Cleft lip

A detailed presentation about cleft lip repair

1. Seminar on cleft lip Presented by Dr.Cathrine Diana PG III

2. content Introduction History Embryology Etiology Epidemiology Classification Parent counselling Feeding Surgical procedures – lip repair Post op care Further procedures Recent advances

3. Introduction A cleft lip is a type of birth defect that affects the upper lip. Cleft lip ( cheiloschisis ) and cleft palate ( palatoschisis ) most common congenital malformation since prehistoric times. O ccurs in a Well-defined places, along definite axis.

4. H istory The 1 st documented CL surgery was from china in 390 BC.in a 18 years old soldier wey young chi Jehan Yperman - 1 st to describe the unilateral and bilateral CL repair Ambrose Pare – 1 st diagrammatic representation of CL repair in 14 th century Le monnier – 1 st successful CP repair in paris (1776) Asensio – novel technique of CL repair in 1950 Germanicus Mirault – originator of traiangular flap – modified by tennison and Randall Ralph Millard – classic- rotational advancement technique in mid 1950s   Cleft-lip – the historic perespetive S.Bhattacharya , V.Khanna,R . Kohli international journal of olastic surgery oct 2009

5. Emryology : Facial embryogenesis:

6. Its not the birth marriage or death but the gastrulation .. Which is truly the most important time in your life - lewis Wolpert

7. Etiology The exact cause of clefting is unknown Multifactorial chemical exposures, radiation, maternal hypoxia, teratogenic drugs, nutritional deficiencies, physical obstruction, and genetic influences.

8. Genetic (non- syndromal ) Genetic basis is significant, but not predictable Lack of potential for mesodermal proliferation across the fusion lines after the component parts are in contact. Error in the transitional shift of the embryonic blood supply. Chromosomal abnormalities causing multiple congential malformations including cleft Obstructing tongue ,asynchronous development or foetal position

9. The syndromal etiologic factors were classified by Pashayan in 1983 into: 1. Major mutant genes usually with a known Mendelian inheritance pattern such as the Treacher -Collins, Stickler or van der Woude syndrome. 2. Chromosomal abnormalities such as the trisomy D,E and G 3. Teratogenic syndromes secondary to drug and alcohol ingestion • > 300 craniofacial syndromes involve cleft lip and/or palate

10. Family relation Affected relatives predicted recurrence CL/P   1 sibling 4.4% 1 parent 3.2% 1 sibling , 1 parent 15.8%  

11.  Environmental : Intensity, duration and the time of action – more important than etiological factor 1. Infections (rubella, toxoplasmosis) 2. Growth hormone deficiency 3. Drugs: Steroids, Diazepam, Aminopterin , Anticonvulsants (incidence10X), Aspirin , 4. Alcohol: fetal alcohol syndrome 5. Smokers (2X incidence) 6. Vitamin B and Folate deficiency 7 . Radiation energy 8. Hypoxia and amniotic fluid alteration

12. Epidemiology Cleft lip and palate occurs in about 1 to 2 per 1000 births in the  developed world. Rates for cleft lip with or without cleft palate and cleft palate alone varies within different  ethnic groups. The highest prevalence rates  for (CL ± P) are reported for Native Americans  and Asians .  Africans have the lowest prevalence rates. Native Americans: 3.74/1000 Japanese 0.82/1000 to 3.36/1000 Chinese 1.45/1000 to 4.04/1000 Caucasians 1.43/1000 to 1.86/1000 Latin Americans : 1.04/1000 Africans: 0.18/1000 to 1.67/1000 Watkins, SE; Meyer, RE; Strauss, RP; Aylsworth , AS (April 2014). "Classification, epidemiology, and genetics of orofacial clefts.". Clinics in plastic surgery. 41 (2): 149–63

13. It caused about 4,000 deaths globally in 2010 down from 8,400 in 1990. CLP – Native americans > Orientals >Caucasians > Blacks . N o preponderance to any race in isolated cleft palate cases. CLP: M:F = 2:1 Isolated palates: F:M = 2:1 Site of clefting : Left: Right: Bilateral 6:3:1

14. CLASSIFICATIONS OF CLP

15. David and Ritchie (1922 ) : according to position of the clefts in relation to the alveolar process. • Group I – Pre-alveolar clefts – unilateral (right or left), bilateral or median • Group II – Post-alveolar clefts – – involving soft palate only – involving soft and hard palates – submucous cleft • Group III – Alveolar clefts – unilateral (right or left), bilateral or median.

