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Cleft Lip & Cleft Palate 38 weeks 2 days, male - Coggle Diagram

- - - - The frontonasal prominence cleave into medial and lateral nasal processes
        then fuse with maxillary process to form upper lip
        Medial nasal processes then fuse in the midline to form the intermaxillary segment, which creates the philtrum of the upper lip and the primary palate
        The lateral nasal processes will go on to form the nasal alae.
        The mandibular processes fuse in the midline to form the lower lip and mandible
        The lateral fusion of the mandibular and maxillary processes forms the oral commissures
        Failure or interruption of these fusion points may result in clefting
        
        The secondary palate forms from initial outgrowths of the maxillary processes: the palatal shelves.
        Initially oriented vertically, posterior to the primary palate, and lateral to the developing tongue
        Begin to orient themselves horizontally in wk 8 and progress towards midline fusion, starting anteriorly, immediately behind the primary palate, with midline fusion progressing posteriorly like a zipper
        As the palatal shelves extend toward one another in the midline, the medial edge epithelium makes a point of contact.
        Then fuse into midline epithelial seam, then degenerating into mesenchymal tissue and establishing mesenchymal continuity of the full palate
        Failure of midline fusion results in cleft palate
- - - - May be complicated by wound dehiscence, with or without fistula development
        If a fistula develops, may be small and insignificant or large and damaging
        scar contracture or scar hypertrophy
        bleeding
        Laryngospasm
        infection
        need for reoperation
        potential need to keep the patient intubated after surgery
        Inadequate palatal movement
        palatal necrosis
        
        Depending on the size and location of the postoperative fistula, may need...
        revision surgery and/or obturator placement
        Orthodontic obturator placement may serve as a stand-in to facilitate normal speech development in while awaiting an appropriate time for major revision
        
        speech, swallowing, nutritional, and psychosocial development
      - lip and nasal deformities not resolved during primary repair, including
        vermillion notching
        misalignment of the white roll
        orbicularis discontinuity
        short or excessive length of the lip
        short or deviated columella
        horizontal orientation of the nares
        abnormalities of nostril size
        disturbance of alar base position.
- - - - Rotation-advancement technique, also called the Millard technique
        Advantages:
        suture line that recreates the philtrum on the cleft side
        access to nasal tip cartilages allowing nasal reconstruction
        allows intraoperative adjustment
        Disadvantages:
        potential nostril stenosis
        difficulty closing wide clefts
        increased difficulty for the inexperienced surgeon
      - Triangular flap technique, also known as the Tennison-Randall technique
        Advantages:
        carefully measured and predetermined landmarks that allow an inexperienced surgeon to perform the procedure easily
        allows wider clefts to be repaired
        Disadvantages:
        technique are mostly related to cosmetic outcomes and include failure to create a philtrum on the cleft side
        scar that crosses cosmetic subunits
        inability to access nasal cartilages during repair
        inability to modify repair once surgery has started
      - First surgery usually occurs between 3-6 months old
        Second surgery, if necessary, usually occurs between 6-9 months old
        Bilateral cleft lip repair poses additional difficulty
        Different surgeons have different techniques ranging from single stage to 2-stage repairs
  - - - Von Langenbeck
        *primary surgical technique
        Bardach ("Two-flap" palatoplasty)
        *modification of the Von Langenbeck palatoplasty in which bilateral monopedicled mucoperiosteal flaps are elevated and closed in the midline
        Veau-Wardill-Kilner ("V to Y pushback")
        
        modification of the Bardach palatoplasty in which bilateral flaps are advanced posteromedially to close the palatal defect and lengthen the soft palate
        
        Due to high incidence of postoperative fistula formation due to single-layer closure and midfacial growth disturbance, most surgeons have abandoned this technique
        
        Furlow Double Opposing Z-Palatoplasty
        
        used for lengthening and closure of soft palate clefts but may be combined with any of these techniques when the hard palate is involved as well.
        
        Sommerlad Technique
        
        uses operation or loupe microscope to perform this technique to provide better magnification and superior visualization
        
        Ancillary Procedures with Cleft Palate Repair:
        Intravelar Veloplasty
        Vomer Flap
        
        most of the currently used vomer flaps rely on a cephalic or superior blood supply.
        
        Pharyngeal Flap
        
        very effective for decreasing velopharyngeal insufficiency but may worsen OSA significantly.