (born in 1806  in Charmes-sur-­ Moselle, died in Paris in 1865) suggested horizontal incisions on both cleft edges (Fig. 1.6) (Malgaigne 1844).

flap from the lateral side into a gap created by making a horizontal incision on the medial side (Fig. 1.7) (Mirault 1844).

1.2.2 Triangular Techniques

1952 Charles W. Tennison from San Antonio, Texas, presented his “stencil technique” at the meeting of the American Society of Plastic and Reconstructive surgeons in Colorado Springs in 1951. He added a Z-plasty on the lateral side to a triangular flap on the medial side and preserved the cupids bow. To simplify the incisions a wire was used as a stencil (Tennison 1952).

1844 In correspondence with Malgaigne, Germanicus Mirault from Paris (born in 1796 in Angers, died in 1879 in Angers) enhanced the technique of his colleague and introduced the triangular flap into cleft lip closure. He inserted a triangular

1959 Peter Randall from the University of Pennsylvania rendered the measurements of Tennison’s technique by geometrical principles more precisely and reduced the size of the triangular flap (Fig. 1.8) (Randall 1959).

1.2 History and Development

5

1.2.3 Rotation-Advancement Technique 1955 David Ralph Millard, Jr. (born in St. Louis, Missouri, in 1919, died in Aventura, Florida, in 2011) finished medical studies at Harvard Medical school in 1944. During his surgical training he was influenced and shaped in England by the famous plastic surgeon Sir Harold Gillies and the cleft and plastic surgeon Thomas Pomfret Kilner. Millard spent most time of his residency in his hometown St. Louis. He completed his training as a plastic surgeon in 1951. Afterwards Millard collaborated with Gillies again and became co-­author of “The Principles and Art of Plastic Surgery.” In the early 1950s he served as a plastic surgeon in the Korean War, where he was inspired to a new technique of cleft lip closure by Korean children. In a Mobile Army Surgical Hospital (MASH) unit he performed his first cleft lip repair on a 10-year-old Korean boy with the rotation-advancement procedure, which he presented at the first Congress of the International Society of Plastic Surgeons in Stockholm in 1955. Hereby, the rotation flap is located on the medial (non-­cleft) side, whereas the advancement flap is placed on the lateral (cleft) side (Fig. 1.9). In 1968 Millard modified his technique especially for broad clefts to Millard II.  As a first step the transverse advancement incision was extended more laterally to mobilize the ala into medial direc-

Fig. 1.9  Incisions for unilateral lip plasty: Millard I technique

Fig. 1.10  Incisions for unilateral lip plasty: Millard II technique

tion. As a second step a backcut was added to the cranial part of the rotation flap to allow more rotation (Fig. 1.10) (Marcus et al. 2017; Wolfe et al. 2012).

1.2.4 Wave-Line Technique 1970 Besides the triangular and shallow-curved (rotation-­ advancement) techniques, Gerhard Pfeifer from Hamburg (born in 1921  in Satzung, Saxonia, died in 2003  in Hamburg) created a third principle of cleft lip repair between 1965 and 1968: the wave-line procedure. Knowing that tissue lengthening between two points can be achieved by joining the points in a curved and not in a straight manner, the height and length of the lip on the medial side is determined by using a flexible wire. The more length has to be gained the more waves have to be incorporated in the incisions on both non-cleft side and cleft side (Fig.  1.11). Regarding the aesthetic aspect the patients benefit from vertical scars on the philtrum columns. This is in strong contrast to triangular techniques which suffer from horizontal scars crossing the aesthetic lines (Pfeifer 1970a; Pfeifer 1970b; Höltje and Ehmann 1973; Schmelzle 2003).

6

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

Fig. 1.11  Incision for unilateral lip plasty after Pfeifer

Fig. 1.13  Incision for unilateral lip plasty in “broken-line” technique

Fig. 1.12  Incision for unilateral lip plasty in Afroze technique

Fig. 1.14  Noordhoff vermilion plasty

1.2.5 Hybrid Techniques

1.2.6 Incorporation of Valuable Modifications to the Basic Techniques

2009 To get the best out of both techniques—rotation and wave-­ line incision—an Indian-Dutch group suggested a ­composition. The so-called Afroze procedure combines a rotation flap on the medial (non-cleft) side with a wave-line incision on the lateral (cleft) side. The cranial peak of the wave is positioned into the triangular defect resulting from the rotation at the base of the columella (Fig. 1.12) (Reddy et  al. 2009; Gosla Reddy et  al. 2010; Gosla-Reddy et  al. 2011). 2019 A South African group introduced another hybrid technique by combining a more wave-line technique (“curvilinear incision,” “broken-line”) on the non-cleft side (philtral column) with an advancement technique on the cleft side (Fig. 1.13) (Madaree 2019).

1984 Samuel Noordhoff (born in Orange City, Iowa, in 1927, died in Grand Rapids, Michigan, in 2018) received his medical degree at the University of Iowa and trained as a general surgeon in Grand Rapids, Michigan. In 1959 he had the opportunity to serve as a missionary surgeon in Taiwan and emigrated together with his family. Facing poor conditions in Taiwan he built up several medical programs besides surgical ones. With Noordhoff as superintendent the now-legendary Chang Gung Memorial Hospital opened in 1976 (Salyer 2019). To overcome a whistle deformity, he contributed a vermilion plasty to cleft lip repair. Noordhoff placed a triangular flap from the excess vermilion of the lateral labial element (cleft side) as an inset into the vermilion of the non-cleft side just above the wet-dry line (Fig.  1.14) (Noordhoff 1984).

1.3 Relevant Anatomy for Unilateral Cleft Lip Plasty

7

Fig. 1.15  Mohler incision onto the columella

1987 Lester Mohler was a plastic surgeon who practiced from 1970 to 1996 in Columbus, Ohio. He placed the cranial backcut of the non-cleft side onto the columella (Fig. 1.15). By this technique he avoids a scar across the upper lip (Mohler 1987; Flores and Cutting 2016).

Fig. 1.16  White roll (in white) and wet-dry vermilion line (gray-­ dotted) as landmarks for incisions, e.g. Noordhoff vermilion plasty

1.3 Relevant Anatomy for Unilateral Cleft Lip Plasty

1.3.3 Relevant Anatomy for Newly Developed Hybrid Technique

1.3.1 Applied Anatomy

In the last few years, our working group has developed a modification of the Millard II technique. A hybrid technique was introduced to compensate for the disadvantages of classical rotation advancement, especially in the case of broad unilateral clefts. The rotation flap on the non-cleft side, which ist often too short is lengthened by an “inverted v-­incision,” which extends aesthetically favorable into the columella. On the cleft side, the vertical component of the advancement flap is performed as a wave cut. With these two maneuvers—cleft-sided and non-cleft-sided—an extension of the cleft-­sided philtral column is achieved. The previously often used triangular flap plasty cranial to the white roll, which causes a horizontal scar directed 90° to the philtral column (Fig.  1.35), is thus avoided (Marcus et  al. 2017; Zhou and Xie 1987). By extending the rotational flap into the lower third of the columella, access to the nasal septum is facilitated via the “inverted v-incision.” The perichondral correction of the septum, which is strongly deviated in broad clefts, is thus easily possible (Figs. 1.19 and 1.20).

For the surgical procedure, the anatomical landmarks described in Fig. 1.4 and Fig. 1.16 are projected onto the unilateral cleft deformity (Fig.  1.17) and doing so, form the basis for the corresponding incisions. The experience of the authors led to the use of the Millard II procedure for narrow cleft lips and to the use of a newly developed hybrid technique for broad cleft lips.

1.3.2 Relevant Anatomy for Millard II Technique In the following, the anatomy important for the Millard II technique is explained using the example of an incomplete cleft lip. The individual incisions and subtechniques are highlighted in different colors (Fig. 1.18).

8

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

Fig. 1.17  Anatomical landmarks for unilateral lip repair in a cleft baby. The red dot indicates the most cranial point of the columella. The green dots mark the superior points of the philtral columns, which are

the transition points of the philtrum columns to the columella. The dark blue dots mark the left and the right peak of cupid’s bow, whereas the light blue dot marks the central inferior point of cupid’s bow

Fig. 1.18  Incision lines related to the anatomic landmarks and skin flaps for Millard II technique: the rotation flap on the non-cleft side (yellow) with backcut (white) and the columella or “C”-flap (pink) are

indicated. The advancement flap on the cleft side (green) is shown and the horizontal cut and the triangular flap of the Noordhoff plasty are marked (gray)

1.3 Relevant Anatomy for Unilateral Cleft Lip Plasty

9

Fig. 1.19  Anatomic landmarks constructed for the newly developed hybrid technique. The planned “inverted-v-incision” ends in the lower third of the columella as indicated by the black dot on the red line. The distance from the central inferior point to the right cupid’s bow is equal to the left cupid’s bow as indicated by dark blue arrows. The distance from the cupid’s bows to the modiolus is the same on both sides as indicated by yellow arrows. This is helpful to find the virtual peak of the

cupid’s bow (Noordhoff’s point) on the cleft side (blue-and-white dotted). Noordhoff’s point can also be found at the point where the lip red is most pronounced and the white roll is most prominent. The dark blue dots mark the left and right peak of the cupid’s bow, whereas the light blue dot marks the central inferior point of the cupid’s bow. The green dots and the green line mark the columellar base through the highest points of both of the philtral columns

Fig. 1.20  Incision lines and skin flaps for the newly developed hybrid technique: the rotation flap (yellow) with the backcut to the philtral column on the non-cleft side (white) is supplemented by an “invertedv-­incision” (black) at the columella that allows better access to the nasal septum. In addition, the rotation flap is extended through the “inverted-­v-­incision.” The columella or “C”-flap (pink) is marked. This lengthening of the philtrum on the non-cleft side is supported by a ver-

tical wave-shaped cut (turquoise) of the advancement flap (green) on the cleft side. The insertion of an additional aesthetically unfavorable triangular flap plasty cranial to the white roll can thus be avoided. The dark blue dots mark the left and right peak of the cupid’s bow, whereas the light blue dot marks the central inferior point of the cupid’s bow. The blue-and-white dot marks the virtual point of the left peak of the cupid’s bow on the cleft side (Noordhoff’s point)

10

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

1.4 An ex vivo Model for Unilateral Lip Plasty 1.4.1 Development of the Model The simulation of surgical interventions and the direct implementation of surgical innovations are prohibited in patients. Preclinical models have therefore become established in research, as well as in teaching. For cleft surgery, however, only relatively expensive silicone-based models are currently available (Ueda et al. 2017; Ueda et al. 2019; Rogers-Vizena et al. 2018; Kantar et al. 2019). Therefore, a simple model based on an ex vivo pig’s snout was developed by the authors. A unilateral cleft lip was transferred to a clear-view template at a scale of 2:1. Using this template, the deformity could be transferred to the pig’s snout. The nostrils of the pig snout served as reference points for the nostrils of the cleft patient. The anatomical landmarks could be transferred seamlessly. In the following, the respective surgical method can be a

marked with further stencils to be made. In this way, the incision technique can be either standardized or individualized as desired. A color contrast of the vermilion is also possible on the model. The tissue texture of the ex vivo model with the muscle in it provides the surgeon with a feel for the fabric (Figs. 1.21 and 1.22).

1.4.2 Simulation of a Millard II Lip Plasty on the Cleft Lip Model In the following, the closure of a unilateral cleft lip on the ex vivo model is presented. Lip closure is demonstrated in a step-by-step manner. A Millard II plasty is performed which is modified by a triangular flap insertion above the white roll to lengthen the philtral column. In order to balance the volume of the vermilion a Noordhoff plasty is added (Figs. 1.23, 1.24, 1.25, 1.26, 1.27, 1.28, 1.29, 1.30, 1.31, 1.32, 1.33, 1.34, 1.35).

b

d

c

f

Fig. 1.21  Design of stencils for later transfer to the ex vivo model. (a, b) measurements on the philtral column to define the size ratio of the model; (c–g) selection of different unilateral cleft lip configurations; (h–l) print of the various unilateral cleft lip configurations on a scale of

e

g

2:1, color-coded tracing of the lip and nose region to a transparent plastic sheet; (m)–(q) transparent plastic sheets serving as stencils for later transfer to a swine snout

1.4 An ex vivo Model for Unilateral Lip Plasty

h

11

i

k

l

m

n

p

Fig. 1.21 (continued)

j

o

q

12

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

a

b

c

d

e

f

g

h

Fig. 1.22  Swine snout serving as an ex vivo model for unilateral cleft lip plasty. Manufacturing of the surgical simulation model. (a) Swine snout; (b) plastic template transferred from a patient case with anatomic landmarks of a possible unilateral cleft lip configuration; (c) drilling holes at the template allows transfer of the anatomical landmarks to the swine snout; (d) color-coded marking of anatomic land-

marks (philtral column points and most cranial point of the columella) on the swine snout model compared to Fig. 1.17; (e) lip vermilion is marked; (f) cleft area is marked; (g) cleft area is cut out up to the level of the muscles; (h) cleft area is completely excised, ex vivo model is prepared for surgical simulation

1.4 An ex vivo Model for Unilateral Lip Plasty

13

Fig. 1.23  Right and left peak (α) as well as central inferior point of cupid’s bow (β) are marked. Corresponding point of the left peak (Noordhoff’s point) is also marked on the contralateral side (α1).

a

Superior points of philtral column (γ) and most superior point of the columella (δ) marked as well. See also Fig. 1.17

b

Fig. 1.24  Modified Millard II technique. (a) Schematic illustration of modified Millard II technique with plasty for vertical deficit compensation at white roll and Noordhoff vermilion plasty. (b) First incisions on the simulation model: Subnasal rotation flap (α) with backcut (β) in the area of ​​the non-cleft philtrum, incision for columella (C)-flap (γ) is blue-marked, cleft-sided advancement flap with subnasal extension (δ).

Additionally, a Noordhoff vermilion plasty with horizontal cut (ε) on the non-cleft side and triangular flap (π) on the cleft side is marked. For compensation of the vertical deficit of the left philtral column a horizontal incision (green) 1 mm cranial to the vermilion (Σ) is made and a triangular flap resulting after excision of the green-marked tissue from the cleft side (Ω) is inserted

14

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

Fig. 1.25  Excess vermilion is removed. Rotation flap, C-flap, advancement flap, and vermilion plasty are cut around

Fig. 1.28  Noordhoff vermilion plasty is to be performed

Fig. 1.26  Preparation of the muscle on both cleft sides—comparable to the orbicularis oris muscle—is simulated. Suture with absorbable material of size 4–0 (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany)

Fig. 1.29  Vermilion plasty and construction of the left peak of cupid’s bow (α) is done

Fig. 1.27  Muscle plasty is performed

Fig. 1.30  C-flap is rotated by 90° (α), inserted subnasally and fixed under the columella. Suture with non-resorbable, monofilament polyamide of size 4–0 (Seralon® 4–0, Serag-Wiessner, Naila, Germany, or Ethilon® 4–0, Ethicon, Norderstedt, Germany)

1.4 An ex vivo Model for Unilateral Lip Plasty

15

Fig. 1.31  Nasal floor (α) is closed

Fig. 1.34  The triangular flap is inserted into the horizontal incision of the cleft side. Suture with non-resorbable, monofilament polyamide of size 4–0

Fig. 1.32  The advancement flap is extended medially (α) and sutured on the columellar base

Fig. 1.35  Lip closure is finished

Fig. 1.33  Alar base of the cleft side is positioned and sutured (α). Suture with non-resorbable, monofilament material of size 4–0. Closure of the cleft-sided philtral column is started. A vertical disharmony between the philtral columns becomes visible. For correction and lengthening of the cleft-sided philtral column a horizontal incision approximately 1 mm cranial to the vermilion is done (β); a triangular flap obtained on the cleft side is marked (γ), see also green markings of Fig. 1.24

16

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

1.5 Patient Cases 1.5.1 Technique of Millard II Lip Plasty in an Incomplete Unilateral Cleft Lip In the current case an incomplete unilateral cleft lip is presented. Lip closure is therefore performed by a Millard II plasty, which is modified by a triangular flap insertion above the white roll to lengthen the philtral column. In order to balance the volume of the vermilion a Noordhoff plasty is added (Figs.  1.36, 1.37, 1.38, 1.39, 1.40, 1.41, 1.42, 1.43, 1.44, 1.45, 1.46, 1.47, 1.48, 1.49, 1.50, 1.51, 1.52, 1.53, and 1.54) (Marcus et al. 2017; Noordhoff 1984; Zhou and Xie 1987).