16. Veau (1931) : divides cleft palates into four groups. • Group I – Cleft of soft palate only. • Group II – Cleft of hard and soft palate • Group III – Complete unilateral cleft • Group IV – Complete bilateral cleft,

17. Kernahan (1971) striped ‘ Y’ classification Millards modification

18. . American Association of Cleft Palate Rehabilitation Classification (AACPR): based on the same principles used by Kernahan and Stark: I . Cleft of primary palate A) Cleft lip – unilateral, bilateral, median, prolabium , congenital scar B) Alveolar cleft – unilateral, bilateral, median II. Cleft of palate proper A) Involving soft palate B) Involving hard palate

19. III. Mandibular process cleft A) Mandibular cleft lip B) Mandibular cleft C) Lower lip pits IV . Naso -ocular cleft – extending from narial region to the medial canthal region V. Oro-ocular cleft – extending from the angle of the mouth towards the palpebral fissure VI. Oro-aural cleft – extending from the angle of the mouth towards the ear

20. Tessier (1973) : Orbitocentric classification of facial clefts. • Facial clefts are numbered 0 – 7 • Cranial clefts from 8-14. • Orbit - reference landmark • Cleft lip is part of clefts 2 and 3.

21. Indian classification Balakrishnan 1975 : Cleft type abbreviation Cleft lip GP 1 Cleft palate GP 2 Ceft lip. Palate alveolus GP 3 Right R Left L Median M Alveolus A Partial P Submucosal S Simonart’s band Sb Microform micro

22. US classification 1995: type 1, cleft lip alone type 2, unilateral cleft lip and palate type 3, bilateral cleft lip and palate type 4, midline cleft lip and palate type 5, facial defects associated with amniotic bands or limb-body-wall complex 

23. Prenatal diagnosis 2D ultrasound between 18-24 weeks (18 –complete clefts, 24 – incomplete clefts) All except isolated cleft palate seen in 67-93% cases.

24. The ultrasonographic surface rendered oro -palatal (SROP) allows the simultaneous visualization on a single scan of the superior lip, alveolar ridge and secondary palate. Parent counselling begins from here itself. Fetal cleft lip and palate detection by three-dimensional ultrasonography W. Lee MD, J. S. Kirk, International Society of Ultrasound in Obstetrics and Gynecology Volume 16, Issue 4 1 September 2000  Pages 314–320

25. Sequence in management 1. Immediately after birth A) pediatric consultation and complete head and neck examination B) parent councelling - special concerns, expected development, treatment and expected outcomes should be explained to the parents . C ) genetic evaluation - first step taken, before initiation of any treatment, to diagnose any associated syndromes. E.g. If a b/l clp is associated with trisomy 13, lip repair should not be done as child is not expected to live beyond early infancy D) feeding E) pre-surgical orthopedics F. Surgical repair

26. Pediatric consultation and complete head and neck examination head – symmetry • Auricle and external canal - for development and location. • Facial analysis - symmetry and harmony, hemifacial hypertrophy or atrophy, and facial clefting • Otologic examination - pneumatic otoscopy and tuning forks. • Anterior and posterior rhinoscopy - clefting , septal abnormalities, intranasal masses, and choanal atresia. • Oral cavity- cleft, dental arch abnormalities and tongue anomalies such as bifid tongue, macroglossia , glossoptosis , or lingual thyroid, malocclusion. • Upper airway tract - adequacy of phonation, cough, and deglutition, and by auscultating and palpating the neck.  

27. Feeding • Unilateral cleft lip alone - seldom present with feeding problems. • Cleft lip and palate or isolated cleft palate – major feeding problems • Easier to breast feed a child with CP than CL.

28. Feeding precautions Minimise nasal regurgitation and aspiration - hold the child at an angle of 45-60° to the horizontal during feeding. 2. Do not flood the pharynx - provoke aspiration. 3. Infant with a major cleft tends to swallow air while feeding – feed more frequently than a normal child. 4. Breast feeding is only sufficient for two weeks. After this, expressing milk and supplement is necessary.

