Repair of Unilateral Cleft Lip Depormity: Maxilla, Nose and Lip

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Abstract
The congenital cleft lip deformity is defined as a tripartite reconstructive problem: restoration of the cleft maxilla, correction of the nasal deformity, and repair of the lip. Procedures extensively based on new principles for the surgical management of these malformations are described and shown in detail. They allow consideration of the entire reconstructive task in the primary operation. For maxillary reconstruction the osteogenic capacity of tissues bordering the cleft is utilized. The operation involves subperiosteal exposure of the bone and the establishment of periosteal continuity between the maxillary segments, using local flaps of the periosteal membranes. Surgicel® is used as a scaffolding between the periosteal surfaces to bring about deposition of a mass of bone. In complete clefts a two-stage procedure is recommended for periosteal repair and for the implantation of Surgicel. Observations on the effect of periosteo-plasty confirmed previous reports: the procedure will lead to the formation of new bone within the cleft, stimulate appositional growth of the lateral maxillary segment, and there is a favourable approximation within the alveolar region. As a result facial symmetry is achieved. It was also found that tooth buds will migrate into the new bone. The need for maxillary correction in incomplete clefts is emphasized; in these cases the technique for maintaining the periosteal membranes in the planned position proved simple and effective. The nature of the characteristic nasal deformity is analysed. It is regarded as being mainly due to dislocation of the anatomical framework, caused by abnormal traction during development as a result of discontinuity of the nostril circumference. Based on this assumption a method for surgical correction was developed, by which the normal shape and topographic anatomy of the dislocated alar cartilage is restored. Prolonged postoperative corrective splinting is recommended to maintain the result. The reasons for recurrence of the deformity are discussed. Minor changes in the author's original design for repair of unilateral clefts of the lip are reported and more emphasis is laid upon the restoration of muscle function. It is realised that lip movements are centered around a vertical axis through the midline of the philtrum. In order to achieve muscle balance the lateral muscle segment is attached to the midportion of the philtrum. By this technique the general appearance of the lip is also improved and a philtrum ridge may form on the cleft side. The advantages of the entire procedure for lip closure are discussed.

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