Fig. 1.38  Right and left peak, as well as central inferior point of cupid’s bow marked. Corresponding point of the left peak (Noordhoff’s point) is also marked on the contralateral side. See also Fig. 1.17

Fig. 1.36  Schematic illustration of modified Millard II technique with triangular flap insertion above the white roll and Noordhoff vermilion plasty

Fig. 1.39  Incision line for a Millard II procedure is marked: Subnasal rotation flap (α) with backcut (β) in the area of the ​​ non-cleft philtrum, columella (C)-flap (γ), cleft-sided advancement flap with subnasal extension (δ)

Fig. 1.37  Incomplete left-sided cleft lip after intubation

1.5 Patient Cases

Fig. 1.40  Injection of local anesthetic with adrenaline 1:100.000 (UDS forte, Sanofi, Frankfurt am Main, Germany). Recommended is a dose of 0.15 ml (6 mg)/kg body weight, for example 1.5 ml for 10 kg body weight

Fig. 1.41  Marking is continued into the vestibule: at the beginning a Noordhoff vermilion flap is planned along the wet-dry line with triangular flap on the cleft side (α) and horizontal incision on the non-cleft side (β) as compensation for the volume of the vermilion; subsequently vertical incisions on both sides to the fold of the vestibule are made (γ); the frenulum is cut on the non-cleft side (δ); a horizontal incision on the cleft side is made in the buccal mucosa at a distance of and 3 mm from the gum (ε); as distal endpoint a vertical cranially orientated backcut is performed (indicated by arrow and Ω)

17

Fig. 1.43  Excision of the cleft area in the vermilion/vestibule with retention of approximately 3 mm of buccal mucosa

Fig. 1.44  Cleft area completely excised

Fig. 1.45  The orbicularis oris muscle at the cleft side is dissected; at the non-cleft side, the muscle is only dissected up to the middle of the philtrum in order to avoid flattening the philtrum Fig. 1.42  The marked line is cut with a diamond knife

18

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

Fig. 1.46  After having prepared the buccal mucosa on the cleft side: “Vestibuloplasty” in order to create a neo-vestibule with absorbable polyglactin sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany)

Fig. 1.49  The C-flap is fixed under the columella to support the columella, suture with monofilament resorbable material of size 6–0 (Maxon® 6–0, Medtronic, Meerbusch, Germany)

Fig. 1.47  Muscle suture of the orbicularis oris muscle with four to five absorbable sutures of size 4–0

Fig. 1.50  Vertical disharmony of the philtral column base, the cranialization of the philtral column at cleft side in the area of ​​the white roll is visible by about 4 mm

Fig. 1.48  Soft tissue situation after suturing the muscle

Fig. 1.51  A horizontal incision in the area of the ​​ white roll parallel to the white roll is done—approximately 1 mm cranial to the white roll at the non-cleft side; a triangular flap obtained on the cleft side is moved into the horizontal incision to lengthen the philtral column

1.5 Patient Cases

Fig. 1.52  Situation before insertion of the triangular flap into the horizontal incision

Fig. 1.53  Vermillion border at cleft side is successfully vertically lengthened and slightly overcorrected; the vermillion volume is compensated by inserting a triangular flap from the cleft side into the non-­ cleft side (Noordhoff vermilion plasty)

19

Fig. 1.54  14 days after surgery with residual parts of absorbable suture material

20

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

1.5.2 Newly Developed Hybrid Technique of Lip Plasty in a Broad Unilateral Cleft Lip The present case shows a broad unilateral cleft lip associated with a cleft palate. Especially the wide cleft lips are closed by the team of authors using the newly developed hybrid technique. The step-by-step procedure in this regard is illustrated below (Figs. 1.55, 1.52, 1.53, 1.54, 1.55, 1.56, 1.57, 1.58, 1.59, 1.60, 1.61, 1.62, 1.63, 1.64, 1.65, 1.66, 1.67, 1.68, 1.69, 1.70, 1.71, 1.72, 1.73, 1.74, 1.75, 1.76, 1.77, 1.78, 1.79, 1.80, 1.81, 1.82, 1.83, 1.84, 1.85, 1.86, 1.87, 1.88, 1.89, 1.90, 1.91, 1.92, 1.93, 1.94, 1.95, 1.96, 1.97, 1.98, 1.99, 1.100, 1.101, 1.102, and 1.103).

Fig. 1.57  Complete left-sided cleft lip after intubation. View from below

Fig. 1.55  Schematic drawing of incisions of newly developed hybrid technique. Modified Rotation/Mohler flap on non-cleft side with “inverted-v-incision” at the columella. Modified advancement flap with vertical wave cut on cleft side. Noordhoff vermilion plasty

Fig. 1.58  Right and left peak as well as central inferior point of cupid’s bow marked

Fig. 1.56  Complete left-sided cleft lip after intubation

1.5 Patient Cases

21

Fig. 1.59  Distance between right peak of cupid’s bow and lip commissure is marked. The distance is mirrored to the cleft side to find the virtual peak of cupid’s bow on the cleft side (Noordhoff’s point). At this point, the “white roll” is pronounced most and the lip vermilion is the most voluminous (α)

Fig. 1.62  Superior points of right (α) and left (α) philtral column (transition points of philtral column to columella) are marked

Fig. 1.60  Construction of the virtual peak of cupid’s bow (Noordhoff’s point) on the cleft side (α)

Fig. 1.63  Measurement of philtral column length on the non-cleft side

Fig. 1.61  Virtual peak of cupid’s bow marked on the cleft side (α)

Fig. 1.64  Measurement of philtral column length on the cleft side to show the difference

22

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

Fig. 1.65  Most cranial point of the columella is marked (α)

Fig. 1.68  The incision line at the cleft side is marked: advancement flap with wave-liked shape (α) to the peak of cupid’s bow and with subnasal extension (β) in cranio-lateral direction

Fig. 1.66  Most cranial point of the “inverted-v-incision” is marked (α) at the columella. It is located at the lower third of the columella

Fig. 1.69  In order to be able to form the floor of the nose later, a horizontal incision (α) is made from the endpoint of the C-flap into the transition zone between oral and nasal mucosa/skin

Fig. 1.67  Incision of newly developed hybrid technique is marked at the non-cleft side: rotation flap with “inverted-v-incision” at the columella (α) and backcut (β) at the non-cleft philtral column. C-flap (γ) running to the nose

Fig. 1.70  A corresponding horizontal incision (α) to form the nasal floor is planned on the cleft side starting from the peak of the advancement flap

1.5 Patient Cases

23

Fig. 1.71  Noordhoff vermilion plasty with triangular flap (α) on the cleft side and horizontal cut (β) on the non-cleft side is designed. The horizontal cut and the peak of the triangular flap are located at the wet-­ dry line of the vermilion. The horizontal cut is extended to the midpoint of the lip

Fig. 1.74  Injection of local anesthetic with adrenaline 1:100.000 (UDS forte, Sanofi, Frankfurt am Main, Germany). Recommended is a dose of 0.15 ml (6 mg)/kg body weight, for example 1.5 ml for 10 kg body weight

Fig. 1.72  Horizontal incision in the vestibule of the cleft side (α) with retention of approximately 3 mm of buccal mucosa

Fig. 1.75  Cut the marked lines with a diamond knife

Fig. 1.73  Left-sided peak of cupid’s bow is tattooed with methylene blue on cleft and non-cleft side

Fig. 1.76  After pre-cutting with the diamond knife, the lines are cut with scalpel no. 11

24

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

Fig. 1.77  Excision of the cleft area in the vermilion/vestibule

Fig. 1.80  Buccal mucosa is prepared for “vestibuloplasty” on the cleft side

Fig. 1.78  Cleft area completely excised

Fig. 1.81  Orbicularis oris muscle is dissected at the cleft side

Fig. 1.79  Buccal mucosa on the cleft side is prepared and separated from the orbicularis oris muscle

Fig. 1.82  Levator labii superioris alaeque nasi muscle is prepared

1.5 Patient Cases

25

Fig. 1.83  Epiperiosteal blunt dissection of adjacent and aberrantly inserting tissue (muscle and fascia) in the infraorbital region on the cleft side Fig. 1.86  Blunt epichondral dissection of the nasal septum for re-­ orientation. This move is made possible via the “inverted-v-incision” at the columella

Fig. 1.84  The frenulum and parts of attached gingiva in the cleft region are cut on the non-cleft side, saving a retention of approximately 3 mm of buccal mucosa

Fig. 1.85  Orbicularis oris muscle is dissected at the non-cleft side. The muscle is only dissected up to the middle of the philtrum in order to avoid flattening the philtrum

Fig. 1.87  Nasal septum is straightened up

26

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

Fig. 1.88  First key suture for vestibuloplasty Fig. 1.91  Distal key suture for nasal floor construction with absorbable polyglactin sutures of size 4–0

Fig. 1.89  Vestibuloplasty with absorbable polyglactin sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany)

Fig. 1.90  Incision of the nasal vestibule according to 1.69 and 1.70

Fig. 1.92  Approximation of the levator labii superioris alaeque nasi muscle to the orbicularis oris muscle with absorbable polyglactin sutures of size 4–0

1.5 Patient Cases

27

Fig. 1.96  Noordhoff vermilion plasty is carried out

Fig. 1.93  Approximation of the levator labii superioris alaeque nasi muscle to the orbicularis oris muscle, cleft-sided skin is kept away and shows rotational movement of the alar base

Fig. 1.97  C-Flap is fixed under the columella. Nasal floor is closed

Fig. 1.94  Muscle suture of the orbicularis oris muscle with four to five absorbable polyglactin sutures of size 4–0

Fig. 1.98  Look inside vestibule Fig. 1.95  The columella is closed primarily with non-resorbable polyamide suture (Ethilon® 6–0 Ethicon, Norderstedt, Germany, or Seralon® 6–0, Serag-Wiessner, Naila, Germany). Titanium-covered polyamide suture as alternative material is also recommended (Seratan® 6–0, Serag-Wiessner, Naila, Germany). A key suture is made at the vermilion border/left peak of cupid’s bow

28

1  Primary Surgery of the Unilateral Cleft Lip: Unilateral Cleft Lip Plasty

Fig. 1.99  Excess tissue is excised

Fig. 1.102  Two weeks postoperatively

Fig. 1.100  Philtral column sutured. Final situation Fig. 1.103  Two weeks postoperatively. Detailed view of the nose and lip region

Fig. 1.101  The feeding tube is inserted and is left in place for 7 days. Polyamide sutures have to be removed after 7 days, titanium-covered sutures after 5 days

References

References Marcus JR, Allori AC, Santiago PE.  Principles of Cleft Lip Repair: Conventions, Commonalities, and Controversies. Plast Reconstr Surg. 2017;139:764e-780e. doi: https://doi.org/10.1097/ PRS.0000000000003148. Campbell A, Costello BJ, Ruiz RL.  Cleft lip and palate surgery: an update of clinical outcomes for primary repair. Oral Maxillofac Surg Clin North Am. 2010;22:43-58. doi: https://doi.org/10.1016/j. coms.2009.11.003. Pfeifer G. Über ein entwicklungsgeschichtlich begründetes Verfahren des Verschlusses von Lippenspalten [An embryologically founded method for the repair of cleft lips]. Dtsch Zahn Mund Kieferheilkd Zentralbl Gesamte. 1970a;54(1):69-77. Pfeifer G.  Lippenkorrekturen nach früheren Spaltenoperationen mit dem Wellenschnittverfahren [Lip corrections following earlier cleft surgery by way of wave-line incisions]. Dtsch Zahnarztl Z. 1970b;25(5):569-76. Höltje WJ, Ehmann G. Wave-line procedure in the repair of cleft lip. J Maxillofac Surg. 1973;1:198-202. doi: https://doi.org/10.1016/ s0301-­0503(73)80041-­4. Reddy GS, Reddy RR, Pagaria N, Berge S. Afroze incision for functional cheiloseptoplasty. J Craniofac Surg. 2009;20 Suppl 2:1733-6. doi: https://doi.org/10.1097/SCS.0b013e3181b73ad3. Gosla Reddy S, Reddy RR, Bronkhorst EM, Prasad R, Kuijpers Jagtman AM, Bergé S. Comparison of three incisions to repair complete unilateral cleft lip. Plast Reconstr Surg. 2010;125:1208-1216. doi: https://doi.org/10.1097/PRS.0b013e3181d45143. Gosla-Reddy S, Nagy K, Mommaerts MY, Reddy RR, Bronkhorst EM, Prasad R, Kuijpers-Jagtman AM, Bergé SJ.  Primary septoplasty in the repair of unilateral complete cleft lip and palate. Plast Reconstr Surg. 2011;127:761-767. doi: https://doi.org/10.1097/ PRS.0b013e318200a97a. Madaree A.  Symmetric Philtral Column Repair for Unilateral Cleft Lip. Plast Reconstr Surg. 2019;143:1147-1153. doi: https://doi. org/10.1097/PRS.0000000000005475. Millard DR. Cleft Craft: The Evolution of Its Surgery; Volume I. The Unilateral Deformity. Boston, MA: Little, Brown & Co; 1976. Burt JD, Byrd HS.  Cleft lip: unilateral primary deformities. Plast Reconstr Surg. 2000105:1043-55; quiz 1056-7. doi: https://doi. org/10.1097/00006534-­200003000-­00032. Wong KC, Wu LT.  History of Chinese medicine: being a chronicle of medical happenings in China from ancient times to the present period. Tientsin: Tientsin Press, Ltd.; 1932. Randall P, Jackson OA.  Part VIII primary cleft lip and palate repair. Chapter 39: A history of cleft lip and cleft palate surgery. In: Losee JE, Kirschner RE, editors. Comprehensive cleft care, 2. 2nd ed. Stuttgart: Thieme; 2016. Prioreschi P.  A History of Medicine: Vol. V  - Medieval medicine. Omaha, NE: Horatius Press; 1996. Vrebos J.  Jehan Yperman, medieval cleft lip surgeon. Plast Reconstr Surg. 1982;70:762-5. doi: https://doi. org/10.1097/00006534-­198212000-­00023. von Pfolsprundt H. Buch der Bündth-Ertznei. In: Haeser H, Middeldorpf A, editors. Reprint. Berlin: Verlag von Georg Reimer; 1868. Richter C. Phytopharmaka und Pharmazeutika in Heinrich von Pfalzpaints Wündärznei (1460). Untersuchungen zur traumatologischen Pharmakobotanik im Mittelalter. Dissertation zur Erlangung

29 des naturwissenschaftlichen Doktorgrades der Bayerischen JuliusMaximilians-Universität Würzburg; 2003. https://opus.bibliothek.uni-wuerzburg.de/opus4-wuerzburg/frontdoor/deliver/index/ docId/620/file/Pfalzpaint_aktuell.pdf. Accessed 4 Jan 2023. Greig A, Gohritz A, Geishauser M, Mühlbauer W.  Heinrich von Pfalzpaint, Pioneer of Arm Flap Nasal Reconstruction in 1460, More Than a Century Before Tagliacozzi. J Craniofac Surg. 2015;26:1165-­ 8. doi: https://doi.org/10.1097/SCS.0000000000001625. Williams AN, Williams J. 'Proper to the duty of a chirurgeon': Ambroise Pare and sixteenth century paediatric surgery. J R Soc Med. 2004;97:446-9. doi: https://doi.org/10.1177/014107680409700916. Malgaigne JF. Du bec-de-lièvre. J de Chir de Paris. 1844;2:1-6. Mirault G. Deux lettres sur l’operation du bec-de-lièvre. J de Chir de Paris. 1844;2:257. Tennison CW The repair of the unilateral cleft lip by the stencil method. Plast Reconstr Surg. 1952;9:115-20. https://doi. org/10.1097/00006534-195202000-00005. Randall P. A triangular flap operation for the primary repair of unilateral clefts of the lip. Plast Reconstr Surg Transplant Bull. 1959;23:331-­ 47. doi: https://doi.org/10.1097/00006534-­195904000-­00003. Wolfe SA.  D Ralph Millard, Jr., M.D., 1919 to 2011. Plast Reconstr Surg. 2012;129:1214-7. doi: https://doi.org/10.1097/ prs.0b013e31824a2e83. Schmelzle R.  Zum Tode von Prof. Dr. Dr. Dr. h.c. Gerhard Pfeifer. Journal DGPW 2003; 28:8-9. Salyer KE.  M Samuel Noordhoff, 1927 to 2018: True Pioneer in the Old World. J Craniofac Surg. 2019;30:963-4. doi: https://doi. org/10.1097/SCS.0000000000005451. Noordhoff MS.  Reconstruction of vermilion in unilateral and bilateral cleft lips. Plast Reconstr Surg. 1984;73:52-61. doi: https://doi. org/10.1097/00006534-­198401000-­00011. Mohler LR. Unilateral cleft lip repair. Plast Reconstr Surg. 1987;80:511-­ 7. doi: https://doi.org/10.1097/00006534-­198710000-­00005. Flores RL, Cutting CB. Part VIII Primary Cleft Lip and Palate Repair. Chapter 44 Extended Mohler Unilateral Cleft Lip Repair. In: Losee JE, Kirschner RE, editors. Comprehensive Cleft Care, Volume 2. 2nd ed. Stuttgart: Thieme; 2016. Zhou ML, Xie DC. [Advanced rotation flap combined with a small triangular flap to repair unilateral cleft lip (report of 16 cases)]. Zhonghua Zheng Xing Shao Shang Wai Ke Za Zhi. 1987;3:193-4, 238. Ueda K, Shigemura Y, Otsuki Y, Fuse A, Mitsuno D. Three-Dimensional Computer-Assisted Two-Layer Elastic Models of the Face. Plast Reconstr Surg. 2017;140:983-6. doi: https://doi.org/10.1097/ PRS.0000000000003764. Ueda K, Hirota Y, Mitsuno D, Okamoto T, Kino H. 3D 2-layer Elastic Models for Cleft Lip Rhinoplasty Made from 3D Camera. Plast Reconstr Surg Glob Open. 2019;7:e1917. doi: https://doi. org/10.1097/GOX.0000000000001917. Rogers-Vizena CR, Saldanha FYL, Hosmer AL, Weinstock PH.  A New Paradigm in Cleft Lip Procedural Excellence: Creation and Preliminary Digital Validation of a Lifelike Simulator. Plast Reconstr Surg. 2018;142:1300-4. doi: https://doi.org/10.1097/ PRS.0000000000004924. Kantar RS, Alfonso AR, Ramly EP, Diaz-Siso JR, Breugem CC, Flores RL.  Simulation in Cleft Surgery. Plast Reconstr Surg Glob Open. 2019;7:e2438. doi: https://doi.org/10.1097/ GOX.0000000000002438.

