Cleft lip and palate basics for medical students

1. Cleft Lip and Palate
Dr. Faisal Ameer MS, MCh, MRCSEd
International Scholar for 2015, Plastic Surgery Foundation of ASPS/ASMS
International Member of American Society of Plastic Surgeons
Member of Royal College of Surgeons Edinburgh
Associate Professor Plastic Surgery
LLRM Medical College
Meerut, U.P. India
+91 9557721163
www.plasticsurgicraft.com

2. Objectives
• Recap of embryology
• Relevant Anatomy and
Pathophysiology
• Classification
• Counseling of parents
• Basic repair techniques

3. Introduction
 Facial clefting is the second most
common congenital deformity (after
clubfoot).
 Affects 1in 1000 births
 Problems are cosmetic, dental,
speech, swallowing, hearing, facial
growth, emotional

4. Pathophysiology
 Complex mechanism of swallowing,
hearing, speech and breathing are
impaired
 Feeding difficulty in neonate. (Cleft
makes creation of negative pressure
difficult)
 Eustachian tube dysfunction
 Secondary defect of tooth
development.
 Psychological problem.

5. Genetics
 Non-syndromic inheritance is
multifactorial
◦ Cleft Lip, With or Without Cleft Palate:
 One Parent-2%
 One Sibling- 4% Two Siblings- 9%
 One Parent + One Sibling- 15%
◦ Cleft Palate:
 One Parent- 7%
 One Sibling- 2% Two Siblings- 1%
 One Parent + One Sibling- 17%

6. Antenatal diagnosis

7. Epidemiology
 Cleft Lip +/- Palate- M:F 2:1
 Cleft Palate - F:M 2:1
 Cleft Lip +/- Palate- Native Americans
> Oriental and Caucasians > Blacks
 Cleft Palate- Same among ethnic
groups
 Environmental: Ethanol, Rubella virus,
Thalidomide, Aminopterin B

10. Embryology

11. Classification
 Nagpur classification
◦ Group I – cleft lip only
◦ Group Ia – cleft lip + cleft alveolus
◦ Group II – cleft palate only
◦ Group III – cleft lip + cleft alveolus + cleft
palate

18. Anatomy

19. • Philtrum
• Philtral Ridges
• Cupid’s Bow
• Philtral Dimple
• Commisure
• White roll
• Tubercle

24. History & Examination
 Cosmetic disfigurement (cleft lip)
 Feeding problems in cleft palate
◦ Suckling difficulties
◦ Nasal regurgitation
 Ear disease
 Respiratory infections
 Malnutrition and failure to thrive (wt. for
age)
 Other congenital anomalies – digits,
cardiac, craniofacial syndromes etc.

25. Pre operative evaluation
 History
 Physical examination
 Laboratory data
 Hb%
 Syndromes – X–ray mandible, Cardiac
workup

26. Investigations
 Blood
 OPG (for canine tooth eruption)
 Occlusal view
 Speech evaluation
◦ Nasendoscopy
◦ Lateral/Frontal videofluroscopy
◦ Flowmetery
 Cephalometry – lateral / AP

27. Management

28. Care of the newborn

42. Lip Repair

43. Timing of Cleft Lip Repair
 At three months of age
◦ Larger anatomical parts
◦ Safer anesthesia
Rule of 10
 10 weeks
 10 grams
 10 pounds
 10k WBC

45. Millard Lip Reapir

47. Randall-Tenisson Lip Reapir

49. Veau Lip Reapir

51. Palate Repair

52. Timing of Cleft Palate repair
 Early repair (< 24 mts) – speech and
hearing improved
 Delayed closure (>4y) – less
retardation of mid facial growth
 Optimal time
 Soft palate 3 – 6 mts
 Hard palate 15-18 mts

53. VWK Palate Reapir

55. Intervelar Veloplasty

56. Furlow’s Palate Reapir

58. Surgical Complications
 Early
Airway compromise
Bleeding
 Late
Fistula
Reduced movement of the soft palate
Persistent VPI
Under developed facial skeleton

59. Conclusions
 Embryology and Anatomy extremely
important.
 Counseling and communication
 Meticulous technique and tissue
respect
 Easy to learn
 Cleft team

60. Thank you
 Teamwork is the key !