29. Feeders: Soft bottles, modified teats - slightly enlarged hole/cruciform design. • Spoon-feeding is an alternative to bottle feeding. Squeeze Haberman feeder. Pigeon feeder

30. Check weigh gain: + 8 ounces (225 gms ) a week (pre & post surgery) • Fever, diarrhea , vomiting, excessive sweating or other reason to lose fluid (drains, bleeding, etc ) greatly increase this requirement

31. PRE-SURGICAL ORTHOPEDICS Reduces the size of cleft; Aids in Surgery Partial obturation aids in feeding

32. CONTROL OF PREMAXILLA Lip correction over a conspicuously protruding premaxilla - excessive tension, dehiscence of the wound or spreading of the scar. • Traction by external elastic with headcap • Lip adhesion • Intra-oral elastic devices • Surgical setback of the premaxilla

33. Orthodontic (lip) taping :

34. Pre-surgical Orthopedic (PSO) appliances - custom-made acrylic base plate that provides improved anchorage in the molding of lip, nasal and alveolar structures during presurgical phase. Duration – 2-3 months The use of infant orthopaedic plate before CL repair may favour correct arch form establishment in infants with unilateral complete cleft lip and palate

35. Latham appliance: screw retained device - significant growth restriction of midface • Grayson’s naso -alveolar molding appliance : non pin retained Quinn – Georgiade appliance designed by Orthodontist, ).  

36. •" The nasal ala projection length demonstrated an average ratio of 93.0 percent in the surgery-alone group and 96.5 percent in the nasoalveolar molding group" Barillas I, Dec W, Warren SM, Cutting CB, Grayson BH (March 2009). " Nasoalveolar molding improves long-term nasal symmetry in complete unilateral cleft lip-cleft palate patients" .  Plast . Reconstr . Surg. 123 (3): 1002–6.

37. Gingivoperiosteoplasty : U sing limited flaps to close alveolar cleft during primary lip/palate repair, in an attempt to have bone formation at the alveolus. .

38. In Isolated cleft lip the incidence of hearing loss is equal to norm al population. • Cleft palate - eustachian tube dysfunction –require frequent evaluation 1 0-12 WEEKS: PRIMARY CHEILORHINOPLASTY : • PRIMARY LIP REAPIR: Aim: • 3 layered closure of skin, muscle and mucosa, approximate normal tissues, excise hypoplastic tissues at cleft margins • reconstruct orbicularis oris into a continuous sphincter.  

39. Primary nasal surgery: – Minimal surgical dissection . Scarring affect the growth –. Goals include closure of the nasal floor and sill, symmetry of the alar base, and symmetry of the lower lateral cartilages with appropriate projection of the dome. Recent literature supports that rhinoplasty performed at the time of the primary cleft lip closure may reduce the frequency and magnitude of required intermediate and definitive rhinoplasty operations. – Alternative - correction of the displaced alar cartilages before school age (approximately 5 years ). Primary nasal reconstruction performed with cleft lip repair makes the nasal tip more symmetric and requires less complex intervention at the time of definitive secondary rhinoplasty Curr Opin Otolaryngol Head Neck Surg.  2014 Aug;22(4):260-6. Update on primary cleft lip rhinoplasty . Gudis DA 1 ,  Patel KG Plast Reconstr Surg.  2012 Mar;129(3):740-8. doi : 10.1097/PRS.0b013e3182402e8e. Long-term effect of primary cleft rhinoplasty on secondary cleft rhinoplasty in patients with unilateral cleft lip-cleft palate. Haddock NT 1 ,  McRae MH ,  Cutting CB

40. Normal anatomy - upper lip Vermillion: The lower margin of the upper lip, characterized by its rosy colour . • Vermillion border: The line or ridge between the skin of the upper lip and the vermilion • White roll: thin raised white line just above vermillion border • Cupid’s bow: the concave or dipped portion of the vermilion border in the centre of the upper lip.

