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Archive for the ‘cleft lip and palate’ Category

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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