CME Correction of Secondary Cleft Lip Deformities CME Correction of Secondary Cleft Lip Deformities

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Text of CME Correction of Secondary Cleft Lip Deformities CME Correction of Secondary Cleft Lip Deformities

  • CME

    Correction of Secondary Cleft Lip Deformities Samuel Stal, M.D., and Larry Hollier, M.D. Houston, Texas

    Learning Objectives: After studying this article, the practitioner should be able to (1) describe the common secondary deformities of the cleft lip, (2) determine the appropriate timing for surgical intervention to correct the deformities, and (3) determine the best method of addressing each of the individual secondary deformities of the cleft lip.

    Secondary deformities are common in children born with a cleft lip and palate. Patients with cleft lip deformity will undergo multiple surgical procedures early in life, so it is imperative to prioritize treatment of their secondary deformities and minimize the number of interventions needed. Of the many approaches used to correct these problems, surprisingly few work well consistently. As with all plastic surgery, the timing and procedure should be predicated on the severity of the deformity. (Plast. Re- constr. Surg. 109: 1672, 2002.)

    Secondary deformities of the cleft lip are the rule rather than the exception. As the patient with a cleft lip deformity will undergo multiple surgical procedures throughout the course of his or her early life, it is imperative to prioritize treatment of the secondary deformities and therefore minimize the number of interven- tions necessary. A myriad of approaches have been used to correct these problems, but sur- prisingly few work well consistently. As with all plastic surgery, timing and the surgical treat- ment should be predicated on the severity of the deformity.

    Essentially all patients with primary cleft lip deformities are operated on within the first year of life. After this, there is a long period of dramatic growth. Although this early surgery is mandatory to minimize secondary functional problems, the powerful variable of growth may ultimately distort the immediate surgical re- sult. Consequently, the correction of these sec- ondary deformities is an integral part of the care of these patients. Indeed, these secondary procedures are frequently more complex than the initial surgery. The problems are so widely varied that the choice of an appropriate tech-

    nique to correct them is challenging. Another extremely important variable is that of appro- priate timing of surgery. Determining the age to surgically intervene is an important compo- nent of a successful outcome. As will be dis- cussed, this must be determined in large part on the basis of the severity of the deformity inasmuch as it relates to normal growth and development.


    Before embarking on secondary surgery for the cleft deformity, one must accurately diag- nose all problems associated with the lip and nose. With respect to the lip, one must care- fully examine the lip scar, the status of the orbicularis muscle, the orientation of the ver- milion and white roll, the Cupid’s bow, and the mucosa. The nasal deformity must be docu- mented and examined for symmetry of the alar bases and nostril shape, length of the colu- mella, and any deformations or deficiencies of the nasal lining. It is imperative that all of these elements be related to the underlying skeletal deformity on which they are based. Skeletal imbalance from maxillary hypoplasia or malpo- sition contributes significantly to the secondary problems commonly seen after initial lip repair.1

    Once the deformity has been accurately di- agnosed, one must make every effort to deter- mine the underlying cause. Although hypopla- sia and distortion occur as a result of the malformation and set the stage for many of the commonly seen secondary deformities, poor preoperative design of the primary operation

    Received for publication October 4, 2000; revised September 21, 2001.


  • contributes as well. For example, a short lip may be caused by something as simple as a tight contracted scar. On the other hand, un- der-rotation of the initial lip repair may be the source of the problem, as may be failure to anatomically reunite the underlying orbicu- laris. The design of the secondary surgery should be focused to correct the specific prob- lem. The solution must take into account the soft tissue, muscle, and the underlying skele- ton. Addressing all short lips with the same operation is not sufficient. Numerous classifi- cation schemes have been devised to simplify the evaluation of secondary cleft lip and nasal deformities. However, they tend to be very cumbersome and do very little to facilitate the diagnosis and its underlying cause.2,3