41. Philtral dimple: Above the center of the upper lip • Philtral columns/lines: the raised ridges on either side of this dimple • Prolabium : In unilateral clefts, the philtrum remain attached to the larger portion of the lip. In bilateral clefts, the philtrum is isolated from the lateral lip segments. • Length of the lip: length of the skin from the base of the nose to the lower margin of the vermilion

42. Timing of surgery Millard "rule of ten’s”:10 weeks old, 10 grams Hb,10 pounds weight, WBC count of 10,000/mm3 • Randall - repair in first ten days of life, as soon as health permitted - maximal healing potential exists, prevents a separate hospitalization and parents leave the hospital with a relatively normal appearing child • Delay of closure - time to complete pediatric evaluation, understanding of the congenital defects Landmarks more visible as age increases. • B/L CL – weight = 12-14 pounds - to have more tissue to work.  

43. Recent protocol 2001 Atlas of oral and maxillofacial Clinics of NA: 2009

44.   Basic surgical preparation GA using oral RAE (Ring – Adair- Elwyn ) tube taped to midline of lower lip - not to produce any lateral distortion • The infant is placed in folded towels with the neck slightly extended. • Points – 30 gauge needle - Bonney’s blue (Brilliant green 1/2 g, Crystal violet 1/2 g, Alcohol 96% 46ml, Water for injection 53ml) or methylene blue. • After markings - 0.5% lignocaine with 1:2,00,000 epinephrine is injected into the lip tissue. It also helps to grip lip firmly between thumb and index finger to avoid bleeding while incising. Wait for 5 minutes after infiltration . GA using oral RAE (Ring – Adair- Elwyn ) tube taped to midline of lower lip - not to produce any lateral distortion

45. Goal of surgery is to achieve a normal looking lip and a normal looking nose, which will not be distorted by the effects of ageing and growth

46. Steffenson (1953) - five criteria for a satisfactory lip repair : 1. Accurate skin, muscle and mucous membrane union with adequate lip lengthening, 2. Symmetrical nostril floor, 3. Symmetrical vermilion border, 4. Slight eversion of the lip and 5. A minimal of scar, which by contraction will not interfere with the accomplishments of the other, stated requirements.  

47. • Two additional criteria were added later by Musgrave (1971) 1. Preservation of the cupid’s bow, 2. Production of symmetrical nostrils.

48. TECHNIQUES OF REPAIR U/L CLEFT LIP • Millard’s rotational advancement • Modifications of millard’s technique: – Millard II – Skoog’s Technique – Mohler’s Technique • Tennison -Randall Triangular flap • Delaire’s Functional lip closure Afroze technique   B/L CLEFT LIP • Straight line closure • Columella lengthening • Millard repair • Tennison -Randall triangular flap • Other techniques: – Bauer Method – Manchester method – Skoog method – Wynn method – Barsky technique – Modified Veau II – Primary Abbe’s flap

49. Ambroise Paré1564

50. Mirault ( Blair and Brown) Mirault (1844) described a lateral inferior triangular flap approximated to a medial pairing, that increased the length of lip. Blair (1930) and Brown (1945) modified to reduce the size of triangular flap – straight line scar without a cupid’s bow and an asymmetric vermillion tubercle.

51. Hagedorn (Le Mesurier ) In 1949, Le Mesurier demonstrated a modification of the Hagedorn technique (1892), in which a quadrilateral flap is introduced into the releasing incision to create and artificial cupid’s bow.

52. Tennison – Z plasty Tennison (1952) –frustrated by straight-line scar contraction in blacks - Z- plasty technique which preserves the cupid’s bow and places it in normal position - He inserted a wedge from the lateral lip into the lower portion of the medial lip, and achieved good results – and called it ‘ stencil method ’ - came to be known as the Tennison triangular flap technique .

53. Randall’s modification Randall (1959) modified - by reducing the size of the inferior triangular flap, and defined the precise mathematics of the method.

54. Disadvantages: Violation of philtrum on the cleft side Difficult in modifying the repair during Secondary revision mathematical precision in measurement is necessary in the pre-operative assessment and during the surgery

55. Millard’s rotation-advancement repair "cut as you go"

56. Advantages: • The flaps can be modified after initial cutting to bring down the cleft side to the level of the non cleft side. This technique scarifies little tissue from the margin of the cleft. • Dissection of muscle as a separate layer is relative straightforward and a three layer closure can be achieved. • This scar is excellent for later revision. It stimulates a normal philtral column and this technique produces a best possible nasal philtrum .   Disadvantages: • The scar is almost always a little short and even when the static length of the new philtral column is satisfactory, dynamic motion will not be natural. In a wide cleft the closure can be difficult to achieve and it an be a very radical procedure where cleft is minimal.  