2

Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

Normal lip development takes place between the fourth and eighth week of pregnancy (Monson et al. 2013; Fajardo et al. 2022). The absence of fusion of the two maxillary processes with the middle nasal process results in a bilateral cleft lip. Bilateral clefts account for only about a ninth to a third of all cleft lips (Monson et al. 2013; Conway et al. 2015; Eshete et  al. 2017; Fijałkowska and Antoszewski 2019; Gundlach and Maus 2006). There are complete as well as incomplete bilateral cleft lips. In the case of a complete bilateral cleft formation, the intermaxillary segment often protrudes far into the cleft formation. The bilateral cleft lip can be symmetrical or asymmetrical. In the case of an unevenly pronounced cleft lip, the intermaxillary segment often deviates to the less pronounced cleft side. In complete clefts the orbicularis oris muscle is completely disrupted and the prolabium is devoid of muscle. In incomplete clefts, muscle fibers may radiate into the area of the prolabium. A cleft lip plasty is usually performed between the third and fifth month of life. The goals of the procedure are similar to the ones of a unilateral cleft (Monson et al. 2013): Create an intact orbicularis oris muscle. Create a harmonic and symmetric philtrum/upper lip, because differences will be aggravated with growth. Create an upper labial sulcus. Reposition the displaced lower lateral cartilages. Reconstruct the median tubercle with the lateral labial segment, as the prolabium lacks white roll and normal coloring. Reconstruct the nostril floor. Create scars as invisible as possible, respectively position them in the areas of the philtral column. In cleft surgery, bilateral cleft lip is the greatest surgical challenge, and the performance of lip construction is considered the most difficult task (Allori and Marcus 2014). One of the main problems with bilateral cleft lip and palate is the

strongly protruding premaxilla. This is due to the lack of sphincter function of the orbicularis oris muscle, which cannot act as a balancing force with a dorsally directed vector. A highly protruded premaxilla carries a high risk of wound dehiscence, as tension-free wound closure is difficult to achieve in these cases. The resection of the premaxilla by early bilateral cleft surgeons was quickly abandoned, as the disadvantages of underdevelopment of the midface, collapse of the lateral maxillary segments, growth disturbances of the prolabium and pseudoprognathia of the mandible outweighed the advantages of an easier surgical option by far. As early as the seventeenth century, methods were developed to move the protruded premaxilla dorsally, with gentler techniques such as dentofacial orthopedic therapy. Preoperative orthodontic therapy (nasoalveolar molding (NAM)) with backward rotation of the premaxilla and approximation of the lateral jaw segments and shaping of the nostrils can facilitate surgical cleft closure. Over time, the trend went from two-stage lip closure surgeries to one-stage surgeries. Complicated geometric techniques with triangular (e.g. the Brown-McDowell-Byars approach) and quadrangular (e.g. Hagedorn) flaps were used besides straight-line (e.g. Veau III or Manchester) techniques. In the course of time, these gave way to rotation advancement techniques (e.g., Mulliken or Millard) (Allori and Marcus 2014). Veau III operation is a straight-line closure without elevation of the prolabial skin and correspondingly without any attempt at restoring the continuity of the orbicularis oris. Manchester maintained the prolabial vermilion to create the cupid’s bow and tubercle, but did not construct an intact orbicularis muscle. Veau and Manchester type closures in bilateral cleft lips carry a high risk of postoperative “whistle deformities.” Millard’s and Mulliken’s techniques addressed this problem by elevating the prolabium and creating an intact orbicularis oris muscle in their techniques.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. Kesting et al., A Visual Guide for Cleft Surgeons, https://doi.org/10.1007/978-3-031-33521-1_2

31

32

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

2.1 Relevant Anatomy of the Lip and Nose

stumps were inserted into the prolabium and then pinned together with one needle near the nose and the other at the bottom of the lip. The needles are then sutured together with silk in a figure eight shape (de La Faye 1743).

See Part I Chap. 1.

2.2 History and Development 2.2.1 Ancient Surgery Cleft formation has been known for a very long time and was also known by Plato and in ancient Egypt, which was proven by mummy finds (Randall and Jackson 2016). Also in ancient Greece 700–300 BC, statues were found with detailed depictions of the malformation in relation to the lip, the premaxilla, and the nostrils (Randall and Jackson 2016).

2.2.2 Development of Bilateral Cleft Surgery from the Fifteenth Century As pointed out above, bilateral cleft lip plasty is a complex and difficult operation. Brown et al. wrote back in 1947 that the bilateral cleft lip deformity is twice as difficult to repair, and the results are only half as good (Brown et al. 1947).

2.2.2.1 From the Sacrificed to the Corrected Premaxilla Great challenges often cry out for simple solutions, but simple solutions often have dramatic consequences. This is also the case with bilateral cleft lip. Early surgical procedures used a martial strategy to simplify lip closure—the resection of the protruded premaxilla. 1561 Pierre Franco (1505–1578), a contemporary of Ambroise Paré (1510–1590), described the repair of unilateral and bilateral clefts in his work “Traité des hernies” in a time where surgery was regularly performed by barber-surgeons and wandering cutters (Franco 1561). For a bilateral cleft he proposed to excise the premaxilla to allow better closure of the defect (Fajardo et al. 2022; Millard 1977).

It was not until late as the decision was made to retract the protruded premaxilla before surgery instead of resecting it during the operation. As corrective measures—in addition to “semi-resective” procedures—these essential ones have been described: 1686/1790 The application of extraoral headgear-like appliances to retract the premaxilla was firstly mentioned by Johann Phillipp Hofmann from Heidelberg in 1686 and by Pierre-­ Joseph Desault (1738–1795), the chief surgeon of the Hôtel-­ Dieu in Paris, in 1790 (Millard 1977; Hofmann 1686). 1864 Gustav Simon (1824–1876) from Rostock described bilateral lip adhesion (Fig. 2.1) to push back the protruded premaxilla (Millard 1977; Simon 1868). 1970s An active retraction of the premaxilla by means of an intraorally fixed appliance was jointly developed by Nicholas Georgiade (1918–2001) at Duke University in Durham, North Carolina, and Ralph Latham (1936–2016) of the Dentals Research Center of the University of North Carolina at Chapel Hill in 1975 (Millard 1977; Georgiade and Latham 1975). As a passive orthopedic device, a palatal plate made of compound soft and hard acrylic was presented by a Zurich team (Hotz et  al. 1987; Hotz and Perko 1974). The group around orthodontists and surgeons influenced the positioning

1661 Hendrik van Roonhuyse (1622–1672) from Amsterdam further advised to remove the protruding premaxilla (Millard 1977). He also promoted to perform the operation at a young age of three to four months (Bhattacharya et al. 2009). 1743 Georges de la Faye (1699–1781) of Paris described a similar technique in which, after removing the premaxilla, the lip

Fig. 2.1  Incisions for bilateral lip plasty after Simon

2.3 Current Techniques

and growth of the jaw segments, including the premaxilla, by successively grinding the plate. 1990s The technique of Naso-Alveolar Molding (NAM) was described. Two groups stood out as the first: The New York University team around Barry H. Grayson and Court Cutting and the Buenos Aires group with Ricardo Bennun and Alvaro Alfredo Figueroa (Bennun and Figueroa 2006; Grayson et al. 1993).

2.2.2.2 Prolabium—For Nose or Lip? After solving the problem with the premaxilla, the prolabium is the second construction site. Where to put the prolabium? On the one hand, the prolabium was used in the past to build up the shortened columella and the nose. The upper lip was formed from the lateral segments. The consequences were a volume deficit of the upper lip and a disharmony of the upper and lower lip. In profile, this resulted in a retrusion of the upper lip and the upper jaw. 1941 In the tradition of French surgeons who used the prolabium to lengthen the columella, August Lindemann (1880–1970) from Duesseldorf (Germany) continued this technique and constructed the upper lip from bilateral nasolabial lobes (Lindemann et al. 1941). 1967 Ivo Pitanguy (1926–2018) from Rio de Janeiro even split the prolabium and used the forked flaps for lengthening the columella (Pitanguy and Franco 1967). Initially, D. Ralph Millard (1919–2011) also used the lateral parts of the prolabium as “parking flaps” to use for secondary columella lengthening. He also emphasized the importance of elevating the prolabium and creating a central vermilion from the lateral portions while connecting the orbicularis oris muscle under the prolabium, leading to the current technique.

33

2.3.1 Straight-Line Technique 2.3.1.1 Brown Technique George Van Ingen Brown (1862–1948) from Milwaukee introduced a simple straight-line bilateral lip closure, which included the complete prolabium (Fig. 2.2). 2.3.1.2 Manchester Technique Sir William Manchester was born in 1913 in Waimate, New Zealand. Impressed by the surgical treatment of a scalp injury he had experienced as a boy, he decided to become a surgeon. He studied medicine at the University of Otago, where he graduated in 1937 (Williams 2000). After holding an anatomy lectureship for a year and an appointment as a surgeon at New Plymouth Hospital, he entered war service with the New Zealand Army Medical Corps in 1940 and, after a brief detour to Egypt, was sent on a convoy to England where he had the opportunity to be mentored by Sir Harold Gillies. At the end of 1941 he was sent back to Egypt to set up a plastic surgery unit in Helwan, near Cairo. After two years he was called back to New Zealand and tasked with setting up New Zealand’s first civilian plastic surgery department at Burwood Hospital near Christchurch (Williams 2000). After his discharge from the New Zealand Army in 1946 he returned to England in 1947 where he worked at East Grinstead Hospital and gained the Fellowship of the Royal College of Surgeons in 1949. Afterwards he returned to Auckland to work at Middlemore Hospital as a plastic surgeon. In 1977 he provided the funds to establish the Chair of Plastic and Reconstructive Surgery in the University of Auckland, which was held by him until his retirement in 1979 (Williams 2000). He was awarded a Knight Commander of the Order of the British Empire in 1987 for his services to medicine. Sir William Manchester passed away in Auckland in 2001 at the age of 88 (Williams 2000).

In the following current surgical techniques, the prolabium now functions in its original function as the base of philtrum and lip construction.

2.3 Current Techniques In a survey of North American cleft surgeons 88% of them perform one-stage lip plasty (Tan et  al. 2012). The techniques most commonly used are Millard (38%), Mulliken (26%), and Manchester (12%) (Tan et al. 2012). These three techniques, supplemented by the quadrilateral technique, are described below.

Fig. 2.2  Incisions for bilateral lip plasty after Brown

34

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

Fig. 2.3  Incisions for bilateral lip plasty after Manchester

Fig. 2.4  Incisions for bilateral lip plasty after LeMesurier

The Manchester technique is described as the most common representative of the straight-line techniques (Fig. 2.3). Manchester, unlike his surgical teachers, was convinced that the prolabium was not part of the columella but part of the upper lip. With his technique, he wanted to compensate for the problem of the too narrow upper lip with a high vertical height (Manchester 1965). Manchester maintained the prolabial vermilion to create the cupid’s bow and tubercle, but did not construct an intact orbicularis muscle. In his paper he states that Schultz described the joining of the orbicularis oris muscle behind the prolabium, which he wants to avoid to hinder “unnecessary tension” (Manchester 1965). The orbicularis oris muscle is instead sutured to the subcutaneous tissue of the prolabium (Manchester 1965). He also emphasized the importance of a one-stage approach to bilateral cleft lip surgery. The advantage of this technique is that it creates wider lips compared to the Millard technique. The central problem with the Manchester techniques remains the tissue deficit in the central upper lip, which can later appear as a “whistle deformity.”

2.3.3 Rotation-Advancement Techniques

2.3.2 Quadrangular Flap Technique The German surgeon Werner Hagedorn (1831–1894) from Magdeburg contributed to bilateral cleft surgery in 1884 by proposing a quadrangular flap instead of a triangular flap for vertical construction. He was later the first to perform bilateral lip plasty in one stage (Fajardo et al. 2022). Arthur B.  LeMesurier (1890–1982) adapted Werner Hagedorn’s quadrangular flap from lateral below the prolabium to lengthen the central lip (Fig. 2.4).

2.3.3.1 Mulliken Technique John Butler Mulliken (born 1938) grew up in Edina, a little suburb outside of Minneapolis. He went to Princeton University for undergraduate school and visited Columbia University, College of Physicians and Surgeons where he graduated in 1964. Afterwards he completed his internship and residency at Massachusetts General Hospital, Boston. As a first-year resident he was already performing unilateral cleft lip surgery. His focus at this time was hemangioma surgery and research. After completion of his military service for the US Army in Korea and at Ft. Devens, Massachusetts, he returned to Boston to complete his residency in plastic surgery at Johns Hopkins Hospital in 1974. In 1977 Ralph D. Millard gave a lecture on bilateral clefts in Boston as a visiting professor, where he presented his results in bilateral cleft surgery and concluded his presentation with the remark “We must do better” (Mulliken 2009). The honest testimony of such an accomplished surgeon inspired Mulliken, and he performed his first bilateral cleft lip with a discouraging result (Mulliken 2009). Consequently, he asked himself (wondered) how he could do it better, and according to his own statement, the magic of cleft lip surgery is still with him today (Mulliken 2009). He presented his first paper in 1985 on bilateral cleft lip surgery (Mulliken 1985). After the analysis of drawbacks from patients with operated bilateral clefts he tried to improve the surgical techniques to eliminate the typical “stigmatic cleft look” (Mulliken 1985).

2.4 Relevant Anatomy for Bilateral Cleft Lip Plasty

35

Fig. 2.5  Incisions for bilateral lip plasty after Mulliken

Fig. 2.6  Incisions for bilateral lip plasty after Millard

He emphasized the importance of a united orbicularis oris muscle, adapted the size and configuration of the prolabium, formed the median tuberosity and the mucosal ridge from tissue of the lateral lip (Mulliken 1985). Furthermore, he pointed out the importance of reducing the width of the prolabium, which should be 2 mm wide at the base of the philtral flap and the peaks of the cupid’s bow should measure 4–5 mm (Fig. 2.5). Initially he elevated the prolabium as a trefoil with blood supply from the columella. The central part serves as philtral part, while the lateral parts are banked beneath the alar base flaps (Mulliken 1985). He also pointed out the advantages of a simultaneous/symmetrical repair of bilateral clefts lips and later on eliminated the forked flaps beside the prolabial flap (Mulliken 1995). Mulliken also recognized the importance of presurgical orthopedics in the treatment of cleft lip and the influence of growth patterns on long-term results after bilateral cleft lip surgery and promoted a simultaneous lip plasty and correction of the nasal deformity in bilateral clefts.

asymmetrical bilateral clefts. As also can be seen in Fig. 2.10 there are many different configurations of bilateral cleft lips. Not only do they differ in the protrusion of the premaxilla, but also in the configuration of length and width of the prolabium, the height and the length of the lateral lip segments, and the extension of a gingival sulcus. According to Millard the width of the cupids bow has a length of 6 mm, but varies from 4 to 10 mm (Millard 1977). The height of the prolabium determines the height of the constructed lip.

2.3.3.2 Millard Technique D. Ralph Millard included the prolabium and the lateral lip segments to create the central portion of the lip. Therefore, his technique enables a better appearance of the central part of the upper lip at the cost of a scar at the lower part of the philtrum and a reduced width of the upper lip. Additional parking flaps can be used secondarily to lengthen the columella (Fig.  2.6). The orbicularis oris muscle is united behind the elevated prolabium. He emphasizes the importance of creating a symmetrical situation in

2.4 Relevant Anatomy for Bilateral Cleft Lip Plasty 2.4.1 Applied Anatomy The anatomical landmarks described in Part I (Figs. 1.4 and 1.16) are projected onto the bilateral cleft deformity (Fig. 2.7). They provide the basis for the planned incision. We prefer the use of the Millard technique for bilateral cleft lips.

2.4.2 Relevant Anatomy for Millard Technique This chapter presents the relevant anatomy for bilateral lip closure using the Millard technique. The incision lines are shown in different colors (Figs. 2.8 and 2.9).

