CASE PRESENTATION ON CLEFT LIP Mazhil.pptx

Case presentation on cleft lip and palate

1. CASE PRESENTATION

2. Name : Magizhan Age/Sex : 11 months / M D.O.B : 06/08/2023 Chief complaint : Patient’s attenders complaint of discontinuity in the lip and palate region for past 11 months durat ion. HOPI : H/O discontinuity in the left side lip and palate region since birth.

3. Family history No H/O of c onsanguineous marriage No H/O cleft lip/palate in both father’s and mother’s side of family One sibling – healthy – 5 years age Pre-Natal History : 3-4 ultrasounds were done during pregnancy, parents were informed about the cleft lip and palate She is not a k/c/o DM/HTN/AIDS Nata l history: Full term delivery(37 weeks) – C-section Weight at birth – 4 kg Cried immediately after birth

4. Postnatal history: Cleft lip and palate at birth Breast feeding till 5 months Bottle feeding afterwards ( nanpro ) Pt is taking solid food also No vaccinations are given No H/o regurgitation of food and liquid No H/O snoring during sleep Milestones of development: 8 th month – crawling/ rolling : Sitting upright

5. General examination: Well built and nourished No signs of Palor , I cterus, C lubbing, Cyanosis, l ymphadenopathy, peda l edema noted

6. Extra oral examination: Facia l form – Mesoprosopic Shape of head - Mesocepha l ic P rofile – straight Mentolabial sulcus – shallow Nose: Wide a l ar base - left side Nasal bridge - normal Columella – deviated towards right Nasa l tip – deviated towards right

7. Extra oral examination: L ips: Incompetent l ips Cleft noted on the left side Intra oral examination: Primary teeth absent Cleft of hard and soft palate and uvula

8. CLASSIFICATIONS KERNAHAN 1971 VEAU 1931

9. Long-term Cleft Care   Perinatal: Genetic counseling , lip taping or NAM 0-6 months: Hearing evaluation and possible ventilating tubes placement, feeding and growth managed by primary clinician, cleft lip repair 9-12 months: Palate repair, ventilating tube placement 1-4 years: Close follow-up for language development, dental evaluation 4-6 years: Evaluation for palate revision/speech surgery, columellar lengthening/nasal tip revision 6-12 years: Alveolar bone grafting, orthodontic intervention > 12 years: Definitive rhinoplasty and orthognathic surgery Phalke N, Goldman JJ. Cleft Palate. [Updated 2023 Jul 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan

10. CLEFT LIP REPAIR Primary Cleft Lip Repair Only: Early lip repair at 3–4 months of age following the Rule of 10s Primary lip and anterior palate repair: Proposed by Abyholm in Oslo protocol. Cleft lip repair using Millard’s technique and anterior hard palate closure using a single layer vomer fap Primary lip and soft palate repair : Soft palate and lip repair at 4–6 . Hard palate repair at 4–5 years. Complete Lip and Palate Repair: In children above 10 months of age

11. Millard’s Rotation-Advancement Flap Nasal prongs, cupid bow and philthral column marking Marking till junction of wet and dry mucosa

12. C flap- between mucosa and philthral column C flap raised and remaining muscle flap – M flap Rotation flap Skin-muscle dissection, oral mucosal layer, release abnormal muscle attachment Incision on medial side : B- Noordhoff’s point D- Junction of skin and mucosa D1 – to separate nasal mucosa and skin

13. *Additional incision in vestibule on cleft side - adequate mobilization of advancement fap L flap- submucosal dissection, mobilization of muscle L flap(muscle)- sutured to nasal floor

14. Closure of oral mucosa- begins at junction of wet and dry mucosa Muscle suturing- junction of white roll and cupid’s bow Skin and vermilion border suturing- z plasty can be done before closure

15. CLEFT PALATE REPAIR

16. Bardach’s Two-flap Palatoplasty, 1967 Modified Langenbeck’s two-flap technique - to decrease scarring and maxillary growth deficiency by minimizing hard palate bony exposure. I ncision is made along the cleft margin and the alveolar margin. These are joined anteriorly to free the mucoperiosteal flaps. Mucoperiosteal flaps are based on the greater palatine artery posteriorly. Karoon Agrawal; Cleft palate repair and variations; Indian J Plast Surg Supplement; 2009

17. Soft plate is repaired in a straight line. Levator palati muscle dissection and reconstruction of the muscle sling Successfully reduced palatal scarring and minimized maxillary hypoplasia but did not correct abnormalities of speech. Commonly followed presently.

18. Furlow Double Opposing Z- Plasty , 1978 Creation and transposition of 2 mirrored z-flaps—an anterior mucosal flap and posterior myomucosal flap Creates an overlapping muscular sling without the need for relaxing incisions. Technique: Incision along cleft margins The muscle is incorporated into the posteriorly based triangular flap on the left side Cleft is closed in two layers without making a lateral incision. Karoon Agrawal; Cleft palate repair and variations; Indian J Plast Surg Supplement; 2009

19. Z- plasty allows for closure of hard palate in one procedure while : Lengthening of soft palate Re- alignes the musculature and reconstructs velopharyngeal sling Reduces palatal scarring and increases palatal mobility Decreases negative effects on maxillary growth Good speech outcomes Karoon Agrawal; Cleft palate repair and variations; Indian J Plast Surg Supplement; 2009

20. THANKYOU

21. Patterns, Anatomy, and Classification of Clefts ;2021 Renato Da Silva Freitas, Isis Juliane Guarezi Nasser

22. Von Langenbeck technique 1861 Palatoplasty using mucoperiosteal flaps for the repair of the hard palate region. Maintain the anterior attachment of the mucoperiosteal flap to the alveolar margin to make it a bipedicle flap . Incise cleft edges – make lateral incision, elevate flap from hard palate, divide palatine musculature and suture them. This technique is still used in isolated cleft palate repair. Karoon Agrawal; Cleft palate repair and variations; Indian J Plast Surg Supplement; 2009

23. Veau-Wardill-Kilner Palatoplasty In this technique V-Y procedure is performed so that the whole mucoperiosteal flap and the soft palate are retroposed and the palate is lengthened. I t leaves an extensive raw area anteriorly and laterally along the alveolar margin with exposed bare membranous bone. The raw area heals with secondary intention. This causes shortening of the palate and results in velopharyngeal incompetence. The raw area adjacent to the alveolar margin also results in alveolar arch deformity and dental malalignment. Because of these drawbacks pushback and V-Y techniques have fallen into disrepute Karoon Agrawal; Cleft palate repair and variations; Indian J Plast Surg Supplement; 2009

24. Furlow’s double-opposing Z- plasty is commonly used today and achieves good speech outcomes. However, this technique may s truggle to close wider clefts and require greater dissection and multiple hard palate flaps to achieve anatomical closure Karoon Agrawal; Cleft palate repair and variations; Indian J Plast Surg Supplement; 2009