57. Millard II operation Adequate rotation has been a problem for a number of surgeons. Millard himself suggested acute back-cut at approximately 90° at the end of the rotation incision , running parallel but medial to the philtrum , and the C flap insertion into the upper half of the back-cut. During the final suturing, the tip of the advancement flap is sutured to the depth of the rotation back-cut. This increases the rotation and ensures adequate lengthening and horizontalisation of the cupid’s bow.

58. Mohler modification He extended the rotation into the base of the columella , made a back-cut, and sutured it to the lateral flap. Muller in 1989 - concept of differential reconstruction of the orbicularis oris muscle in unilateral cleft lip repair’ The Mohler technique yielded a more symmetric result

59. Skooge’s Modification

60. Delaire’s functional lip closure • Does not make use of flaps - accurate reconstruction of the 3 rings of muscles of the Lip and nose • Creates a highly symmetric nose and a functional lip: separates cosmetics from function

61. Delaire – 3 rings of muscles   • NASO-LABIAL/UPPER RING: Transverses nasi , levator labii superioris alequi nasi , levator labii superioris , zygomaticus minor and the levator anguli oris . • BILABIAL/MIDDLE RING: Represents oral sphincter, consisting of the upper and lower lip orbicularis oris muscle. • LABIO-MENTAL/LOWER RING:Lower ring has an incomplete circumference and consists of orbicularis inferior, triangularis labii and quadrates labii inferioris .  

62. •Concept : The integrity of the first ring is fundamental for sustaining and allowing normal functioning of the other two. The cartilaginous nasal septum stimulates the periosteum of anterior part of maxilla and ensures harmonius growth of the latter. Labial motility in addition to modeling directly the underlying dento alveolar structure by means of median septum acts in positively influencing the growth of premaxilla . The lower ring acts by remodeling the dento alveolar complex and chin portion of the mandible vertically and transversely . Drawback: Straight-line scar and inability to achieve adequate lengthening of the lip, resulting in a notching. But its proponents claim that this lack of lip symmetry will gradually reduce by the effect of normal labial muscle function.

63. Afroze technique: Afroze Incision for Functional Cheiloseptoplasty . Gosla srinivas reddy , rajgopal R reddy , Stefaan Berg The Journal of craniofacial surgery  20 Suppl 2(8):1733-6 · September 2009 The Afroze incision is a combination 2 incision, that is, the Millard incision on the noncleft side and Pfeiffer incision on the cleft side

64. The advantage of this technique is that there is no tension on the postoperative scar because the incision is essentially horizontal in nature, and the contracture of the scar occurs horizontally rather than vertically incision can be used in all types of complete unilateral cleft lip regardless of the width of the cleft, shortening the cleft lip segment.

65. Afroze Incision for Functional Cheiloseptoplasty

66. B/L cleft lip repair A lip that is completely cleft on both sides - usually associated with a cleft of primary or whole palate. • Prolabium - total absence of orbicularis oris muscle and is attached to the tip of the nose by an almost non-existent columella . PRE-TREATMENT EVALUATION: 1. Whether the cleft is complete or incomplete 2. The size and position of the premaxilla and the prolabium 3. The length of the columella 4. Whether the inter-alveolar space is sufficient to accommodate the premaxilla 5. The presence or absence of associated anomalies, like lip pits.

67. 1. Straight Line Closure ( Veau III operation) • Simplest technique with satisfactory results • Some resulting scar contracture – symmetrical an accentuates cupid’s bow

68. 2. Tennison’s adaptation The procedure for unilateral clefts is done on both sides. This repair results in zigzag scars. The central part of the vermilion margin protrudes in a more normal manner than is achieved with the straight-line repair. Usually, a two-stage procedure is necessary, one side repaired at a time

69. Bauer, Trusler , Tondra (1959 , 1971) Opposed any surgery on a protruding pre-maxilla and preferred controlling it by operating one side at a time, with incisions similar to Tennison .

70. 4. Millard repair (1960) Forked flaps are raised initially and stored for future use while the lip is closed in one stage. A prime requisite of this technique is a fairly large prolabium ( if the prolabium is too narrow, a straight-line repair or the Wynn method is more preferable ).