    There is no absolute rule for delineating the precise timing of surgery for secondary defor- mities. Although Millard’s admonition that sur- gery may result in exaggerated scar formation in patients aged 8 to 18 years must be consid- ered, many patients will absolutely require sur- gical revision during this time period.4 The severity of the individual patient’s deformity and its effect on the child from a psychosocial or functional standpoint is also a critical factor to be considered. Secondary procedures to im- prove functional problems, such as speech, breathing, or eating, are frequently indicated and need to be aggressively addressed regard- less of age. Perhaps the most common age for revisional soft-tissue surgery in our clinic is in the preschool period from 4 to 5 years of age. Peer interactions begin to develop at this time, and the child is extremely impressionable and vulnerable. Another common period for surgi- cal correction is during early adolescence. The nature of peer interaction is frequently chang- ing at this time, and teenagers often become extremely self-conscious. In addition, teenage patients usually express their opinions more vocally regarding their appearance and should be involved in the decision-making process re- garding secondary surgery.

    The cessation of facial growth is another critical landmark in the timing of secondary operations. However, it must be remembered that different components of the face cease growing at different ages. Whereas mandibular growth may not be complete until age 16 or older, nasal growth in girls has been conclu- sively shown to stop at approximately 11 to 12

    years of age and in boys at approximately 13 to 14 years of age.5

    Cleft Lip

    Normal lip anatomy. The anatomy of the up- per lip and its relation to the lower lip is re- markably constant between individuals. The central defining structure of the upper lip is the Cupid’s bow. The gentle curve of this structure between the Cupid’s bow peaks, and its rela- tionship to the white roll is important to recon- struct. In the 3-month-old child, the Cupid’s bow is generally less than or equal to 5 to 6 mm. As one ascends the philtrum above this, the philtral columns on either side gradually nar- row as the columella is approached, where they are generally 10 to 11 mm apart. These are important measurements in the repair of the cleft lip deformity, because the reconstructed philtrum has a tendency to stretch significantly over time. This is particularly true with the bi- lateral cleft lip deformity, in which the orbicu- laris muscle is usually sutured together, or to either side of the prolabium. This causes the new philtrum to stretch. As such, the width of a Cupid’s bow should be designed no greater than 4 to 5 mm at the time of primary surgery to avoid the commonly seen wide philtrum.

    Another important component to upper lip anatomy is the length of the upper lip. At rest, the upper lip normally projects 2 to 3 mm anterior to the lower lip. The upper and lower lips rest together in the relaxed state. A com- petent seal is easily created with light pressure. Failure to achieve adequate upper lip length at the time of primary surgeries results in a fore- shortened tight-lip appearance. In the wide cleft, this is sometimes inevitable, because there is a primary deficiency of tissue. How- ever, inappropriate design of the lip rotation may also limit potential lip length.

    Finally, the vermilion border, the distinct convex white roll, and the precise relation be- tween these two structures are absolutely criti- cal in lip repair. The white roll is a structure that cannot be duplicated surgically. In second- ary surgery, incisions should be carefully de- signed, preserving and aligning the white roll precisely, because a malalignment of more than 1 mm is clearly noticeable at a conversa- tional distance. Any intervening scar, whether hypopigmented or hyperpigmented, interrupt- ing the continuous anatomic line is very notice- able. This is also true for the line of demarca- tion between the wet and dry vermilion. The


  • vermilion lip line is normally straight, with an increased fullness in the midline tubercle. Any deviation from this with a notch or convexity is abnormal.

    Prevention of Secondary Cleft Lip Deformities

    The ideal time to address secondary defor- mities is at the time of the initial operation, when every effort should be made to prevent them. We have recently seen a shift in philos- ophy from staged, delayed procedures to an early aggressive repair of clefts to minimize deformities early.5–14 As such, it is important even before the surgery to use the techniques of surgical orthopedics to align the cleft mar- gins, minimizing the tension on the repair and improving the bony platform for the nasal cor- rection. In the past, many devices have been described that allow either passive or active manipulation of the cleft segment into a more anatomic relationship.15,16 The passive plate maintains the transverse width of the maxillary segments using external forces to retract the premaxilla or malpositioned segment using ad- hesive tape and elastic ban