36

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

Fig. 2.7  Anatomical landmarks for bilateral lip repair in a cleft baby. The red dot indicates the most cranial point of the columella. The green dots mark the superior points of the philtral columns, which are the

transition points of the philtrum columns to the columella. The dark blue dots mark the left and the right peak of cupid’s bow, whereas the light blue dot marks the central inferior point of cupid’s bow

Fig. 2.8  The distance from the central inferior point to the right cupid’s bow is equal to the left cupid’s bow as indicated by dark blue arrows. The distance from the cupid’s bows to the modiolus is the same on both sides as indicated by yellow arrows. This is helpful in finding the virtual

peak of the cupid’s bow. The dark blue dots mark the left and right peak of the cupid’s bow, whereas the light blue dot marks the central inferior point of the cupid’s bow. The green dots mark the columellar base through the highest points of both philtral columns

2.5 An ex vivo Model for Bilateral Lip Plasty

Fig. 2.9  Incision lines related to the anatomic landmarks and skin flaps for Millard technique. The advancement flap on both sides (green) is shown and the horizontal cuts are marked (gray), starting at the peaks

2.5 An ex vivo Model for Bilateral Lip Plasty

37

of the lateral segments (white dot). The prolabium flap is outlined (brown). An optional “parking flap” (yellow) can be circumcised (dotted brown)

beginners in cleft surgery, on which the individual steps of cleft surgery can be trained, but also to be able to depict all steps of bilateral cleft lip surgery with the ex vivo model as realistically as possible, to also enable the model to be used 2.5.1 Development of the Model to further develop individual techniques. As also displayed in Bilateral cleft lip surgery is even more complex than unilat- the unilateral ex vivo cleft model the clinical situation of a eral cleft surgery. To cite Sir William Manchester: “No patient with a symmetrical bilateral cleft was transferred to a greater problem exists in the whole field of surgery than the clear-view template at a scale of 2:1. By using this template, successful treatment of a patient suffering from complete the clinical situation was transferred to the ex vivo model. As bilateral cleft lip and palate” (Manchester 1965). This puts in the unilateral cleft model, the nasal entrances served as a aspiring cleft surgeons in a dilemma. Anyone attempting to reference and the anatomical landmarks could be transferred operate on a bilateral cleft lip takes on a huge responsibility without any problems. The landmarks for the surgical techwhich, if unsuccessful, will affect the patient for his lifetime nique can also be easily transferred with a stencil, allowing and can only be partially alleviated by secondary procedures. everyone who is using the newly developed ex vivo model to Therefore, preclinical training models are essential to learn reproduce the model and the surgical steps easily with a the basic techniques and skills before performing surgery on ­minimal effort. Due to the high resemblance of the pig’s a patient. The aim was to establish a highly available, cost-­ snout to the upper lip of a human, the model can provide the effective training model for learning bilateral cleft lip sur- surgeon with a high textural fidelity of the tissues of the skin gery on a newly developed model of the bilateral cleft and the muscle tissues. Thus, all steps of a bilateral cleft closurgery on an ex vivo model of the pig’s snout. In addition, it sure can be simulated very close to nature with the model was planned not only to create an ex  vivo model for the (Figs. 2.10 and 2.11).

38

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

a

b

c

d

e

f

g

h

i

j

k

l

m

n

Fig. 2.10  Design of stencils for later transfer to the ex vivo model. (a, b) Measurements on the philtral column to define the size ratio of the model in “Blender” (Blender Foundation, Amsterdam, The Netherlands) after three-dimensional digitalization with an intraoral scanner (Trios 4, 3Shape, Copenhagen, Denmark) of the cleft patient and the pig’s snout. A 1:2 magnification, which was already found for the unilateral cleft,

was confirmed in the three-dimensional evaluation of bilateral clefts; (c–f) selection of different bilateral cleft lip configurations; (g–j) print of the various unilateral cleft lip configurations on a scale of 2:1, color-­ coded tracing of the lip and nose region to a transparent plastic sheet; (k–n) transparent plastic sheets serving as stencils for later transfer to a swine snout

2.5 An ex vivo Model for Bilateral Lip Plasty

39

a

b

c

d

e

f

g

h

Fig. 2.11  Swine snout serving as ex vivo model for bilateral cleft lip plasty. Manufacturing of the surgical simulation model. (a) Swine snout; (b) plastic template transferred from a patient case with anatomic landmarks of a possible bilateral cleft lip configuration; (c) drilling holes at the template allow transfer of the anatomical landmarks to the swine snout; (d) plastic template, which is cut in the cleft area to

transfer the markings to the cleft area; (e) marking of anatomic landmarks (from (c)) and the cleft area (from (d)) and the outline of the lips on the swine snout model compared to Fig.  2.7; (f) lip vermilion is marked in red; (g) cleft area is cut out up to the level of the muscles; (h) cleft area is completely excised, ex vivo model is prepared for surgical simulation

40

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

2.5.2 Simulation of a Millard Lip Plasty on the Bilateral Cleft Lip ex vivo Model This chapter presents the repair of a bilateral cleft lip in the ex  vivo model. All steps of a bilateral cleft lip closure according to Millard can be simulated (Figs.  2.12, 2.13, 2.14, 2.15, 2.16, 2.17, 2.18, 2.19, 2.20, 2.21, 2.22, 2.23, and 2.24).

Fig. 2.12  Right and left peak (α), as well as central inferior point of cupid’s bow (β) are marked. Corresponding points of the lateral lip segments are marked on both sides (α1 and β1). Superior points of philtral column (γ) and most superior point of the columella (δ) marked as well. See also Fig. 2.7

a

Fig. 2.13  Millard technique for bilateral lip plasty. (a) Schematic illustration of Millard technique. See also Fig.  2.8. (b) Incisions on the simulation model: Incision lines related to the anatomic landmarks and skin flaps for Millard’s technique. The advancement flap on both sides

b

(α) shown and the horizontal cuts at the (β), starting at the peaks of the lateral segments (γ). The prolabium flap is outlined (δ). An optional “parking flap” (ε) can be circumcised

2.5 An ex vivo Model for Bilateral Lip Plasty

41

Fig. 2.14  The muscle has been resected from the prolabial part

Fig. 2.16  Preparation of the muscle on both cleft sides—comparable to M. levator labii superioris alaeque nasi and the orbicularis oris muscle

Fig. 2.15  Excess vermilion has been removed and the marked incisions have been cut

Fig. 2.17  Suturing of the M. levator labii superioris alaeque nasi on both sides with absorbable material of size 4–0 (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany)

42

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

Fig. 2.20  Situation after completing the muscle suture with 4–5 stitches

Fig. 2.18  After elevation of the prolabium with a pair of forceps, the approximation of the nasal alae can be seen by the suturing of the M. levator labii superioris alaeque nasi with absorbable material of size 4–0

Fig. 2.19  Suturing of the M. orbicularis oris with absorbable material of size 4–0

Fig. 2.21  Vermilion plasty is performed. Suture with non-resorbable, monofilament polyamide of size 4–0 (Seralon® 4–0, Serag-Wiessner, Naila, Germany, or Ethilon® 4–0, Ethicon, Norderstedt, Germany)

2.5 An ex vivo Model for Bilateral Lip Plasty

43

Fig. 2.22  Construction of the right peak of cupid’s bow by suturing (α on α1; see Fig. 2.12)

Fig. 2.24  Lip closure of bilateral cleft lip is completed

Fig. 2.23  Completing of the suture of the prolabium (α on α1, on the left side). Construction of the nostrils on both sides. Suture with non-­ resorbable, monofilament material of size 4–0

44

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

2.6 Patient Cases 2.6.1 Technique of Millard Lip Plasty in a Complete Symmetrical Bilateral Cleft Lip In the current case a complete bilateral cleft lip is presented (Figs.  2.25, 2.26, 2.27, 2.28, 2.29, 2.30, 2.31, 2.32, 2.33, 2.34, 2.35, 2.36, 2.37, 2.38, 2.39, 2.40, 2.41, 2.42, 2.43, 2.44, 2.45, 2.46, 2.47, 2.48, 2.49, 2.50, 2.51, 2.52, 2.53, and 2.54). Lip closure is performed by a Millard lip plasty. In this case we did not use “parking flaps.”

Fig. 2.25  Complete bilateral cleft lip after intubation

a

b

Fig. 2.26  The protrusion of the premaxilla is clearly visible from lateral (a) and through an intraoral mirror image (b)

2.6 Patient Cases

45

Fig. 2.29  Marking of the incision. “Parking flaps” were not planned in this case

Fig. 2.27  The width of a symmetrical bilateral cleft is about 40% greater than the width in the coronal plane (width x √2) Fig. 2.30  Marking is continued into the vestibule in the transition area between fixed and movable gingiva at a distance of 3 mm from the movable gingiva down to the molar area with a vertical cranially orientated backcut in this area

Fig. 2.28  Right and left peak, as well as central inferior point of cupid’s bow are marked. Corresponding points on the lateral lips are also marked. See also Fig. 2.7 and Fig. 2.9

Fig. 2.31  Injection of local anesthetic with adrenaline 1:100.000 (UDS forte, Sanofi, Frankfurt am Main, Germany). Recommended is a dose of 0.15 ml (6 mg)/kg body weight

46

Fig. 2.32  Tattooing important landmarks (the peaks of the cupid’s bow in both sides and the corresponding points at the peaks of the lateral segments) with methylene blue (Laboratoire Aguettant, France)

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

Fig. 2.35  Cutting of the outlined markings of the diamond knife using a scalpel no. 3 with an 11 blade (cuttings are performed like cutting “a piece of cake”)

Fig. 2.33  The marked line is cut with a diamond knife

Fig. 2.36  Cleft area completely excised and the prolabium (here elevated with a pair of forceps) is dissected

Fig. 2.34  Completion of the incision along the marked line with a diamond knife

Fig. 2.37  The orbicularis oris muscle at the left side is dissected

2.6 Patient Cases

47

Fig. 2.41  “Vestibuloplasty” to create a neo-vestibule with absorbable polyglactin sutures

Fig. 2.38  Dissection of the orbicularis oris muscle on the right side

Fig. 2.39  Epiperiosteal dissection of the perioral muscles with release of the misinsertions

Fig. 2.42  Muscle suture of the orbicularis oris muscle with four to five absorbable sutures of size 4–0. A green sterile rubber blanket was placed underneath the orbicularis oris muscle for better visualization

Fig. 2.40  After having prepared the buccal mucosa on the left side. Preparation of the “vestibuloplasty” in order to create a neo-vestibule with absorbable polyglactin sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany)

48

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

Fig. 2.43  Muscle suture of the levator labii superioris alaeque nasi muscle with absorbable sutures of size 4–0

Fig. 2.44  Adapting the skin of the nasal entrance to check the accuracy of fit and the mobility of the lateral nasal alae

2.6 Patient Cases

49

Fig. 2.45  Creation of the nasal entrance and suturing with absorbable sutures of size 4–0

Fig. 2.46  Situation after constructing the nasal entrances. The prolabium is pulled down with a pair of forceps, which generates tension onto the columella

50

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

Fig. 2.47  Situation after suturing the prolabium at the peaks of cupid’s bow. The lateral segments are sutured at the midline in the white roll above the vermilion. Suturing is performed with non-resorbable poly-

amide suture (Ethilon® 6–0 Ethicon, Norderstedt, Germany, or Seralon® 6–0, Serag-Wiessner, Naila, Germany)

Fig. 2.48  Situation after completion of the sutures on the lip with Ethilon 6–0 and from the wet-dry line to intraoral with Vicryl 4–0—en face view

2.6 Patient Cases

Fig. 2.49  Deep suctioning of the patient by the surgeon to prevent bronchospasm during extubation

51

Fig. 2.52  Situation 7 days postoperatively right before the removal of the sutures

Fig. 2.53  Situation 7  days postoperatively after the removal of the sutures

Fig. 2.50  Placement of the feeding tube by the surgeon

Fig. 2.51  Situation after application of steri-strips® (3 M Deutschland, Neuss, Germany) to reduce tension on the wound on the upper lip Fig. 2.54  Three months after lip plasty and 12 days after palatoplasty

52

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

2.6.2 Technique of Millard Lip Plasty in an Incomplete Asymmetric Bilateral Cleft Lip In this case an incomplete asymmetric bilateral cleft lip is presented (Figs. 2.55, 2.56, 2.57, 2.58, 2.59, 2.60, 2.61, 2.62, 2.63, 2.64, 2.65, 2.66, 2.67, 2.68, 2.69, 2.70, 2.71, 2.72, 2.73, and 2.74, 2.75, 2.76, 2.77, 2.78, 2.79, 2.80, 2.81, 2.82, 2.83, 2.84, 2.85, 2.86, 2.87, 2.88, 2.89, 2.90, 2.91, 2.92, and 2.93, 2.94).

Fig. 2.57  Preoperative findings, the child is 5 months old on the preoperative day

Fig. 2.58  Incomplete bilateral asymmetric cleft lip after intubation

Fig. 2.55  Preoperative findings, child on the day of birth

Fig. 2.59  Soft tissue situation in the region of the maxillary vestibule in a mirror image; note the adhesion in the cleft region on the right side. The image has been mirrored for simplicity

Fig. 2.56  Preoperative findings, the child is 16 weeks old

53

2.6 Patient Cases

Fig. 2.60  Preoperative measurement of the lip length (corner of the mouth to the white role) with the Zielinsky circle

Fig. 2.62  Finalized markings of the planned incision

Fig. 2.61  Lip markings of the planned incision with a thin surgical marker. The markings have to be performed before the local anesthesia is applied. Otherwise, the injection may cause distortion of the tissue

54

a

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

b

Fig. 2.63 (a) and (b) Tattooing of the key points with methylene blue and a disposable needle

Fig. 2.64  Injection of local anesthetics with adrenaline 1:100.000 (UDS forte, Sanofi, Frankfurt am Main, Germany). Recommended is a dose of 0.15 ml (6 mg)/kg body weight

Fig. 2.66  The incision at the prolabium is simplified by carefully pulling with a pair of forceps in the area of the philtral vermilion

Fig. 2.65  Tracing the marked incision line with a diamond knife. Holding the upper lip with the surgeon’s left hand simplifies the incision and at the same time compresses the superior labial artery to reduce bleeding

Fig. 2.67  Cutting of the outlined markings of the diamond knife using a scalpel no. 3 with a no. 11 blade (cuttings are performed like cutting “a piece of cake”)

2.6 Patient Cases

Fig. 2.68  Completed incision at the outlined markings using a scalpel no. 3 with a no. 11 blade

Fig. 2.69  Excision of the cleft area in the vermilion/vestibule

Fig. 2.70  Preparation of the prolabium

55

Fig. 2.71  Situation after excision of the excessive tissue and preparation of the prolabium (pulled down with a pair of forceps). In this case with an incomplete bilateral cleft the columella has a nearly normal length. Note the differences in the resected tissue at the nasal entrances of both sides resulting from the asymmetric nature of the cleft

Fig. 2.72  Epiperiosteal dissection of the misinserted muscles with a periosteal elevator according to Freer up to below the infraorbital nerve

Fig. 2.73  Dissection of the orbicularis oris muscle at the left side

56

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

Fig. 2.77  Situation after completion of “vestibuloplasty” Fig. 2.74  Dissection of the orbicularis oris muscle at the right side

Fig. 2.75  “Vestibuloplasty” in order to create a neo-vestibule with absorbable polyglactin sutures of size 4–0—lateral view

Fig. 2.76  “Vestibuloplasty” in order to create a neo-vestibule with absorbable polyglactin sutures of size 4–0—frontal view

Fig. 2.78  Soft tissue situation during muscle suturing with four to five absorbable polyglactin sutures of size 4–0

Fig. 2.79  Soft tissue situation during muscle suturing with absorbable polyglactin sutures of size 4–0. For a better visualization of the muscle, a green rubber blanket was put underneath. Note the change in the shape of the right nasal entrance due to structural support from the nasal fascicle of the levator superior alaeque nasi, which is joined in the midline

2.6 Patient Cases

57

Fig. 2.80  Adaption of the vermilion border with monofilament non-­ Fig. 2.83  Soft tissue situation in the area of the nasal entrance on the resorbable sutures of size 6–0 right side. Elevation of the nostril with a nerve hook for better visualization

Fig. 2.81  Situation after vermilion plasty with non-resorbable sutures of size 6–0 and suturing of the prolabium to the peak of the cupid’s bow on the right side with non-resorbable sutures of size 6–0 and thus creating the right philtral column

Fig. 2.84  Creating the nasal entrance with resorbable polyglactin sutures of size 4–0 by suturing the columellar base flap to the cutaneous flap of the alar segment

Fig. 2.82  Removal of parking flaps, which were not necessary in this case

Fig. 2.85  Symmetrical nose after suture of the nasal entrance

58

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

Fig. 2.86  Trimming the excess tissue of the right advancement flap

Fig. 2.89  Completion of sutures in the mucosal part with resorbable polyglactin sutures of size 4–0. The vermilion is now symmetrical

Fig. 2.87  Completing sutures at the right philtral column with non-­ resorbable polyamide suture (Ethilon® 6–0, Ethicon, Norderstedt, Germany, or Seralon® 6–0, Serag-Wiessner, Naila, Germany)

Fig. 2.90  Situation after application of steri-strips®

Fig. 2.88  Correction of vermilion asymmetry technique is similar to the Noordhoff triangular flap (see chapter unilateral clefts)

Fig. 2.91  Placement of a feeding tube after deep suctioning

2.6 Patient Cases

59

Fig. 2.94  Situation 4 months postoperatively

Fig. 2.92  Situation after placement of bracing “Snuggle Wraps” (Pediatric Medical Solutions, Johns Island (SC), United States) to prevent the child from manipulating the lip with the hands or removing the feeding tube

Fig. 2.93  Situation after removal of the non-absorbable suture material 1 week postoperatively