71. The lateral vermilion mucosal flaps with the white roll are brought to the midline while the prolabial vermilion is turned downward. As a second stage , a V-Y advancement of the banked flaps on the floor of the nose is employed to lengthen the columella .

72. Primary b/l chilorhinoplasty modified M illard technique INTRA-OPERATIVE CLINICAL MARKINGS MARKINGS TO ASSESS THE DISTANCE – TO OPTIMISE EQUALITY FROM COMMISURES TO PROPOSED PEAKS OF CUPID’S BOW

73. RESIDUAL VERMILLION – TRIMMED AND USED TO AID CLOSURE OF PRE-MAXILLARY MUCOSA FULL THICKNESS INCISION TO RELEASE EACH RESPECTIVE LATERAL LIP ELEMENT.

74. AFTER SHARP DISSECTION OF 3 LAYERS, INCISION OF NASOALVEOLAR WEBBING IS DONE FOR FINAL LATERAL LIP RELEASE SUTURING OF LATERAL LIP MUCOSA TO PRE-MAXILLARY MUCOSA ON EACH SIDE

75. INSET OF NEWLY CONSTRUCTED PHILTRUM AND CLOSURE. STERILE STRIPSAND ADHESIVE TAPES APPLIED TILL SUTURE REMOVAL

76. Muliken technique Stage 1 Stage 2

77. 6- Manchester method 2 stage repair of B/L lip and palate • 1st – 5 months PSO – straight line closure preserving prolabium , anterior palate repair • 2nd – push back palate repair at 9 months of age • Drawback – whistle deformity

78. Columella lengthening A shortened columella is almost always associated with a complete bilateral cleft lip. Columellar lengthening is usually not attempted at the time of initial lip repair. It has been found that early repair results in downward slippage of the columella and lip over the premaxilla . Lengthening of columella may be done any time after the patient is 2-3 years of age .

79. Cronin (1958) described a method of advancing skin from the floor of the nose and base of the ala into the columella . Converse (1957) also used skin from the floor of the nose. Millard (1958, 1971) and associates used a forked flap from the prolabium . Brauer and Fara (1966) employed the V-Y principle in the region of wide tip.

80. Post op care: Dressing to be in place for 24 hrs Logan’s bow may be used Feed with bulb syring – 10-14 days All skin sutures were removed on 4 th post op day Steri -strips for 10 days I.V. Rehydration with maintenance fluids – • 4 cc/ hr /kg for each of the first 10 kg • 2 cc/ hr /kg for each kg between 10 and 20 kg • 1 cc/ hr /kg for each kg above 20 kg

81. Complications of lip repair 1. Wound infection 2. Wound disruption / spreading of scar - only supporting tapes should be used in the initial phase. No definitive repair should be attempted until all the induration has subsided. 3. Lip scars – unavoidable – revision – Z plasty , W plasty , waveline excision. Remove sutures within 4 days and use adhesive tapes 4. Long lip (vertical excess) – Tennison -Randall and LeMesurier techniques, or excessive rotation in Millard flap. Correction – full thickness horizontal excision below nostrill

82. 5 . Short lip (vertical defeciency ) – notching – vertical scar along suture line, inadequate rotation of medial flap . 6. Tight Lip (Horizontal defeciency ): sacrifice of excessive tissue during primary repair – indrawn upper lip stretched across teeth. Correction is done using Abbe’s flap – 180 degree transposition of lower lip flap inserted into upper lip. Or maxillary advancement by orthognathic surgery 7 . Orbicularis oris abnormalities: defeciency , discontinuity, diastasis.

83. 8. Whistle deformity- thin central vermillion – after Manchester type repair - may be prevented by augmenting the thickness of the prolabium . B/L V-Y advancement or vermillion island flaps used for correction. 9. Vermillion border defeciency : most common – corrected by Z plasty , V-Y plasty , transposition flaps, free grafts, cross lip flaps 10. Buccal sulcus defeciency : corrected by V-Y or V-Z advancements. 11. Collapse of maxillary segments behind the premaxilla

84. Recent advances Neonatal chieloplasty : involving neonatal cleft lip repair and one-stage palatal repair performed up to the first year of UCLP patient's life, has shown good speech outcomes . Non- surgical correction of nasal deformity in CLP cases using special retainer during neonatal period In utero correction of CLP - Successful open repair of a cleft lip in utero has the advantage of scarless wound healing in the fetus . – in animal study Repair of Cleft Lip in Utero by Reactivation of Craniofacial Developmental Programs Journal of Pediatric Otorhinolaryngology, Volume 90, November 2016, Pages 71-76

