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Archive for the ‘cleft lip and palate’ Category

Case Study – Teenage Male Cleft Rhinoplasty

Friday, August 11th, 2017

 

Background: Of all the difficult cases in rhinoplasty surgery, the cleft  nose remains one of the most challenging. While this challenge is magnified in the bilateral cleft nose, it is only slightly less in the unilateral cleft lip and palate patient. The challenge its not in understanding the deformity but working with nasal tissues that are both deformed and often congenitally deficient.

While the cleft nasal cartilages are deformed due to the asymmetry caused by the cleft that runs up through its nasal floor, the overlying skin also poses limitations. The affected nasal alar rim is always pulled down and the skin is often restricted by a recessed nasal base. Equally importantly the internal vestibular tissues usually have a web that is both limiting in elevation and for which a satisfactory solution remains elusive.

While many cleft patients undergo limited nasal reshaping procedures as an infant or child,  the more formal septorhinoplasty awaits until after puberty. When that should be done can be debated but it is most accepted that it awaits until after any jaw surgery may be done or the determination made that it is not needed. A stable maxillary base that will  to change in the future is a prerequisite for rhinoplasty surgery.

Case Study: This teenage left cleft lip and palpate male has been through all of his primary cleft lip and palate repairs as well as secondary alveolar bone grafting. He had also had a tip rhinoplasty as a child as well.

Under general anesthesia, an open seiptorhinoplasty was performed. Septal cartilage was used for a columellar strut, left middle vault spreader graft and left alar batten graft. Bilateral subtotal inferior turbinectomies were also done.

In a cleft rhinoplasty some of the most important goals are to improve the shape of the nasal tip and cleft-sided nostril deformity. To do so requires septal correction and in the process the harvest of cartilage grafts to provide the structural rigidity that is needed to do so.

Highlights:

  1. The cleft nasal deformity is a combination of structural deformity and structural deficiency.
  2. Cleft septorhinioplasties almost always needs to be done with an open approach and usually requires cartilage grafting as well.
  3. The nasal tip deformity in the cleft nose can never be normalized completely but it can have major improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Cleft Lip Revision with Buccal Fat Graft

Monday, June 19th, 2017

 

Background: Repair of a primary cleft lip deformity is one of the common pediatric plastic surgery procedures performed in infants. Usually done around three to four months of age, its repair is usually done by the rotation-advancement technique. This well established cleft lip repair procedure works by derotating the shortened medial lip element and bringing in the lateral lip element in its wake. Once in alignment the lip vermilion is then debulked and put together for a smoother and more uniform red part of the lip.

But despite how good a cleft lip repair may look at 6 months or one year of life, the effects of growth and scarring/wound contracture are often not kind. Over time many well-executed cleft lip repairs will change in appearance. The most common changes are shortening of the philtral length, notching of the vermilion lower lip edge and mismatching of the vermilion-cutaneous border at the Cupid’s bow area. As a result the need for secondary cleft lip revisions is the norm rather than the exception.

While there are numerous detailed techniques in cleft lip revision, one of the major ones used is the correction of a notched vermilion and to improve its projection/fullness. Realignment  of the vermilion and mucosal V-Y advancements are useful secondary vermilion enhancement methods. One very effective method for improving vermilion full ness with a scar revision/realignment is a fat graft. Fat grafts not only bring in volume but healthy tissue as well.

Case Study: This 16 year-old female teenager was born with a right complete cleft lip and palate deformity. She had primary cleft lp and palate repairs as well as a secondary alveolar bone graft. As a teenager her initial cleft lip repair showed vertical philtral length shortening, an inverted V notch at the lower edge of the upper lip and lack of adequate projection/protrusion.

Under general anesthesia a V-Y mucosal advancement was done, rolling out the lip mucosa to help correct the inverted V notch deformity. To prevent its contraction with healing and to help add some lip volume a free fat graft was placed prior to its closure. The fat graft was harvested from the opposite buccal fat pad through an intraoral incision. Only a small piece of the buccal fat pad was needed. (much less than even a subtotal buccal lipectomy.