60

References

2  Primary Surgery of the Bilateral Cleft Lip: Bilateral Cleft Lip Plasty

Georgiade NG, Latham RA.  Maxillary arch alignment in the bilateral cleft lip and palate infant, using pinned coaxial screw appliance. Plast Reconstr Surg. 1975;56:52-60. doi: https://doi. Monson LA, Kirschner RE, Losee JE. Primary repair of cleft lip and org/10.1097/00006534-­197507000-­00011. nasal deformity. Plast Reconstr Surg. 2013;132:1040e-53e. doi: Hotz M, Perko M, Gnoinski W.  Early orthopaedic stabilizahttps://doi.org/10.1097/PRS.0b013e3182a808e6. tion of the praemaxilla in complete bilateral cleft lip and palFajardo MA, Tow DJ, Hughes C, Castiglione C. Cleft Lip and Palate ate in combination with the Celesnik lip repair. Scand J Plast Surgery. In: Ferneini EM, Goupil MT, Halepas S, editors. The Reconstr Surg Hand Surg. 1987;21:45-51. doi: https://doi. History of Maxillofacial Surgery: An Evidence-Based Journey. org/10.3109/02844318709083579. Cham: Springer International Publishing; 2022. p. 391-409. Hotz MM, Perko M. Early management of bilateral total cleft lip and Conway JC, Taub PJ, Kling R, Oberoi K, Doucette J, Jabs EW. Ten-­ palate. Scand J Plast Reconstr Surg. 1974;8:104-8. doi: https://doi. year experience of more than 35,000 orofacial clefts in Africa. BMC org/10.3109/02844317409084378. Pediatr. 2015;15:8. doi: https://doi.org/10.1186/s12887-­015-­0328-­5. Bennun RD, Figueroa AA.  Dynamic presurgical nasal remodeling in Eshete M, Butali A, Deressa W, Pagan-Rivera K, Hailu T, Abate F, patients with unilateral and bilateral cleft lip and palate: modificaet  al. Descriptive Epidemiology of Orofacial Clefts in Ethiopia. tion to the original technique. Cleft Palate Craniofac J. 2006;43:639-­ J Craniofac Surg. 2017;28:334-7. doi: https://doi.org/10.1097/ 48. doi: https://doi.org/10.1597/05-­054. scs.0000000000003234. Grayson BH, Cutting C, Wood R. Preoperative columella lengthening Fijałkowska M, Antoszewski B. Frequency of various craniofacial clefts in bilateral cleft lip and palate. Plast Reconstr Surg. 1993;92:1422-3. observed in a single center during a period of 34 years. Pol Przegl Chir. Lindemann A, Lange G, Frenzel H. Die Chirurgie des Gesichts, 2019;92:29-33. doi: https://doi.org/10.5604/01.3001.0013.5925. der Mundhöhle und der Luftwege. Berlin, Wien: Urban & Gundlach KK, Maus C.  Epidemiological studies on the frequency of Schwarzenberg; 1941. clefts in Europe and world-wide. J Craniomaxillofac Surg. 2006;34 Pitanguy I, Franco T.  Nonoperated facial fissures in adults. Suppl 2:1-2. doi: https://doi.org/10.1016/s1010-­5182(06)60001-­2. Plast Reconstr Surg. 1967;39:569-77. doi: https://doi. Allori AC, Marcus JR.  Modern tenets for repair of bilateral cleft lip. org/10.1097/00006534-­196706000-­00005. Clin Plast Surg. 2014;41:179-88. doi: https://doi.org/10.1016/j. Tan SPK, Greene AK, Mulliken JB. Current Surgical Management of cps.2014-­01.003. Bilateral Cleft Lip in North America. Plastic and Reconstructive Randall P, Jackson OA. A History of Cleft Lip and Cleft Palate Surgery. Surgery. 2012;129:1347-55. doi: https://doi.org/10.1097/ Second Edition ed. Comprehensive Cleft Care, Volume 2. Stuttgart: PRS.0b013e31824ecbd3. Georg Thieme Verlag 2016. Williams JH.  Sir William Manchester Memorial Lecture 1999: the Brown JB, Mc DF, Byars LT. Double clefts of the lip. Surg Gynecol influence of one man on plastic and reconstructive surgery in Obstet. 1947;85:20-9. New Zealand. Aust N Z J Surg. 2000;70:308-12. doi: https://doi. Franco P. Traité des hernies. Lyon; 1561. org/10.1046/j.1440-­1622.2000.01798.x. Millard DR.  Cleft Craft: The Evolution of Its Surgery—Volume II: Manchester WM. The repair of bilateral cleft lip and palate. Br J Surg. Bilateral and rare deformities. Boston: Little, Brown and Company; 1965;52:878-82. doi: https://doi.org/10.1002/bjs.1800521111. 1977. Mulliken JB. Sense of wonder. J Craniofac Surg. 2009;20 Suppl 1:603-­ Bhattacharya S, Khanna V, Kohli R. Cleft lip: The historical perspec7. doi: https://doi.org/10.1097/SCS.0b013e31819298a8. tive. Indian J Plast Surg. 2009;42 Suppl:S4-8. doi: https://doi. Mulliken JB.  Principles and techniques of bilateral complete cleft org/10.4103/0970-­0358.57180. lip repair. Plast Reconstr Surg. 1985;75:477-87. doi: https://doi. de La Faye G. Observations sur le bec-de-liévre. Memoires de l'Acad org/10.1097/00006534-­198504000-­00003. Royal de Chir 1:605; 1743. Mulliken JB. Bilateral complete cleft lip and nasal deformity: an anthroHofmann J.  Dissertatio inauguralis medica de labiis leporinis. pometric analysis of staged to synchronous repair. Plast Reconstr Universität Heidelberg; 1686. Surg. 1995;96:9-23; discussion 4-6. Simon G.  Mittheilungen aus der chirurgischen Klinik des Rostocker Krankenhauses waehrend der Jahre 1861-1865. Prague: Verlag von Carl Reichenecker; 1868.

3

Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

Palatoplasty is a field with lots of controversial aspects. Treatment goals are as follows: Create perfect anatomical circumstances for speech development. Avoid velopharyngeal insufficiency, Lengthen the palate, Separate the oral from the nasal cavity by closing the oronasal fistula. Surgery without future growth disturbance of the maxilla and the face. Prevent postoperative oronasal fistula. The variations of cleft palates range from isolated and submucous soft palate clefts to unilateral hard and soft palate clefts associated with lip clefts (see Figs.  3.2b, 3.3b). The most severe challenges are formed by bilateral cleft lip cases with bilateral hard and soft palate clefts (see Figs. 3.2c and 3.3a, which are associated with the additional problem of an alveolus cleft and protruded premaxilla (see Figs. 3.4a, b and c). The discussion about the ideal technique and timing of palatal cleft closure is just as wide-ranging. There have been ongoing debates among surgeons, orthodontists, and other healthcare providers on the time of closure, on one-step or two-step-surgeries, and on which technique should be applied best. When considering one type of closure you have to bear in mind both advantages and disadvantages of the procedure. There are surgical techniques that aim to avoid palatal shortness. Using these techniques, the rate of velopharyngeal insufficiency is much smaller. However, these methods do not offer the possibility of a safe three-layer closure and patients suffer from a higher percentage of oronasal fistula development. Other surgical procedures offer the possibility to lengthen the soft palate primarily, but in the same procedure there has to be a denudation of the palatal bone which goes along with a negative impact on maxillary development (Pantaloni and Hollier 2001; Leow and Lo 2008; Millard 1980; Woo 2017).

3.1 History and Development 1762/1764 A French dentist named Le Monnier from Rouen was probably the first to close a cleft palate in a child. In a three-step-­procedure he first introduced the sutures, cauterized the cleft edges, and then brought the freshened edges together before fixing them (Leow and Lo 2008; Millard 1980). 1816 Carl Ferdinand von Graefe (born in 1877 in Warsaw, died in 1840 in Hanover) was a German military surgeon and ophthalmologist. From 1810 on he was Professor at Berlin Charité and founder of the surgical department. In 1816 he presented an interesting case to close a cleft palate. Von Graefe invented special needles and needle holders and sutured the soft palate after etching its margins to cause inflammation. He presented the case at the meeting of Berlin Medical-Surgical Society and published it one  year later (Leow and Lo 2008; McDowell 1971). 1819 Philibert Joseph Roux (born in 1780  in Auxerre, France, died in 1854  in Paris) was a French surgeon. In 1819 he was visited by two Canadian students doing their medical studies in Edinburgh. Dr. Roux noticed John Stevenson’s indistinct pronunciation, which resulted from his cleft palate. Roux examined Stevenson and expressed his interest in repairing the defect. On September 28, he closed it successfully under “cognac anesthesia.” Another year later John Stevenson dedicated his thesis “De Velosynthesis” in Edinburgh to the surgery from the patient’s point of view. In 1825 Roux himself reported about Stevenson and his procedure he called “staphyloraphie.” Roux and Graefe were counterparts—supporters blamed each other with the crime of surgical plagiarism (McDowell 1971; Entin 1999).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. Kesting et al., A Visual Guide for Cleft Surgeons, https://doi.org/10.1007/978-3-031-33521-1_3

61

62

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

1859 Bernhard von Langenbeck (born in 1810 in Padingbuettel near Cuxhaven, Germany, died in 1787 in Wiesbaden) received his medical education in Goettingen and became Director of the Department of Surgery at Kiel University in 1842. In 1848 he took over the position as the Head of the Surgical Department of Berlin Charité. Langenbeck revolutionized cleft palate closure with a technique still used today, mainly in incomplete clefts. In a first step, he made two sagittal relaxing incisions following the palatal side of the alveolar ridge. After that he mobilized from there a mucoperiosteal flap on each side to the midline before he sutured both flaps in the midline (see Fig. 3.1a) (Leow and Lo 2008; Goldwyn 1969). 1920 Hugo Ganzer (born in Neumuenster, Germany, in 1879, died in 1960 in Berlin) was a dentist being famous for working as a plastic surgeon in the “Jaw Clinic” in Berlin-Charlottenburg during World War I. He lengthened Langenbeck’s technique by a V-incision in the anterior part of the palate. As a result, the velum is pushed back while applying a V-Y-plasty (Rittersma 1988; Ganzer 1920). 1926 Hans Pichler (born in 1877  in Vienna, Austria, died in 1949 in Vienna), the surgeon of Sigmund Freud’s maxillary cancer, introduced his vomerine plasty for hard palate closure (Leow and Lo 2008). 1931 Victor Veau (born in 1871  in Auxey-Duresses in Burgundy, France, died in 1949 in Paris) took over Ganzer’s V-plasty and additionally introduced milestones to cleft palate surgery: The nasal mucoperiosteal closure of the hard palate by the use of a vomerine flap and his “suture musculaire” (Veau 1931). 1937 British surgeons were very much influenced by Veau’s technique. William Edward M.  Wardill (born in 1898  in Gateshead, Great Britain, died in 1960 in Newcastle) refined the method at his work in Newcastle-upon-Tyne by an additional pharyngoplasty. Later on, he emigrated to South Africa and took over the chair of the Royal Medical College in Bagdad. Pomfret Kilner (born in 1890 in Manchester, died in 1964 in Oxford) being Professor in Oxford summarized the techniques to what is known today as Veau-Wardill-Kilner (VWK) method or V-Y-pushback technique (see Fig. 3.1c) (Pantaloni and Hollier 2001; Veau 1931; Kilner 1937; Ivy 1964; Wardill 1937; Potter 1982). 1944 The German otorhinolaryngologist Hermann Heinrich Schweckendiek (born in 1884  in Aerzen, died in 1960  in Marburg) suggested a two-stage procedure in complete cleft

palates. After early closure of the soft palate (4–6 months) the hard palate closure is performed later at an age of 4–5 years (sometimes even at age 14–15 years). The rationale is narrowing the hard palate without surgery at a young age and thus causing less maxillary growth retardation (see Fig. 3.1b) (Leow and Lo 2008; Schweckendiek 1978). 1967 Janusz Bardach (born in 1919 in Odessa, died in 2002 in Iowa City, USA) was not only a reconstructive surgeon who introduced his two-flap palatoplasty to cleft palate surgery. Born as a Polish Jew in the Ukrainian part of the Soviet Union he was recruited to the Red Army in 1939. Because of a tank accident he was sentenced to death and later on to 10 years of hard labor in the goldmines near Kolyma in the Soviet Far East. In his memoirs “Man is Wolf to Man: Surviving the Gulag” he wrote down his dramatic experiences there. After 5 years he was released, trained in Moscow, and developed his two-flap palatoplasty technique in Lodz, Poland (Tanne 2002; Pace 2002). This method allows closing of a complete unilateral cleft directly behind the alveolar margin and avoids oronasal fistula in this region. Lengthening the palate is difficult with this method, but it has hardly any restrictions on maxillofacial growth. In 1972 Bardach moved to the USA and became chairman of the division of Plastic and Reconstructive Surgery of Iowa University (Bardach 1995). 1969 Otto Kriens (born in 1930 in Rheine/Westphalia, Germany, died in 2014 in Bremen) received his medical education in Muenster. During his training in Hamburg, Kriens paid attention on the muscles of the soft palate and analyzed the anatomic basis in cleft patients. He presented his results for the first time at the 1969 International Cleft Congress in Houston, Texas. His surgical technique—the intravelar veloplasty—is nowadays the pillar of functional construction of the soft palate. Kriens became Professor in Erlangen in 1975 and one year later he took over the leading position of the Department of Maxillofacial Surgery at Bremen General Hospital (Kriens 1969; Thieme 2014). 1986 Leonard Furlow Jr. from Gainesville, Florida, USA, wrote: In an attempt to improve speech results following palate repair while allowing adequate maxillary growth, a palatoplasty using two opposing Z-plasties of the soft palate, one of the oral and one of the nasal layers, has been used in 22 infants. Eight patients had an unilateral cleft lip and palate, eight had a bilateral cleft lip and palate, and six had a cleft palate. The Z-plasties facilitate effective dissection and redirection of the palatal muscles to produce an overlapping muscle sling and lengthen the velum without using tissue from the hard palate, which permits hard palate closure without pushback or lateral relaxing incisions (Furlow 1978;

3.1 History and Development Fig. 3.1  Common techniques for palatoplasty. (a) von Langenbeck palatoplasty; (b) Schweckendiek’s “two-stage” palatoplasty: initial closure of the soft palate with holding device for the first 7 days after surgery; (c) Veau-­ Wardill-­Kilner (VWK) “push back” palatoplasty; (d) Furlow Z-palatoplasty

63

a

b

c

d

64

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

Furlow Jr. 1986; Kaye and Kirschner 2016). Furlow’s Z-plasty is displayed in Fig. 3.1d.

3.2 Current Concepts A survey among 306 American cleft surgeons evaluated that the most common surgical procedure for cleft palatoplasty was an one-stage repair technique in Bardach style with intravelar veloplasty. Surgery was mostly performed between 6 and 12 months of age. Several studies have shown favor-

able results by additionally using Pichler’s vomerine flap for hard palate closure, especially with respect to facial growth (Katzel et al. 2009).

3.3 Relevant Anatomy for Palatoplasty In the following chapter the relevant anatomy for palatoplasty will be shown in schematic images. Important landmarks of physiologic and pathophysiologic anatomy will be explained (Figs. 3.2, 3.3, 3.4, and 3.5).

a

b

c

d

Fig. 3.2  Schematic palatal anatomy of infants, special attention is paid to localization of the greater palatal artery. (a) Non-cleft child; (b) Infant with isolated cleft malformation of the palate; (c) Infant with

bilateral cleft malformation of lip, alveolar crest, and palate; (d) Infant with unilateral cleft malformation of the left-sided lip, alveolar crest, and palate

3.3 Relevant Anatomy for Palatoplasty

65

a

Fig. 3.3  Schematic palatal anatomy of infants with cleft malformation, special attention is paid to the maxillary processes and vomer. (a) Infant with bilateral cleft malformation of lip, alveolar crest, and palate; (b)

b

Infant with unilateral left-sided cleft malformation of the lip, alveolar crest, and palate

a

b

c

d

Fig. 3.4  Schematic and clinical palatal anatomy of infants, special attention is paid to the muscles of the soft palate (and premaxilla). (a) Infant with bilateral cleft malformation of lip, alveolar crest, and palate; (b) Intraoral photograph of infant with bilateral cleft formation of lip,

alveolar crest, and palate and extremely protruded premaxilla; (c) Infant with bilateral cleft malformation of lip, alveolar crest, and palate; (d) Infant without cleft malformation and standard anatomy

66

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

a

b

c

d

Fig. 3.5  Palatal anatomy of infants, special attention is paid to the skull bones and bony processes. (a) Non-cleft child; (b) Infant with isolated cleft malformation of the palate; (c) Infant with bilateral cleft

malformation of lip, alveolar crest, and palate; (d) Infant with unilateral left-sided cleft malformation of the lip, alveolar crest, and palate

3.4 Technique of Palatoplasty in Isolated Cleft Palates

anatomically correct transverse alignment. In the case of wide complete hard and soft palate clefts, a vomerine plasty according to Pichler is performed by the authors. The intention is to prevent the occurrence of oronasal fistulas in the area of the hard palate by stabilizing the nasal layer. In the following section, the detailed surgical procedure for isolated cleft palate repair will be explained in three exemplary cases. For postoperative management, the authors recommend prolonged feeding with a nasogastric feeding tube for 7 days. This tube will be inserted intraoperatively after completion of palate repair surgery.