85. References: 1 .Fonseca volume 6: Cleft and craniofacial deformities 2. Mc Carthy : PLASTIC SURGERY. Vol.4. Cleft lip & palate and Craniofacial Anomalies 3. Peterson’s principles of oral and maxillofacial surgery volume 2 4. Atlas of oral and maxillofacial Clinics of NA: 2009 5. Cleft-lip – the historic perespetive S.Bhattacharya , V.Khanna,R . Kohli international journal of olastic surgery oct 2009 6.   Barillas I, Dec W, Warren SM, Cutting CB, Grayson BH (March 2009). " Nasoalveolar molding improves long-term nasal symmetry in complete unilateral cleft lip-cleft palate patients" .   Plast . Reconstr . Surg.   123   (3): 1002–6. 7. Fukuyama E, Omura S, Fujita K, Soma K, Torikai K (November 2006).  "Excessive rapid palatal expansion with Latham appliance for distal repositioning of protruded premaxilla in bilateral cleft lip and alveolus" . Cleft Palate Craniofac . J. 43 (6): 673–7 8. Watkins, SE; Meyer, RE; Strauss, RP; Aylsworth , AS (April 2014). "Classification, epidemiology, and genetics of orofacial clefts.". Clinics in plastic surgery. 41 (2): 149–63. 9. Repair of Cleft Lip with Nonsurgical Correction of Nasal Deformity in the Early Neonatal Period. Matsuo, Kiyoshi M.D.; Hirose, Takeshi M.D.; Otagiri , Tetsutaro M.D.; Norose , Noboru M.D. 1989American Society of Plastic Surgeons 10 Repair of Cleft Lip in Utero by Reactivation of Craniofacial Developmental Programs Hermann, CD; Lawrence, KA; Olivares- Navarrete , R; Williams, JK; Schwartz, ZPlastic & Reconstructive Surgery: July 2012 - Volume 130 - Issue 1S - p 77

86. 11.Palatal growth in complete unilateral cleft lip and palate patients following neonatal cheiloplasty : Classic and geometric morphometric assessment International Journal of Pediatric Otorhinolaryngology, Volume 90, November 2016, Pages 71-76 Eva Hoffmannova , Šárka Bejdová , Jiri Borský , Ján Dupej , Veronika Cagáňová , Jana Velemínsk 12. Variation trends of the postoperative outcomes for unilateral cleft lip patients by modified Mohler and Tennison -Randall cheiloplasties Journal of Cranio -Maxillofacial Surgery, In Press, Accepted Manuscript, Available online 9 September 2016 Liqi Li, Lishu Liao, Yuxiang Zhong , Yuangui Li, Li Xiang, Wanshan L   13. Comparison of two treatment protocols in children with unilateral complete cleft lip and palate: Tridimensional evaluation of the maxillary dental a rch Journal of Cranio -Maxillofacial Surgery, Volume 44, Issue 9, September 2016, Pages 1117-1122 Paula Karine Jorge, Wanda Gnoinski , Karine Vaz Laskos , Cleide Felício Carvalho Carrara , Daniela Gamba Garib , Terumi Okada Ozawa, Maria Aparecida Andrade Moreira Machado, Fabrício Pinelli Valarelli , Thais Marchini Oliveira   14. Treatment outcome after neonatal cleft lip repair in 5-year-old children with unilateral cleft lip and palate International Journal of Pediatric Otorhinolaryngology, Volume 87, August 2016, Pages 71-77 Olga Košková , Jitka Vokurková , Jan Vokurka , Alena Bryšova , Pavel Šenovský , Julie Čefelínová , Darina Lukášová , Petra Dorociaková , Juraj Abelovský 15. Prenatal diagnosis of cleft lip/palate: The surface rendered oro -palatal (SROP) view of the fetal lips and palate, a tool to improve information-sharing within the orofacial team and with the parents Jean-Marc Levaillant a , Romain Nicot a , Laurence Benouaiche b , Gerard Couly c , Daniel Rotten  

87. Thank you