Many cleft lip revisions have a need for increased volume. Autologous fat is a logical soft tissue graft that can be incorporated into many cleft lip revisions. The buccal fad pad is both a regionally convenient and hardy fat source which can be harvested without scarring. The volume removed is minimal but still should be taken from the non-cleated side of the face since the buccal fat pad on the cleft is already slightly smaller in most cases.

Highlights:

  1. Very few primary cleft lip repairs ever do not need a secondary revision.
  2. One of the most common secondary cleft lip issues is a lack of vermilion volume.
  3. One source of adding additional volume is with the use of free fat grafts, specifically that from the buccal fat pad.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Incomplete Cleft Lip Repair

Sunday, May 28th, 2017

Background: While cleft lip and palate is a widely recognized orofacial deformity, it is less commonly appreciated that it has a wide spectrum of presentations. It occurs in basic categories of combined cleft lip and palate and isolated cleft lip and isolated cleft palate, but every  possible variation in between these basic categories occurs. Its diverse presentations has to do with the remarkable formation of the upper lip due to the embryologic union (and lack of adhesion in clefts) of the lateral lip and nasal elements.

The incomplete cleft, as the name implies, involves just one element of the lip and palate. Externally this would be an incomplete cleft lip without any palatal involvement. Careful inspection of the incomplete cleft lip, however, shows that there is still some nasal involvement and a notch may also appear on the underlying alveolus as well.

Other than isolated cleft palate, which presents no visible external deformity, incomplete cleft lip would be the next most favorable cleft deformity to have.

Case Study: This 4 month-old female was born with an incomplete cleft lip that spared the nasal sill. There was still nasal malformation with a misshapen nostril. There was no underlying involvement of the alveolus.

Under general anesthesia she had a unilateral cleft lip repair using a rotation-advancement technique. (central lip element rotates downward and the lateral lip element advances in behind it. Primary nose repair was done by alar cartilage dissection and the placement of a small overlying resorbable plate for support.

One year follow-up shows good length and alignment of the philtral column, adequate vermilion fullness and an improved nostril shape. Some visible scarring is seen at the nasal sill. Whether a cleft lip revision will eventually be needed will require years of growth to determine.

Highlights:

  1. The incomplete cleft lip  usually spares the alveolus and palate, making it a more ‘favorable’ orofacial cleft
  2. Primary repair of the incomplete cleft lip is the one cleft lip deformity that has a chance of being a one time surgery.
  1. The incomplete cleft lip repair his usually performed around 3 to 4 months of age.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Unilateral Cleft Lip Repair

Saturday, May 6th, 2017

 

Background: The term, cleft lip and palate, refers to a spectrum of congenital clefting conditions that emanate out from the mouth area. In its most common presentation, it  involves both the cleft lip and palate (technically cleft lip-alveolus-nose-palate) but it can also occur as an isolated cleft lip or an isolated cleft palate.

These common orofacial clefts occur in about 1 per 1,000 births but the frequency changes based on race. Asians have roughly twice this number while African-Americans have half this number. These different occurrence rates appear to be due to the forward projection of how the face forms amongst the races as one major contributing factor. Interestingly cleft lip occurs more frequently in males while isolated cleft palate is more common in females.

The surgical treatment of cleft lip and palate is like a golfing event. It will take 18 holes (years) to complete and each hole’s score (year of age and surgery) impacts the final game’s score. (fully grown result) The first hole is the initial cleft lip repair.

Case Study: This 3 month old male infant was born with a left complete cleft lip and palate deformity. The cleft ran through the lip, base of the nose, alveolus and hard and soft palate. There was no prior history of facial clefts on either side of the parents. He was otherwise healthy.