The authors prefer an one-stage palate closure at the age of 12 to 15  months. The main reason for this timing is that surgery is completed before language acquisition and provides the child with optimal anatomical conditions for this. The surgical concept involves a three-layer closure of the nasal mucosa, the muscles of the soft palate and the oral mucosa. For this purpose, a two-flap palatoplasty according to Bardach is performed. In addition, an intravelar veloplasty is done. This procedure facilitates reorientation of the misinsertion of the muscles of the soft palate in an

3.4 Technique of Palatoplasty in Isolated Cleft Palates

67

3.4.1 One-Stage Repair in a Moderately Wide Cleft of the Hard and Soft Palate: Bardach Two-Flap Palatoplasty with Intravelar Veloplasty—Case 1 The following chapter shows the procedure for one-stage Palatoplasty in a clinical case of a moderately wide cleft of the hard and soft palate (Figs. 3.6, 3.7, 3.8, 3.9, 3.10, 3.11, 3.12, 3.13, 3.14, 3.15, 3.16, 3.17, 3.18, 3.19, 3.20, 3.21, 3.22, and 3.23)

Fig. 3.8  Harvesting of palatal flaps. Harvest of the left-sided palatal flap, incision of the right-sided palatal flap is marked. Prevent arterial bleeding at the anterior aspect of the palatal flap by bipolar electrocoagulation (arrow)

Fig. 3.6  Infiltration of local anesthetics with adrenaline 1:100.000 (UDS forte, Sanofi, Frankfurt am Main, Germany). Recommended is a dose of 0.15 ml (6 mg)/kg body weight

Fig. 3.9  Completed harvesting of left-sided palatal flap. Subperiosteal preparation with a raspatory in posterior direction is performed. Elevation of the flap until the palatal artery/greater palatine foramen. Take care not to hurt the palatal artery (green arrow)! Palatal spines and palatal grooves (white arrow) might mimic the greater palatine foramen with the palatal artery!

Fig. 3.7  Incision lines of a pedicled palatal flap marked at each side of the cleft palate. In the midline from the uvula (cleft borders) to the transverse folds of the hard palate the incision is performed. U-shaped incision in the region of the transverse palatal folds. Incisions are extended laterally with a distance of 5 mm from the alveolar ridge in posterior direction to the maxillary tuberosity. Distally from this landmark a relief cut is made into the buccal mucosa Fig. 3.10  Malinsertion of soft palatal muscles (levator muscle) (arrow) becomes visible

68

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

Fig. 3.11  Circular preparation of the palatal artery with Partsch raspatory (arrow)

Fig. 3.13  Intraoperative visualization of the step shown in Fig. 3.12: Cutting off the malpositioned levator veli palatini muscle/aponeurosis (marked with a white arrow)

Fig. 3.14  Schematic visualization of nasal mucosa release. Releasing the nasal mucosa with small Partsch raspatory from the medial and posterior border of the hard palate (blue arrows). From the midline/soft palate cleft border on separation of the soft palate muscles from the oral mucosa is performed Fig. 3.12  Cutting off the malpositioned levator veli palatini muscle/ aponeurosis (highlighted in yellow color) from the posterior border of the palatine bone and mobilization of the muscle

3.4 Technique of Palatoplasty in Isolated Cleft Palates

Fig. 3.15  Schematic visualization of the complete mobilization of the palatal flaps

Fig. 3.16  Intraoperative situs of both mobilized flaps

Fig. 3.17  Closure of the nasal mucosa

69

Fig. 3.18  Mucosal reconstruction of the uvula and posterior nasal mucosa with traction sutures. Resorbable sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany) are used and reconstruction of the nasal mucosa with single-button sutures is done. Do not try to close the nasal mucosa too anteriorly! The reconstructive aim is tension-free closure!

Fig. 3.19  Surgical repositioning of the soft palate muscles into transversal direction

Fig. 3.20  Schematic view of soft palate muscle reconstruction

70

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

Fig. 3.21  The muscular bundle is reconstructed with single-button sutures. Resorbable sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany) are used. Closure is done starting from posterior into anterior direction > Kriens’ intravelar palatoplasty

Fig. 3.23  Intraoperative situs of finished oral mucosa closure. Oral mucosa is reconstructed from the uvula into anterior direction and closure is performed using with single-button resorbable sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany). Both united pedicled flaps are sutured to the anterior folds with 5/8 circle needle (Serafit 4–0 with FR-10 needle, Serag-­ Wiessner, Naila, Germany). Adaptation—not tight closure—of both lateral releasing incisions with 4–0 resorbable sutures is done. In case of minor bleeding fill up the dead space with collagen fleece (Lyostypt, B. Braun, Melsungen, Germany)

3.4.2 One-Stage Repair in a Wide Cleft of the Hard and Soft Palate (Pierre-­ Robin-­Patient): Bardach Two-Flap Palatoplasty with Intravelar Veloplasty and Pichler’s Vomerine Plasty—Case 2

Fig. 3.22  Schematic visualization of finished oral mucosa closure

The following chapter shows the procedure for one-stage Palatoplasty in a clinical case of a wide isolated cleft of the hard and soft palate in a Pierre-Robin-Patient. A step-by-step explanation from preoperative positioning to the insertion of the feeding tube and immobilization of the infant’s elbows is presented (Figs. 3.24, 3.25, 3.26, 3.27, 3.28, 3.29, 3.30, 3.31, 3.32, 3.33, 3.34, 3.35, 3.36, 3.37, 3.38, 3.39, 3.40, 3.41, 3.42, 3.43, 3.44, 3.45, 3.46, 3.47, 3.48, 3.49, 3.50, 3.51, 3.52, 3.53, 3.54, 3.55, 3.56, 3.57, 3.58, 3.59, 3.60, 3.61, 3.62, 3.63, 3.64, 3.65, 3.66, 3.67, 3.68, 3.69, 3.70, 3.71, 3.72, 3.73, 3.74, 3.75, 3.76, and 3.77).

3.4 Technique of Palatoplasty in Isolated Cleft Palates

Fig. 3.24  Preoperative positioning. When positioning for cleft palate closure, ensure that the head is clearly hyperextended in order to improve visualization of the palate. Carefully grease the lips

71

Fig. 3.27  Application of local anesthetic. Infiltration of local anesthetic with adrenaline 1:100.000 (UDS forte, Sanofi, Frankfurt am Main, Germany). Recommended is a dose of 0.15 ml (6 mg)/kg body weight. Thus, prevention of bleeding and improved separation of the tissue layers can be achieved

Fig. 3.25  Visualization of the cleft. Intraoral presentation of a wide cleft palate in a Pierre-Robin patient

Fig. 3.28  Marking of the incisions. To get optimal exposure of the left palate, the cleft lock on the left side is retracted from the alveolar ridge (blue arrow). Incisions are marked using a blue tissue pen. For schematic visualization of the incisions see Fig. 3.7

Fig. 3.26  Insertion of the cleft lock. Carefully secure the endotracheal tube when inserting the cleft lock

Fig. 3.29  Incisions. Perform the incisions in the soft palate up to a depth of about 2  mm into the tissue and at the hard palate until you reach bone level

72

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

Fig. 3.30  Preparation of palatal flaps. Harvest of the left-sided palatal flap using a raspatory. Subperiosteal preparation from anterior to posterior to elevate the flap

Fig. 3.33  Identification of the palatal artery. Careful blunt dorsal subperiosteal preparation gives exposure to the palatal artery

Fig. 3.31  Preparation of palatal flaps. Careful hemostasis is performed during elevation of the left-sided palatal flap. The major source of bleeding is the anterior end of the palatal artery anteriorly. Bipolar electrocoagulation is applied there

Fig. 3.34  Identification of the palatal artery. The palatal artery is successfully identified (arrow) by blunt preparation. In addition, the dorsal edge of the hard palate is identified

Fig. 3.32  Finished incision around the left-sided palatal flap. Further preparation steps are easier when careful hemostasis is applied after this step

Fig. 3.35  Identification of the palatal artery. The palatal artery completely visualized (dotted lines). It is sometimes necessary to sharply dissect small connective tissue fibers circumferentially to the artery. The dorsal edge of the hard palate is completely visualized (*)

3.4 Technique of Palatoplasty in Isolated Cleft Palates

73

Fig. 3.36  Preparation of the soft palate muscles. After complete elevation of the palatal artery flaps on the hard palate and secure identification of the palatal artery, the oral mucosa layer is separated from the soft palate muscles. Use of sharp scissors is recommended for this preparation step. Careful preparation is carried out to not perforate the thin oral mucosa

Fig. 3.39  Circular exposure of the palatal artery. After dissecting the medial and anterior parts of the oral mucosa and soft palate muscles, a safe circular preparation of the palatal artery can be performed. This increases the mobility of the palatal flap and helps protecting the artery during further preparation

Fig. 3.37  Preparation of the soft palate muscles. It is critical to ensure good, bleeding-free visualization to prevent perforation of the mucosa

Fig. 3.40  Preparation of the soft palate oral mucosa. Subsequently, the oral mucosa is completely dissected from the soft palate muscles. Preparation is extended dorsally to the uvula. Preparation is extended laterally, until the scissors become visible at the lateral release incision dorsally to the palatal artery (arrow). Preparation is performed using scissors. Carefully mind not to perforate the oral mucosa layer

Fig. 3.38  Preparation of the soft palate muscles. The soft palate muscles get exposed (arrow). See the posterior-anterior direction of the muscle fibers (dotted lines) with aberrant insertion on the dorsal margin of the hard palate

74

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

Fig. 3.41  Preparation of the soft palate nasal mucosa. After separation of the oral mucosa from the soft palate muscles, the muscle layer needs to be separated from the aberrant insertion to the hard palate and from the nasal mucosa. The oral mucosa is retracted using a hook. Muscle fibers are dissected from the hard palate and the nasal mucosa

Fig. 3.44  Separation of the muscles from the hard palate. Afterwards, the muscles are completely detached from their aberrant insertion to the dorsal edge of the hard palate. See the orientation of the scissors during this preparation step

Fig. 3.42  Preparation of the soft palate nasal mucosa. After dissecting muscle fibers, the nasal mucosa becomes visible (white surface indicated by an arrow). Carefully mind not to perforate the nasal mucosa. Use bipolar hemostasis until good visualization is achieved

Fig. 3.45  Separation of the muscles from the hard palate. Perform the preparation laterally and dorsally following the edge of the hard palate behind the palatal artery. Extend this preparation until you have sufficient mobility of the muscle layer to reach the midline without tension

Fig. 3.43  Preparation of the soft palate nasal mucosa. Extend the separation of the nasal mucosa and soft palate muscles dorsally until you reach the uvula

Fig. 3.46  Complete preparation of the soft palate. The three tissue layers of the soft palate (nasal mucosa, muscle layer, oral mucosa) are completely separated

3.4 Technique of Palatoplasty in Isolated Cleft Palates

75

Fig. 3.47  Complete preparation of the soft palate. See the tensionless mobilization of the soft palate muscles to the midline

Fig. 3.50  Complete preparation of palatal flaps on both sides. Insertion of a ligature on the anterior margin of each palatal flap helps maneuvering the flaps into the oral cavity

Fig. 3.48  Separation of nasal mucosa from the hard palate. Mobilize the nasal mucosa from the hard palate anteriorly using a raspatory. Mobilize the nasal mucosa at the dorsal border of the hard palate until the palatal artery

Fig. 3.51 Ensuring maximal mobilization of the palatal flaps. Dissecting muscle and connective tissue fibers from the pterygoid hamulus laterally to the palatal artery helps increasing the mobility of the palatal flaps

Fig. 3.49  Separation of nasal mucosa from the hard palate. After separation from the hard palate, the nasal mucosa can be mobilized medially without tension

Fig. 3.52  Complete preparation of the nasal mucosa. On both sides all three tissue layers of the soft palate, as well as the bilateral palatal flaps, are prepared

76

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

Fig. 3.53  Preparation of vomerine flaps. Incision is made medially on the vomer bone to prepare a vomerine mucosal flap

Fig. 3.56  Anterior closure of the nasal layer. Vomerine flaps are sutured to the anterior nasal mucosa with single-button resorbable sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany). The suture can be extended dorsally until tension-free closure is no longer possible

Fig. 3.54  Preparation of vomerine flaps. The vomerine mucosa is detached from the bone using a raspatory

Fig. 3.57  Suture of the uvula. Suture of the nasal mucosa layer begins with suturing the tip of the uvula

Fig. 3.55  Preparation of vomerine flaps. The vomerine mucosa flaps (*) are completely dissected

Fig. 3.58  Suture of the uvula. Complete suture of the uvula

3.4 Technique of Palatoplasty in Isolated Cleft Palates

77

Fig. 3.59  Suture of the uvula. The uvula is retracted anteriorly to facilitate suturing the nasal layer

Fig. 3.62  Suture of the nasal mucosa layer. The closure of the nasal mucosa layer is extended anteriorly until tension-free closure can no longer be ensured. If possible, extend the suture anteriorly until you reach the vomerine flaps. This was not possible in the current case, so the anterior section of the nasal layer had to stay unclosed

Fig. 3.60  Suture of the nasal mucosa layer. The nasal mucosa layer is sutured from posterior to anterior using resorbable sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany)

Fig. 3.63  Closure of the muscle layer. The soft palate muscles are sutured

Fig. 3.61  Suture of the nasal mucosa layer. Tension-free closure must be ensured

Fig. 3.64  Closure of the muscle layer. Three to five single-button resorbable sutures are used to reach tension-free closure of the muscle layers. See the muscle fibers that are now oriented horizontally

78

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

Fig. 3.65  Closure of the oral mucosa layer. The oral mucosa layer is closed from posterior to anterior using the same resorbable sutures

Fig. 3.68  Anterior attachment of the palatal flaps. Anterior attachment of the palatal flaps is partially complete

Fig. 3.66  Closure of the oral mucosa layer. Completed closure of the oral mucosa layer

Fig. 3.69  Anterior attachment of the palatal flaps. To perform the anterior attachment of the palatal flap sutures with small needle and high curvature are beneficial. Use of a 5/8 circle needle (Serafit® 4–0 with FR-10 needle, Serag-Wiessner, Naila, Germany) is recommended

Fig. 3.67  Anterior attachment of the palatal flaps. The palatal flaps are carefully attached anteriorly to the local hard palate mucosa

Fig. 3.70  Anterior attachment of the palatal flaps. High curvature needles help suturing in the highly concave anterior palate

3.4 Technique of Palatoplasty in Isolated Cleft Palates

79

Fig. 3.71  Anterior attachment of the palatal flaps. Complete anterior attachment of the palatal flaps

Fig. 3.74  Complete palate closure. See the intraoperative situs after completion of surgery

Fig. 3.72  Complete closure of the oral mucosa. See the complete closure of the oral mucosa with the lateral diastasis at the releasing incisions (*)

Fig. 3.75  Insertion of nasogastral feeding tube. The nasogastral feeding tube is carefully placed at the end of surgery. Auscultatory or visual control of correct placement is mandatory

Fig. 3.73  Adaption of lateral releasing incisions. Adaptation—not tight closure—of both lateral releasing incisions. In case of minor bleeding fill up dead space with collagen fleece (Lyostypt®, B. Braun, Melsungen, Germany)

80

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

a

b

Fig. 3.76  Placement of snuggle wraps. Cushion the skin carefully to avoid pressure points (a) and place fitting snuggle wraps (b). Thus, immobilization of the elbows and prevention of accidental removal of the feeding tube is ensured

3.5 Technique of Palatoplasty in Bilateral Cleft Lip and Palate In the following section, the detailed surgical procedure of palatoplasty in bilateral cleft lip and palate patients will be explained in one exemplary case.

3.5.1 One-Stage Repair: Bardach Two-Flap Palatoplasty with Intravelar Veloplasty and Pichler’s Vomerine Plasty—Case 3

Fig. 3.77  Placement of snuggle wraps. Snuggle wraps are secured with adhesive tape and the patient is handed over to the recovery room

The following chapter shows the procedure for one-stage Palatoplasty in a clinical case of a bilateral cleft (Figs. 3.78, 3.79, 3.80, 3.81, 3.82, 3.83, 3.84, 3.85, 3.86, 3.87, 3.88, 3.89, 3.90, 3.91, 3.92, 3.93, 3.94, 3.95, 3.96, 3.97, 3.98, 3.99, 3.100, and 3.101)

3.5 Technique of Palatoplasty in Bilateral Cleft Lip and Palate

81

Fig. 3.78  Situation before surgery

Fig. 3.81  Lateral incicion is perforemd with a distance of 5 mm from the alveolar ridge. Relief incisions are made posteriorly to the maxillary tuberosity into the buccal mucosa

Fig. 3.79  Infiltration of local anesthetics. Infiltration of local anesthetics with adrenaline 1:100.000 (UDS forte, Sanofi, Frankfurt am Main, Germany). Recommended is a dose of 0.15 ml (6 mg)/kg body weight

Fig. 3.82  Incision along the landmarks mentioned above

Fig. 3.80  Incision lines of a pedicled palatal flap marked at each side of the cleft palate. In the midline from the uvula (cleft borders) to the transverse folds of the hard palate. U-shaped incision in the region of the transverse palatine folds

82

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

Fig. 3.83  Prevent arterial bleeding at the anterior aspect of the palatal flap by electrocoagulation

Fig. 3.84  Prevent arterial bleeding at the anterior aspect of the palatal flap by electrocoagulation

Fig. 3.85 Subperiosteal preparation with raspatory in posterior direction

3.5 Technique of Palatoplasty in Bilateral Cleft Lip and Palate

a

c

83

b

d

Fig. 3.86 (a–d) Elevation of the flap to the palatal artery/greater palatine foramen. Take care not to hurt the palatal artery! Palatal spines and palatal grooves might mimic the greater palatine foramen with the pala-

tal artery! Preparation with raspatory to the medial posterior border of the hard palate

84

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

Fig. 3.87  Cutting off the malpositioned levator veli palatini muscle/ aponeurosis from the posterior border of the palatine bone Fig. 3.90  Surgical repositioning of the soft palate muscles into transversal direction

Fig. 3.88  Releasing the nasal mucosa with small raspatory according to Partsch from the medial and posterior border of the hard palate

Fig. 3.89  Release the soft palate muscles from the nasal and oral mucosa

Fig. 3.91  Circular preparation of the palatal artery with raspatory according to Partsch

3.5 Technique of Palatoplasty in Bilateral Cleft Lip and Palate

85

Fig. 3.94  Incision of the inferior vomerine margin from anterior in posterior direction

Fig. 3.92  Both of the Bardach flaps harvested

Fig. 3.95  Raising of lateral mucoperiosteal flaps

Fig. 3.93  Mucosal reconstruction of the uvula with traction sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-­ Wiessner, Naila, Germany)

86

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

b a

d c

Fig. 3.96  Vomerine flap harvesting. Vomerine flaps are sutured to the nasal lining of the palatal shelf of the neighbored anterior hard palate with single-button sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany). (a) sche-

matic visualization of complete vomerine flap harvesting; (b) intraoperative situs of vomerine flap preparation; (c) schematic visualization of vomerine flap closure; (d) intraoperative situs after vomerine flap closure

3.5 Technique of Palatoplasty in Bilateral Cleft Lip and Palate

Fig. 3.97  Reconstruction of the nasal mucosa. Reconstruction of the nasal mucosa is carried out with single-button sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany). Do not try to close the nasal mucosa too anteriorly! Aim of reconstruction is tension-free closure!

