MODIFIED ANATOMICAL SUBUNIT REPAIR FOR UNILATERAL CLEFT LIP PATIENTS WITHOUT PRE-SURGICAL INFANT ORTHOPEDICS

Souvik Adhikari; Debtanu Bhattacharya

doi:10.33695/jss.v9i4.599

Souvik Adhikari Department of Plastic Surgery, Institute of Post Graduate Medical Education & Research, Kolkata, India
Debtanu Bhattacharya Department of Plastic Surgery, Institute of Post Graduate Medical Education & Research, Kolkata, India

DOI: https://doi.org/10.33695/jss.v9i4.599

Keywords: Cleft Lip, Fisher's repair, Anatomical Subunit Repair, PSIO, Unilateral Cleft Lip

Abstract

BACKGROUND: There has been no consensus till date regarding the best method of repair of a child with a cleft lip deformity with many surgical procedures producing excellent results. Millard’s rotation advancement method has been practised by surgeons for years with excellent results. The anatomical subunit cleft lip repair advocated by Dr David Fisher places the scar on the philtral column of the cleft side which parallels the non-cleft side. A small inferior triangle effectively lengthens the cleft side lip. In this article we have adopted small modifications of the Fisher technique in our patients who did not have presurgical infant orthopedics prior to surgery. PATIENTS AND METHODS: Between June 2020 to July 2022, 10 patients with complete cleft lip, 5 patients with incomplete cleft lip and 1 patient with Tessier Cleft 3 were operated using Fisher’s technique. Small modifications which included increasing the base of the inferior triangle till 3 mm in required cases, overlapping of the lateral muscle over the medial muscle segment, dissection and elimination of the alar web with overcorrection using sutures and incorporating some muscle into the triangular vermillion flap to mimic the central vermillion tubercle were done. RESULTS: Satisfaction score among the parents was extremely high. Nasal aesthetics were improved in all but 2 cases. In one case, wound disruption occurred which required secondary suturing. CONCLUSION: The anatomical subunit repair can produce excellent results in patients with cleft lip and minor modifications may be instituted based on need of individual patients.

References

[1] W. C. Shaw, V. Brattstrom, K. Molsted, B. Prahl-Andersen, C. T. Roberts and G. Semb, “The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 5: discussion and conclusions,” Cleft Palate Craniofac J, vol 42, pp. 93–98, 2005.
[2] S. Richardson and R. V. S. Khandeparker, "Cleft Rhinoplasty," in Oral and Maxillofacial Surgery for the Clinician, K. Bonanthaya, E. Panneerselvam, S. Manuel, V. V. Kumar and A. Rai, Eds. Springer, Singapore. 2021, pp. 1703-1732.
[3] M. Kornbluth, R. E. Campbell, J. Daskalogiannakis, E. J. Ross, P. H. Glick, K. A. Russell, J. C. Doucet, R. R. Hathaway, R. E. Long, Jr and T. J, Sitzman, “Active Presurgical Infant Orthopedics for Unilateral Cleft Lip and Palate: Inter-Center Outcome Comparison of Latham, Modified McNeil, and Nasoalveolar Molding,” Cleft Palate Craniofac J, vol 55, no 5, pp. 639–648, May 2018.
[4] C. W. Tennison, “The repair of the unilateral cleft lip by the stencil method,” Plast Reconstr Surg, vol 9, no 2, pp. 115-20, 1946.
[5] P. Randall, “A triangular flap operation for the primary repair of unilateral clefts of the lip,” Plast Reconstr Surg Transplant Bull, vol 23, no 4, pp. 331-47, Apr 1959.
[6] D. R. Millard, Cleft Craft: The Evolution of its Surgery. Vol 1: The Unilateral Deformity, Boston: Little, Brown, 1976.
[7] W. B. van der Sluis, N. S. S. Kornmann, R. A. Tan and J. P. W. Don Griot, "Other Scar Types: Optimal Functional and Aesthetic Outcome of Scarring in Cleft Patients," in Textbook on Scar Management, L. Téot, T. A. Mustoe, E. Middelkoop and G. G. Gauglitz, Eds. Springer, Cham. 2020, pp. 51-57.
[8] D. M. Fisher, “Unilateral cleft lip repair: an anatomical subunit approximation technique,” Plast Reconstr Surg, vol 116, no 1, pp. 61-71, Jul. 2005.
[9] K. Garland, B. McNeely, L. Dubois and D. Matic, "Systematic Review of the Long-Term Effects of Presurgical Orthopedic Devices on Patient Outcomes," Cleft Palate Craniofac J, vol 59, no 2, pp. 156-165, Feb 2022.
[10] P. Sharma, A. K. Khera and P. Raghav, “Role of orthodontist in cleft lip and palate.” J Oral Health Craniofac Sci, vol 6, pp. 8-15, 2021.
[11] M. S. Noordhoff, “The Surgical Technique for the Unilateral Cleft Lip-Nasal Deformity”, Taipei: Noordhoff Craniofacial Foundation, 1997.
[12] A. Mehra, H. Sarma, "Rationale for the treatment of unilateral cleft lip – GC4 protocol." J Cleft Lip Palate Craniofac Anomal, vol 8, pp. 41-48, 2021.
[13] R. W. Tse, E. Mercan, D. M. Fisher, R. A. Hopper, C. B. Birgfeld and J. S. Gruss, "Unilateral Cleft Lip Nasal Deformity: Foundation-Based Approach to Primary Rhinoplasty," Plast Reconstr Surg, vol 144, no 5, pp. 1138–1149, Nov 2019.
[14] M. Chopan, L. Sayadi, and D. R. Laub, "Surgical Techniques for Treatment of Unilateral Cleft Lip", in Designing Strategies for Cleft Lip and Palate Care. London, United Kingdom: IntechOpen, 2017.
[15] M. B. Seagle and Furlow LT Jr, “Muscle reconstruction in cleft lip repair,” Plast Reconstr Surg, vol 113, no 6, pp. 1537-47, May 2004.
[16] A. F. Markus and J. Delaire, “Functional primary closure of cleft lip,” Br. J. Oral Maxillofac. Surg, vol 31, no 5, pp. 281-291, Oct 1993.
[17] B. Cakir, K. Gideroglu, M. Akan, G. Taylan and T. Akoz, “Jack-like eversion by splitting the orbicularis oris muscle for reconstruction of the philtral column in secondary cleft lip,” Scand J Plast Reconstr Surg Hand Surg, vol 43, no 1, pp. 8–15, 2009.
[18] B. C. Cho, “New technique for correction of the microform cleft lip using vertical interdigitation of the orbicularis oris muscle through the intraoral incision,” Plast Reconstr Surg vol 114, no 5, pp. 1032–1041, Oct 2004.
[19] S. Van, C. Aaron, J. Burge, R. Bos, G. Parker and D. K. Chong, "The Anatomical Subunit Approach to Managing Tessier Numbers 3 and 4 Craniofacial Clefts," Plastic and Reconstructive Surgery - Global Open, vol 10, no 9, p e4553, Sep 2022.
[20] S. Dutta, K. C. Mandal, S. Majumder, S. Roy, L. Neilasano and P. K. Halder, "Role of presurgical nasoalveolar molding in the repair of unilateral cleft lip," Int J Oral Health Sci, vol 11, pp. 103-108, 2021.