Left Cleft Lip Repair Dr Barry Eppley Indianapolis At 4 months of age and at 14 lbs,, a cleft lip and nose repair was done using a rotation-advancement technique under general anesthesia. Continuity of the orbicularis msucle was established as well as rotating the medial lip element down and advancing into alignment the lateral lip element. The slumped lower alar cartilage-nostril was treated by the placement of a small resorbable plate to give it an uplift and support.

He went on to have a cleft palate repair at 9 months of age. When seen at two years of age, he had good alignment of his lip and fullness to the vermilion. His nasal base and nostril shape was reasonable albeit far from perfect. His next surgery would be alveolar bone grafting somewhere between ages 6 to 8 depending on his permanent tooth eruption pattern.

The foundation of the surgical treatment of cleft lip and palate is the initial cleft lip repair. It sets the tone for how the eventual facial result can look but a lot of facial and oral development as well as other surgeries will take place before the ‘course’ is completed.

Highlights:

  1. Cleft lip and palate is a common congenital facial deformity that isomer than just two facial segments that did not come together.
  2. Primary cleft lip repair is done within 3 to 4 months after birth and often involves some manipulation of the nose as well.
  1. Primary cleft lip and nose repair is never the last corrective procedure performed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Bilateral Cleft Rhinoplasty

Friday, March 24th, 2017

 

Background: The bilateral cleft lip and palate deformity poses major reconstructive challenges. At its root cause is the shortage of tissue that has resulted from the cleft as well as scar tissue that has occurred from prior surgeries.

The bilateral cleft nose has many typical features from a wide and blunt nasal tip, an underdeveloped underlying septal support, a columellar shortage of skin and wide flaring nostrils.

A more complete rhinoplasty is done in the bilateral cleft patient during their teenage years when they are past puberty. There is some debate as to whether it should be done before or after an upper jaw advancement which is eventually needed in more than half of bilateral cleft patients. That would depend on when the jaw advancement is planned and how much forward movement is needed. But in most cases it is best done six months or longer after the LeFort I osteotomy has been done.

Case Study: This 17 year-old teenage male had multiple previous surgeries for a bilateral complete cleft lip and palate birth defect. He had completed his upper jaw surgery one year previously. He had a good occlusion and adequate upper lip support. His nose showed a strong and high dorsal line, wide nasal bones and a blunted and ill-defined nasal tip.

Bllateral Cleft Septorhinoplasty result side view Dr Barry Eppley IndianapolisUnder general anesthesia he had an open septorhinoplasty performed. The nasal bridge was lowered slightly and the nasal bones narrowed. A septal cartilage graft was used to create a strong columellar strut onto which the tip cartilages could be reshaped. The nostrils were also brought inward.

Bilateral Cleft Septorhinoplasty result oblique view Dr Barry Eppley IndianapolisBilateral Cleft Septorhinoplasty result front view Dr Barry Eppley IndianapoliosHis after surgery results show definite improvement in his overall nasal shape. But like mamy cleft rhinoplasty surgeries the result always leaves one hoping for more.

Highlights:

  1. The bilateral cleft nose poses a reconstructive challenge due to both tissue hypoplasia and tissue scar.
  2. The bilateral cleft rhinoplasty should be done after an upper jaw advancement =has been completed and healed to provide good skeletal support.
  3. The most important reconstructive element in the bilateral cleft nose is to achieve a strong columellar support onto which the nasal tip can be built.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Bilateral Cleft Lip Repair

Friday, August 21st, 2015

 

Background: Cleft lip and palate is one of the most common facial birth defects often cited as occurring in about 1 in every 1,000 births. While there are race, gender and world wide differences in this occurrence rate, it is a condition that is well recognized around the world for its prevalance. Almost everyone has seen or knows someone who has been affected by some facial cleft problem.

Despite the generic name of cleft lip and palate, it  is a collection of orofacial birth defects that has a wide range of variability in how it appears. The cleft can affect one side of the lip, both sides or can cause a cleft palate only. Even in bilateral cleft lip and palate there is great variability. The cleft lip may be complete on both sides, complete on one and incomplete on the other, or incomplete on both sides. This variability in the cleft ip becomes compounded when one factors in the internal cleft palate and alveolar component which can occur variably as well.