87

Fig. 3.99  Complete closure of the soft palate muscles

Fig. 3.98  Muscle construction. The muscular bundle is constructed with single-button sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-Wiessner, Naila, Germany) starting from posterior into anterior direction > Kriens’ intravelar palatoplasty

Fig. 3.100  Oral mucosa closure. Oral mucosa is reconstructed from the uvula into anterior direction with resorbable single-button sutures (Vicryl® 4–0, Ethicon, Norderstedt, Germany, or Serafit® 4–0, Serag-­ Wiessner, Naila, Germany). Both united pedicled flaps are sutured to the anterior folds with 5/8 circle needle (Serafit 4–0 with FR-10 needle, Serag-Wiessner, Naila, Germany)

88

3  Primary Repair of the Palatal Cleft: Surgical Treatment Concept of Primary Palatoplasty

Fig. 3.101  Adaptation of the releasing incisions. Adaptation—not tight closure—of both lateral releasing incisions with 4–0 resorbable sutures. In case of minor bleeding fill up dead space with collagen fleece (Lyostypt, B. Braun, Melsungen, Germany). Insertion of feeding tube or alternatively before surgery

References

References

89

Potter J.  William Wardill. Ann Plast Surg. 1982;9:344-7. doi: https:// doi.org/10.1097/00000637-­198210000-­00015. Schweckendiek W.  Primary veloplasty: long-term results without Pantaloni M, Hollier L. Cleft Palate and velopharyngeal incompetence. maxillary deformity. a twenty-five year report. Cleft Palate J. In: Selected readings in Plastic Surgery, 9. Dallas (TX): University 1978;15:268-74. of Texas Southwestern. 2001; 1–36. Tanne JH.  Janusz Bardach. A plastic surgeon who survived Leow AM, Lo LJ.  Palatoplasty: evolution and controversies. Chang imprisonment in the Siberian gold mines. BMJ. 2002;325: Gung Med J. 2008; 31:335-45. 906. Millard DR.  Cleft Craft: The Evolution of Its Surgery. Alveolar and Pace E.  Janusz Bardach, 83, Gulag Survivor and Leading Plastic palatal deformities. Volume 3. Little, Brown; 1980. Surgeon. New York Times. Aug 31, 2002 Woo AS.  Evidence-Based Medicine: Cleft Palate. Plast Reconstr Bardach J.  Two-flap palatoplasty: Bardach’s technique. Oper Tech Surg. 2017;139:191e-203e. doi:https://doi.org/10.1097/ Plast Reconstr Surg. 1995;2:211-4. doi:https://doi.org/10.1016/ PRS.0000000000002854 S1071-­0949(06)80034-­X. McDowell F. The classic reprint: Graefe's first closure of a cleft palate. Kriens OB.  An anatomical approach to veloplasty. Plast Reconstr Surg. 1971;47:375-6. Plast Reconstr Surg. 1969;43:29-41. doi: https://doi. Entin MA. Dr. Roux's first operation of soft palate in 1819: a historiorg/10.1097/00006534-­196901000-­00006. cal vignette. Cleft Palate Craniofac J. 1999;36:27-9. doi: https://doi. Thieme V.  Nachruf für Herrn Prof. Dr. Dr. Otto Kriens (1930-2014). org/10.1597/1545-­1569_1999_036_0027_drsfoo_2.3.co_2. Der MKG-Chirurg. 2014;3:233 Goldwyn RM.  Bernhard Von Langenbeck. His life and legFurlow LT. Cleft palate repair: preliminary report on lengthening and acy. Plast Reconstr Surg. 1969;44:248-54. doi: https://doi. muscle transposition by Z-plasty. Paper presented at the annual org/10.1097/00006534-­196909000-­00005. meeting of South-eastern society of plastic and reconstructive surRittersma J.  The dentist as a plastic surgeon (Hugo Ganzer 1879-­ geons, Boca Raton, FL, May 16, 1978. 1960). J Craniomaxillofac Surg. 1988;16:51-4. doi: https://doi. Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. org/10.1016/s1010-­5182(88)80017-­9. Plast Reconstr Surg. 1986 Dec;78(6):724-38. doi: https://doi. Ganzer H.  Wolfsrachenplastik mit Ausnützung des gesamten org/10.1097/00006534-­198678060-­00002. Schleimhautmaterials zur Vermeidung der Verkürzung des Kaye A. Kirschner RE. Part VIII Primary Cleft Lip and Palate Repair. Gaumensegels. Berl Klin Wschr 1920;57:619. Chapter 49 The Furlow Double-Opposing Z-Plasty Repair for Cleft Veau V. Division palatine. Paris: Masson; 1931. Palate. In: Losee JE, Kirschner RE, editors. Comprehensive Cleft Kilner TP. Cleft lip and palate repair technique. St. Thomas Hosp Rep. Care, Volume 2. 2nd ed. Stuttgart: Thieme; 2016. 1937;2:127. Katzel EB, Basile P, Koltz PF, Marcus JR, Girotto JA.  Current Ivy RH. T. Pomfret Kilner, C.B.E., F.R.C.S. EMERITUS PROFESSOR Surgical Practices in Cleft Care: Cleft Palate Repair Techniques OF PLASTIC SURGERY, UNIVERSITY OF OXFORD.  Plast and Postoperative Care. Plast Reconstr Surg. 2009;124:899-906. Reconstr Surg. 1964;34:313-4. doi:https://doi.org/10.1097/PRS.0b013e3181b03824. Wardill WEM. The technique of operation for cleft palate. Br J Surg. 1937;25:117-30.

4

Surgery of the Alveolar Cleft: Secondary Bone Grafting of Alveolar Clefts

Bone grafting in alveolar bone grafts may be done primarily, secondarily, or tertiarily. When grafting is performed during early childhood the repair is classified as primarily. Current “state of the art” is secondary bone grafting at the end of the mixed dentition—usually between the ages of 9 and 12 years. The secondary procedure is performed prior to full eruption of the cleft side permanent canine, which allows the canine to erupt through the bone (Murthy and Lehman 2005; Weissler et  al. 2016). Tertiary or late bone grafting is performed in the permanent dentition, mainly to support implant-related prosthodontic rehabilitation. Although bone substitutes have been used clinically, autogenous particulate marrow and cancellous bone from the iliac crest has proven to be the best option (Weissler et al. 2016; Guo et al. 2011). Goals of the secondary bone grafting procedure are: Create bone for eruption of the teeth at the cleft side Stabilization of the (intermediate) jaw segments and prevention of collapse Allowing sustainable orthodontic therapy Create a bony continuity of the alveolar process for stomatognathic rehabilitation Installing symmetry in the maxillofacial region Eliminating oronasal fistula Improving aesthetics Improving speech (Weissler et al. 2016; McCrary and Skirko 2021) Some aspects of the surgical procedure deserve special attention. Soft tissue management for sufficient coverage of the bone graft plays an important role. A tension-free closure should be achieved and shortening of the vestibule avoided by targeted incision guidance or thoughtful selection of the soft tissue graft. In bilateral wide clefts, a two-stage closure—one side after the other at a minimum interval of three months—is recommended because of the lack of soft tissue. If the nasal floor is not preserved, a tight plastic of the same is obligatory before the bone graft is inserted.

4.1 History and Development To understand the current concept of secondary osteoplasty, a retrospective view of the evolution of alveolar cleft repair is essential. While archaic methods were initially indicated for tertiary osteoplasty, techniques have subsequently been adapted to functional and chronological requirements in consideration of donor site morbidity. In the following, the most important surgical developments and their protagonists are described by means of anecdotal stories.

4.1.1 Primary and Tertiary Osteoplasty 1901 Anton von Eiselsberg (born 1860 in Steinhaus in Lower Austria, died in 1939  in a train accident near Saint Valentin in Lower Austria) studied medicine in Vienna, Wuerzburg, Zurich, and Paris. He completed his surgical training with Theodor Billroth in Vienna. From 1893 onwards he was director of surgery at Utrecht University, from 1896 at the University of Koenigsberg/East Prussia, before he became Head of the First Department of Surgery at the University of Vienna in 1901. Von Eiselsberg retired in 1931 and is considered as the founder of one of the largest surgical schools in Europe— Hans Pichler was one of his subordinates (Von Eiselsberg 1937). Besides his valuable contributions to neurosurgery, he made initial efforts for autogenous tissue transplantation into the alveolar clefts. In 1901 he reported about a pedicled composite tissue transplant in a 19-yearold daughter of a baker. Von Eiselsberg transplanted the entire little finger into the alveolar cleft. He deepithelialized the volar surface of the finger, removed tendons and fingernail, and sutured the finger to the premaxilla (Fig.  4.1). Twenty days afterwards he cut the pedicle (Von Eiselsberg 1901; Haeseker 1990).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. Kesting et al., A Visual Guide for Cleft Surgeons, https://doi.org/10.1007/978-3-031-33521-1_4

91

92

4  Surgery of the Alveolar Cleft: Secondary Bone Grafting of Alveolar Clefts

Krailling near Munich) completed his medical studies in Kiel and in Munich. He began his training as a surgeon and particularly as a pediatric surgeon at Munich University in 1909. During his work at the Hauner Children Hospital (1912-1936) he paid special focus on cleft surgery and did over 50 palatoplasties in 1913. Twenty years later he reported of 94 palatoplasties per year which was the largest number of a single center in Germany (Kaufmann 1998). In 1914 Drachter reported about bone grafting into the broad bilateral cleft of a 7-year-old boy. He described problems with bone and periosteum transplantation from the tibia to the palate and alveolus in doing the case. A particular challenge was to establish a wound bed which he obtained from soft tissue of the inferior turbinate and the vomer (Drachter 1914).

Fig. 4.1  Drawing of finger transplantation into a 19-year-old female (From Von Eiselsberg F. Zur Technik der Uranoplastik. Arch Klin Chir. 1901;64:509-29; public domain)

1908 Erich Lexer (born in Freiburg im Breisgau in 1867, died in a telephone box in Berlin in 1937) completed medical school in Wuerzburg. After anatomical research and work in Goettingen, he was trained in surgery at the Charité. In 1905 he became director of surgery at the University of Koenigsberg/East Prussia, before he became Head of the Surgical Department of the University of Jena in 1910. In 1919 he took over the Chair of Surgery at Freiburg University before he finally became Head of the Surgical Department at Munich University in 1928, where he extended the surgical capacity to nearly 500 beds. Besides Jacques Joseph Erich Lexer is considered as father of plastic surgery in Germany. While Jacques Joseph lost his medical licensure due to his Jewish descent in the 1930s (Bhattacharya 2008), Erich Lexer was a respected surgeon under National Socialism. He published the detailed step-by-step procedure for sterilization and castration of undesirable men under the Nazi Forced Sterilization Law (Zimmermann 2016). But Lexer was also one of the first surgeons dealing with bone transplantation. On April 21, 1908, he reported in a lecture held at the German Surgical Congress about the use of autologous tibial bone grafts after undermining the soft tissue of older cleft children (Lexer 1908; Bonatesta 2000). 1914 Richard Drachter (born in 1883  in Ellwangen/Germany, died of pulmonary gangrene due to tuberculosis in 1936 in

1952 Eduard Schmid (born in Kressbronn near Lake Constance in 1912, died in Stuttgart in 1992) received his surgical education in Martin Wassmund’s Department at the Charité. After treating lots of soldiers with facial wounds in World War II he founded the Department for Reconstructive Surgery at the Marienhospital in Stuttgart in 1950. Eduard Schmid contributed essentially to alveolus repair. After a visit to Schmid the US-American surgeon Richard Schultz described that Schmid had begun in 1944 already to implant bone in palatal defects. Initially he had used tubed flaps as carriers (Schultz 1964). Schmid himself reported about primary hip bone grafting between the separated alveolar processes since 1952. He performed the technique at an age of 8 months (Schmid 1955; Schmid 1954). From 1962 on he suggested additional grafting of the bony gap in the hard palate of the cleft patients (Schmid 1967).

4.1.2 The Way to Secondary Osteoplasty 1954 In Sweden, another “primary bone grafting” group developed around the plastic surgeon Bengt Johanson (born in 1920 in Borås, died in 2007). Johanson was well known for his contributions to urethroplasty, but Johanson also set a landmark in cleft alveoloplasty. In his period as associate professor at Karolinska Institute in Stockholm he cooperated with the orthodontist Karl-Erik Nordin. Their interdisciplinary approach incorporated initial orthodontic alignment of the jaw stumps. After that the stumps were stabilized by surgically implanted bone to the alveolar cleft and additionally to the hard palate (Schultz 1964). Bengt Johanson moved to Gothenburg in 1956 where he became Head of Department of Plastic Surgery at Sahlgrenska University Hospital. At the 1964 Hamburg cleft symposium he started to question the procedure of primary bone grafting. In view of the effects of orthodontic treatment without early bone graft, he changed

4.2 Patient Case

93

his policy: from 1968 on Johanson did secondary bone grafting in the mixed dentition (Johanson et al. 1974; Randall and LaRossa 2006). 1972 The current principles of secondary bone grafting were established by Philip Boyne (born in 1924  in Houlton, Maine, died in 2008 in Loma Linda, California) (Boyne and Sands 1972; Boyne and Sands 1976). Boyne graduated at Tufts Dental School in Boston in 1947 before he spent a twenty-year career in the US Navy. After that he entered his second career as a researcher for bone grafts and ideal biomaterials. Initially, he worked as a scientist and professor at the UCLA. In 1975, he became founding dean at the School of Dentistry at the University of Texas in San Antonio, Texas, before he decided to come back to California three years later. Boyne took over a faculty position at Loma Linda Dental School where he worked until his retirement (Spector 2008).

Fig. 4.3  Incision hardly buccal of the alveolar crest and careful preparation of palatal mucoperiosteal flaps

4.2 Patient Case 4.2.1 Secondary Bone Grafting of Alveolar Cleft In the current case a right-sided alveolar cleft lip is presented. The alveolar cleft is grafted with autologous cancellous bone harvested from the anterior iliac crest. Closure is performed with palatal flaps and an Axhausen flap of the buccal mucosa (Figs. 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.14, 4.15, 4.16, 4.17, 4.18, 4.19, 4.20, 4.21, and 4.22) (Axhausen 1930).

Fig. 4.4  Approximation of the palatal flaps with a 4-0 absorbable suture

Fig. 4.2  Alveolar cleft at the left side, frontal view

Fig. 4.5  Approximated palatal flaps, view from buccally

94

4  Surgery of the Alveolar Cleft: Secondary Bone Grafting of Alveolar Clefts

Fig. 4.6  Approximated palatal flaps, if necessary tight closure of nasal mucosa

Fig. 4.9  Cancellous bone graft from the iliac crest

Fig. 4.7  Incision at the anterior spine of the iliac crest

Fig. 4.10  Placement of a collagen swab into the donor site

Fig. 4.8  Harvest of a cancellous bone graft with a trephine/Shepard’s osteotome

Fig. 4.11  Axhausen flap design in the posterior vestibulum

4.2 Patient Case

95

Fig. 4.12  Harvest of pedicled Axhausen flap for vestibuloplasty

Fig. 4.15  Transpositioned Axhausen flap fixed with resorbable 4-0 sutures for vestibuloplasty

Fig. 4.13  Transposed Axhausen flap for vestibuloplasty

Fig. 4.16  Axhausen flap donor site closed primarily

Fig. 4.14  Cancellous bone packed into the alveolar cleft

Fig. 4.17  Ten days postoperatively after removal of sutures

96

4  Surgery of the Alveolar Cleft: Secondary Bone Grafting of Alveolar Clefts

Fig. 4.21  Forty-six months postoperatively—orthodontic therapy finished, intraoral view from lateral

Fig. 4.18  Six weeks postoperatively with erupted canine (tooth 13)

Fig. 4.19  Five months postoperatively with erupted canine (tooth 13) and premolar (tooth 14)

Fig. 4.20  Nineteen months postoperatively after tooth alignment

Fig. 4.22  Forty-six months postoperatively—orthodontic therapy finished, frontal view intraorally

References

References

97

Bonatesta G.  Die Entwicklung der Knochenplastik im Unterkiefer zwischen 1919 und 1939  in Deutschland [The development of osteoplastic surgery in Germany between 1919 and 1939]. Zur Murthy AS, Lehman JA.  Evaluation of alveolar bone grafting: a surMedizingesch Abh. 2000;285:1-73. vey of ACPA teams. Cleft Palate Craniofac J. 2005;42:99-101. doi: Kaufmann T.  Die Kinderchirurgie auf dem Weg zu Selbständigkeit. https://doi.org/10.1597/03-­045.1. Richard Drachter (1883-1936): Leben und Werk. Freiburg im Weissler EH, Paine KM, Ahmed MK, Taub PJ.  Alveolar Bone Breisgau; 1998. Grafting and Cleft Lip and Palate: A Review. Plast Reconstr Drachter R. Die Gaumenspalte und deren operative Behandlung. Dtsch Surg. 2016;138:1287-95. doi: https://doi.org/10.1097/ Z Chir. 1914;131:1–89. PRS.0000000000002778. Schultz RC.  A Survey of European and Scandinavian bone grafting Guo J, Li C, Zhang Q, Wu G, Deacon SA, Chen J, Hu H, et al. Secondary procedures for cleft palate deformities. Cleft Palate J. 1964;12: bone grafting for alveolar cleft in children with cleft lip or cleft lip 188-90. and palate. Cochrane Database Syst Rev. 2011;CD008050. doi: Schmid E.  Die Annäherung der Kieferstuempfe bei Lippen-Kiefer-­ https://doi.org/10.1002/14651858.CD008050.pub2. Gaumenspalten; ihre schädlichen Folgen und Vermeidung. Fortschr McCrary H, Skirko JR.  Bone Grafting of Alveolar Clefts. Oral Kiefer Gesichtschir. Stuttgart: Georg Thieme; 1955. p. 37-40. Maxillofac Surg Clin North Am. 2021. doi: https://doi.org/10.1016/j. Schmid E. Die aufbauende Kieferkammplastik [Constructive alveolar coms.2021.01.007. crest gnathoplasty]. Osterr Z Stomatol. 1954;51:582-3. Von Eiselsberg A.  Lebensweg eines Chirurgen. Innsbruck: Tyrolia-­ Schmid E. Entwicklung und Gegenwärtiger Stand der Knochenplastik Verlag; 1937. in der Spaltchirurgie [Development and present state of bone plasty Von Eiselsberg F.  Zur Technik der Uranoplastik. Arch Klin Chir. in the surgery of cleft palate]. Acta Chir Plast. 1967;9:15-24. 1901;64:509-29. Johanson B, Ohlsson A, Friede H, Ahlgren J. A follow-up study of cleft Haeseker B.  Digits in the mouth; a peculiar chapter in cleft lip and lip and palate patients treated with orthodontics, secondary bone palate surgery. Br J Plast Surg. 1990;43:724-7. doi: https://doi. grafting, and prosthetic rehabilitation. Scand J Plast Reconstr Surg. org/10.1016/0007-­1226(90)90198-­9. 1974;8:121-35. doi: https://doi.org/10.3109/02844317409084381. Bhattacharya S.  Jacques Joseph: Father of modern aesthetic surgery. Randall P, LaRossa D.  Chapter 12: A Short History of Prepalatal Indian J Plast Surg. 2008;41(Suppl):S3-8. Clefts. In: Berkowitz S, editor. Cleft Lip and Palate: Diagnosis and Zimmermann F. Der Chirurg Erich Lexer war ein Arzt im Dienste des Management. 2nd ed. Berlin, Heidelberg: Springer Verlag; 2006. NS-Regimes. In: Badische Zeitung. 2016. https://www.badische-­ Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and zeitung.de/freiburg/der-­c hirurg-­e rich-­l exer-­w ar-­e in-­a rzt-­i m-­ palatal clefts. J Oral Surg. 1972;30:87-92. dienste-­des-­ns-­regimes%2D%2D129362180.html. Accessed 28 Boyne PJ, Sands NR. Combined orthodontic-surgical management of Dec 2022. residual palato-alveolar cleft defects. Am J Orthod. 1976;70:20-37. Lexer E.  Die Eingriffe zur Unfruchtbarmachungen des Mannes doi: https://doi.org/10.1016/0002-­9416(76)90258-­x. und zur Entmannung. In: Gesetz zur Verhuetung erbkranken Spector M. Obituary: Ideas and inspiration: a remembrance of Philip Nachwuchses nebst Verordnung vom 5. Dezember 1933 ueber die J Boyne, DMD, MS, DSc. Biomed Mater. 2008. doi: https://doi. Ausfuehrung des Gesetzes, Auszug aus dem Gesetz gegen gefährliorg/10.1088/1748-­605X/3/3/030401 che Gewohnheitsverbrecher und ueber Maßregeln der Sicherung Axhausen G. Über den plastischen Verschluß von Mund-Antrumund Besserung vom 24. November 1933. 2nd ed. Muenchen: J. F. Verbindungen. Dtsch Monatsschr Zahnheilkd. 1930;3:193–8. Lehmanns Verlag; 1934. Lexer E. Die Verwendung der freien Knochenplastik nebst Versuchen ueber Gelenkversteifung und Gelenktransplantation. Langenbecks Arch Klin Chir Ver Dtsch Z Chir. 1908;86:939–54.

5

Surgery of the Transverse Facial Cleft/ Congenital Macrostomia: Lip and Commissuroplasty in the Transverse Facial Cleft

Transverse facial clefts—classified as number 7 according to Tessier—result from non-fusion of the embryonic mandibular and maxillary processes. Mild forms involve the oral commissure alone, while severe forms are associated with hypoplastic forms of first and second branchial arch derivates (Khorasani et al. 2019; Bütow and Botha 2010; May 1962; Stark and Saunders 1962; Boo-Chai 1969). Macrostomia repair consists of commissuroplasty which includes restoration of the mucosal, the skin, and the muscle parts. Surgery should be performed between 3rd and 5th months of life. Goals of macrostomia repair are:

Estlander (born 1831 in Lapväärtti/Finland, died in 1881 in Messina/Sicily) (Khorasani et al. 2019; May 1962; Estlander 1872; Westrin 1907). Estlander, who became professor of the Emperor University of Helsinki in 1860, describes the case of Oskar Hanström, a 17-year-old farmer boy, who lost parts of his upper lip because of Typhus. In 1868 Estlander rotated a full-thickness part of the lower lip—pedicled on the labial artery—into the defect of the upper lip (Fig. 5.1). After waiting for the transplant to heal he cut through the bridge between lower and upper lip containing the nourishing artery (Estlander 1872; Westrin 1907).

Create a harmonic skin-vermilion border Create a symmetric (with the non-affected side) and functional labial commissure Create a neo-modiolus Avoid lateral and downward displacement of the commissure and the scar Produce preferably invisible scars and avoid contractures (Khorasani et al. 2019; Bütow and Botha 2010)

5.1 Basic Technique Numerous surgical techniques for macrostomia repair are available. Basically, skin and mucosal construction are founded on the technique of the Finnish-Swedish surgeon Jakob August

Fig. 5.1  Estlander flap: Full-thickness defect of the upper lip and commissure region (indicated by gray marking) covered with pedicled fullthickness transposition flap from the lower lip. The nourishing labial artery is indicated by red marking

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. Kesting et al., A Visual Guide for Cleft Surgeons, https://doi.org/10.1007/978-3-031-33521-1_5

99

100

5  Surgery of the Transverse Facial Cleft/Congenital Macrostomia: Lip and Commissuroplasty in the Transverse Facial Cleft

5.2 Recommended Procedures Depending on the Extent of the Cleft Macrostomia repair is performed in the following steps: After excision of excess lip vermilion in the lateral part of the cleft and closure of intraoral mucosa, the basic correction includes the transfer of lower lip vermilion to the upper lip. Muscle plasty to restore function is done by commissuroplasty and construction of a neo-modiolus (Khorasani et al. 2019; Bütow and Botha 2010). Depending on the width of the transverse cleft the lateral skin part is corrected by: Straight line closure in minor clefts Z-Plasty in broad and minor clefts Double Z-Plasty in broad clefts wider than 1cm W-Plasty in broad clefts (Bütow and Botha 2010)

5.3 History and Development of the Techniques 1961 Richard Stark (1915–2008) and David Saunders (1931– 2021) from New  York held a lecture about “The First Branchial Syndrome” at the Meeting of the American Society of Plastic and Reconstructive Surgery in New Orleans in September 1961. Hereby they presented a Z-plasty technique for large transverse clefts. In the following paper published in 1962 they pointed out that first the excess tissue from the rima was paired and subsequently closed. After that a Z-plasty was performed on the skin (Fig. 5.2). To restore the angle of the lip a small mucosal pedicle was raised and inserted into the opposite lip (Stark and Saunders 1962; Weatherly-White 2008; Longacre et al. 1963). Jacob James Longacre (1907–1976) once alone and a second time with his coworkers from Cincinnati, Ohio, referred to the technique in publications in 1963 and 1965 and outlined the Z-plasty technique in a photography (Longacre 1965; Stark 1976; Oakey 1977).

Fig. 5.2  Incisions for Z-plasty for large transverse clefts after Stark and Saunders

1961 At the same congress in New Orleans in September 1961 Hans May presented the commissuroplasty according to Estlander’s technique. He described his coworker Richard S. Oakey, Jr. switching a triangular flap from the lower lip— pedicled on the labial artery—to a triangular incision of the upper lip. Prior to this transplantation the vermilion in the transverse cleft area was excised (Fig.  5.3) (May 1962). Hans May (born in 1902  in Germany, died in 1975  in Philadelphia) was taught as a plastic surgeon by Erich Lexer in Munich and immigrated to the United States in 1934. In 1953 he became chief of plastic surgery in Lankenau Hospital in Philadelphia (Oakey 1977). 1969 Khoo Boo-Chai (born 1929  in Singapore, died 2012  in Singapore) added oblique incisions in the upper and lower lip vermilion to the Z-plasty in the lateral skin (Fig.  5.4). Furthermore, he paid much attention to the oral muscles. He prepared the oral muscles and stitched them as close to the new commissure as possible (Boo-Chai 1969). 1982 Bruce Bauer from Chicago and his colleagues described a W-plasty technique for the lateral skin part to improve the aesthetic result. First, they marked the virtual new commissure and cut a small triangular flap at this site in the upper and lower lip (Fig. 5.5). After removal of excess vermilion

Fig. 5.3  Modified Estlander plasty for transverse clefts—commissuroplasty technique after May and Oakey, Jr.

Fig. 5.4  Incisions for modified Z-plasty with oblique vermilion incisions after Boo-Chai

5.4 Case Report

101

Fig. 5.5  Incisions for W-plasty after Bauer and colleagues Fig. 5.7  Z-Plasty technique after Bütow and Botha Fig. 5.6  Schematic diagram of the muscles involved and construction of the modiolus

and skin tissue in the lateral part of the cleft, the orbicularis oris muscle and the buccinator muscle were dissected free, before the oral mucosa was closed in a straight-line manner. Then the lateral part is closed by several interdigitating W-flaps (Bauer et al. 1982). 2010 Maxillofacial surgeon Kurt Bütow (born in 1948  in Windhoek, Namibia) and his coworker Andre Botha from Pretoria published a new classification of lateral clefts— a superior, a middle, an inferior, and an agenetic form. As surgical technique they recommended the following steps: Straight line closure of the mucosa Superior-pedicled vermilion flap from the upper lip inserted into rectangular incision of the lower lip Construction of a neo-modiolus out of orbicularis oris, zygomatic major, risorius, and depressor anguli oris muscle (Fig. 5.6)

Lateral cutaneous closure with one (Fig.  5.7) or several Z-plasties depending on the extent of the cleft (single Z-plasty in clefts under 1cm width, several Z-plasties in wider clefts) (Khorasani et  al. 2019; Bütow and Botha 2010)

5.4 Case Report 5.4.1 Technique of Lip Plasty and Commissuroplasty in a Transverse Cleft Lip The following case shows a moderately wide transverse cleft lip associated with ipsilateral accessory auricular appendages. As mentioned above, a single Z-Plasty in broad and minor clefts is recommended. The team of authors used the technique according to Bütow and Botha as shown step by step in the following (Figs. 5.8, 5.9, 5.10, 5.11, 5.12, 5.13, 5.14, 5.15, 5.16, 5.17, 5.18, 5.19, 5.20, 5.21, 5.22, 5.23, and 5.24).

102

5  Surgery of the Transverse Facial Cleft/Congenital Macrostomia: Lip and Commissuroplasty in the Transverse Facial Cleft

Fig. 5.8  Right-sided unilateral transverse cleft lip, frontal view Fig. 5.11  Marking of the upper and lower lip midline, marking the distance to the intact commissure, marking the virtual distance to the neo-commissure in the upper and lower lip

Fig. 5.9  Right-sided unilateral transverse cleft lip with accessory auricular appendages

Fig. 5.12  Triangular excision of the extended vermilion of the macrostoma; quadrangular flaps at the upper lip and a complementary quadrangular flap at the lower lip are marked, both are laterally neighbored by triangular flaps

Fig. 5.10  After nasal intubation

Fig. 5.13  Macrostoma tissue is excised by saving the mucosal tissue; quadrangular flaps are incised

5.4 Case Report

103

Fig. 5.14  Orbicularis oris muscle is prepared at the medial stumps

Fig. 5.17  Marking of the excess buccal mucosa

Fig. 5.15  Further preparation of the lower orbicularis oris muscle

Fig. 5.18  "Vestibuloplasty" after excision of excess mucosa with absorbable sutures of size 4-0 (Vicryl® 4-0, Ethicon, Norderstedt, Germany, or Serafit® 4-0, Serag-Wiessner, Naila, Germany)

Fig. 5.16  Preparation of the upper orbicularis oris muscle

Fig. 5.19  After muscle preparation the neo-modiolus is constructed

104

5  Surgery of the Transverse Facial Cleft/Congenital Macrostomia: Lip and Commissuroplasty in the Transverse Facial Cleft

Fig. 5.20  Key suture with non-resorbable, monofilament polyamide of size 6-0 (Ethilon® 6-0, Ethicon, Norderstedt, Germany) before construction of lip vermilion, quadrangular flaps approximated

Fig. 5.21  After having sutured the quadrangular flaps with monofilament polyamide of size 6-0 the lateral triangular flaps for Z-plasty are marked again

Fig. 5.22  By transpositioning of the triangular flaps, a Z-plasty is done. Hereby a vertical disharmony of both commissures is corrected

Fig. 5.23  Z-plasty is done with monofilament polyamide of size 6-0

Fig. 5.24  Frontal view of the patient 7 ½  months postoperatively, sutures have been removed seven days postoperatively

References

References

105

substance in one lip from the other lip). Arch Klin Chir. 1872;14: 622. Westrin T (ed.). Nordisk familjebok, Konversationslexikon och Khorasani H, Boljanovic S, Knudsen MAK, Jakobsen LP.  Surgical Realencyklopedi. Uggleupplagan 2nd ed. 7. Egyptologi  -­ management of the Tessier 7 cleft: A review and presentation of Feinschmecker. Stockholm; 1907. p. 953-4. 5 cases. JPRAS Open. 2019;22:9-18. doi: https://doi.org/10.1016/j. Weatherly-White C.  Richard Boies Stark, M.D., 1915 to 2008. Plast jpra.2019.07.004. Reconstr Surg. 2008;122:998-9. Bütow KW, Botha A.  A classification and construction of congenital Longacre JJ, DeStefano GA, Holmstrand KE.  The surgical managelateral facial clefts. J Craniomaxillofac Surg. 2010;38:477-84. doi: ment of first and second branchial arch syndromes. Plast Reconstr https://doi.org/10.1016/j.jcms.2010.02.007. Surg. 1963;122:998-9. May H.  Transverse facial clefts and their repair. Plast Reconstr Surg Longacre JJ. The surgical management of the first and second branchial Transplant Bull. 1962;29:240-9. arch syndrome. Br J Plast Surg. 1965;18:243-53. Stark RB, Saunders DE.  The first branchial syndrome. The oral-­ Stark RB.  Obituary. Jacob James Longacre, M.D., Ph.D. 1907-1976. mandibular-­ auricular syndrome. Plast Reconstr Surg Transplant Plast Reconstr Surg. 1976;58:657-9. Bull. 1962;29:229-39. Oakey RS.  In memoriam: Hans May (1902-1975). J Hand Surg Am. Boo-Chai K.  The transverse facial cleft: its repair. Br J Plast 1977;2:245. Surg. 1969;22:119-24. doi: https://doi.org/10.1016/ Bauer BS, Wilkes GH, Kernahan DA.  Incorporation of the W-plasty s0007-­1226(69)80052-­4. in repair of macrostomia. Plast Reconstr Surg. 1982;70:752-7. doi: Estlander JA. Eine Methode aus der einen Lippe Substanzverluste der https://doi.org/10.1097/00006534-­198212000-­00019. anderen zu ersetzen [German] (A method of reconstructing loss of