Regardless of the type of bilateral cleft lip and palate deformity, the first step in the reconstructive process begins with the bilateral cleft lip repair. While usually done at around 3 to 4 months of age, its timing may be affected by the location of the premaxillary segment beneath the cleft upper lip segment. If it is excessively protrusive and displacing the central upper lip segment far forward, its repositioning by tapes or active appliances (e.g., nasoalveolar molding) may be needed first. Such manuevers put the central lip segment closer to the sides of the lip to avoid extreme tension on the bilateral cleft lip repair after surgery.

Case Study: This infant male was born with a bilateral complete cleft lip and palate deformity. Despite being complete the central lip segment was not projecting too far forward because of the good position of the underlying premaxilla. Taping of the lip segments was done which was adequate for central and lateral lip alignment. Under general anesthesia at 4 1/2 months of age a bilateral cleft lip repair was performed.

Bilateral Cleft Lip Repair submental view Dr Barry Eppley IndianapolisBilateral Cleft Lip Repair oblique view Dr Barry Eppley IndianapolisHis postoperative results showed that a fairly good initial result with all of the main objectives of a bilateral cleft lip repair achieved. This was helped considerably by the extent of the bilateral cleft deformity and the not unduly protrusive position of the underlying premaxilla. Not all bilateral cleft lip repairs will end up with such good lip repair results. Such a favorable initial lip repair sets the stage for promising additional reconstructive surgery results.

Bilateral Cleft Lip Repair result front view Dr Barry Eppley IndianapoliisBilateral cleft lip repair is challenging. Multiple objectives are strived for including keeping the width of the central lip segment narrow, reconstruction of a cupid’s bow and central vermilion (pink part of the lip), and have a symmetric height of the both sides of the lip without extending the incision around the base of the nose to name a few of the most important.

Highlights:

1) Bilateral cleft lip and palate is the most severe form of the typical facial cleft birth defects.

2) Reconstruction of the bilateral cleft lip and palate deformity consists of a number of orofacial procedures (often 6 to 8 total) done up to 18 years of age.

3) The first reconstructive surgery in the bilateral cleft patient begins at 4 months of age with an initial bilateral cleft lip repair.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Cleft Lip Scar Hair Transplants

Sunday, July 12th, 2015

 

Despite the best efforts at cleft lip repair, whether done as an infant, teenager or as an adult cleft lip revision, the ability to detect the cleft lip scar usually persists. This is most manifest in men because the thickness of the upper lip beard skin on both sides of the cleft lip scar make the hairless scar that much more apparent.

While cleft lip scar revision is the best method to minimize the width of the cleft lip scar, it does not always work as well as one would like. It can be very difficult to get a cleft lip scar that is narrow as one would like, no matter how many efforts are made to revise the scar.

Cleft Lip Scar HairTransplant Grafts Dr Barry Eppley IndianapolisCleft Lip Scar Hair Transplants Dr Barry Eppley IndianapolisIt is important to recognize that the cleft lip scar in a male has two fundamental deficits…lack of hair follicles and skin that is thinner and more atrophic. One simple method to address one of the deficits of the cleft lip scar is that of hair transplants. Placing small hair transplants (follicular extraction units, FUE) into he cleft lip scar not only adds hair growth to the scar but the presence of a follicular unit also has a rejuvenative effect on the lip scar. Whether the man ends up with a fuller moustache that crosses the cleft lip scar or merely ends up shaving (microdermabrasion) the cleft lip scar on a daily basis, the hair transplant helps with cleft lip scar camouflage.

When placing hair transplant into the cleft lip scar it is important to orient the hairs in a completely downward orientation that is nearly parallel to the surface of the skin. This will allow them to grow downward in the same direction as the rest of the upper lip hairs.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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