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BackTable / ENT / Article
Cleft Lip Repair Techniques: Unilateral vs Bilateral
Quynh-Chi Dang • Jun 17, 2021 • 295 hits
A cleft lip refers to the improper separation of the lip. Cleft lip repair surgery is sometimes necessary once the infant is nutritionally stable in order to improve infant feeding and breathing. The aim of cleft lip repair surgery is to recreate the orbicularis oris and to minimize a post-operative cleft lip scar. Both unilateral and bilateral cleft lip repair techniques are discussed.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Cleft lip refers to a separation of the lip. The condition can arise through genetic and/or environmental conditions.
• A bilateral cleft lip refers to a separation that is present on two sides of the lip, while a unilateral cleft lip is only present on one side of the lip. Furthermore, cleft lips can be categorized as incomplete or complete depending on how large the separations between the lip and nostril are.
• The most common cleft lip repair technique involves recreating the orbicularis oris, the muscular ring around the mouth. Dr. Goudy recommends a unilateral cleft lip repair at three or four months and a bilateral cleft lip repair at five or six months.
• Although a cleft lip scar is inevitable in cleft lip repair surgery, scars can be disguised as the philtrum.
Table of Contents
(1) What is a Cleft Lip?
(2) Cleft Lip Surgery Considerations: Weight & Nutrition
(3) Unilateral & Bilateral Cleft Lip Repair Techniques
(4) Cleft Lip Repair Post-operative Scars
What is a Cleft Lip?
A cleft lip is an embryonic malformation that results from a separation of the lip. The condition can arise from environmental or genetic factors. They can be categorized by unilateral or bilateral cleft lips and further classified as complete or incomplete.
[Dr. Ashley Agan]
The topic of cleft lip and palate is pretty big. Can you first explain what that is and what it means?
[Dr. Steven Goudy]
The meaning of the word “cleft” is separation. So, a cleft of the lip is a separation of the lip. When your body is forming, your face is growing from the sides towards the middle, and the middle part is growing down. If they don't grow fast enough to touch, or they grow fast enough but then they don't join, you get a separation. We all start out with a cleft lip and a cleft palate. But for whatever reason, genetic or environmental or some combination therein, about a 1 in 1000 live births in the U.S. have a cleft or a separation of the lip or the palate. Cleft lip and cleft palate can be present alone, or as part of a syndrome among a constellation of other findings.
[Dr. Gopi Shah]
Since we're on the topic of cleft lip, can you go into the difference between complete and incomplete cleft lip, and how surgery or expectations are different with those nuances?
[Dr. Steven Goudy]
Incomplete means that the separation doesn't go from the top to the bottom of the nostril through the lip, so there is some attachment that is remaining. That attachment has been referred to eponymously as Simonart's band.
Then, you can have lots of different variants of incomplete separation. It can be very subtle, called a microform, meaning very small cleft and so there may just be a tiny notch or indentation in the lip. It can be super wide or it can be anywhere in between. You can have a bilateral cleft lip, meaning both sides, where one is complete and the other one is incomplete.
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Cleft Lip Surgery Considerations: Weight & Nutrition
Because cleft lips affect breathing and feeding, many surgeons choose to operate as soon as the infants are healthy and nutritionally stable. Special bottles--such as the Haberman bottles, Dr. Brown’s bottles, and pigeon bottles--may help infants reach the minimum weight for cleft lip surgery.
[Dr. Ashley Agan]
When patients first present to you, you mentioned that the first thing you're worried about is basic needs like feeding and breathing. What happens after that, as far as timing of repair?
[Dr. Steven Goudy]
Babies are obligate nose breathers and so if they do have a cleft in their lip, and it's fairly wide, then that gives them actually more space to breathe through. If there is a cleft in the roof of their mouth, then they can't suck very well. That suck, swallow, breathe rhythm is interrupted and there's a lot of time spent trying to get them to eat before we can really consider the operation. They need to be healthy and growing and nutritionally taken care of.
With feeding, there are specialty bottles. There are Haberman bottles, pigeon bottles, and Dr. Brown's specialty bottles. I don't have any disclosures with respect to bottles, so I'm bottle-agnostic. Dr. Brown's specialty bottle can be found at Target, so a lot of families use that one. Assuming that we are on a good trajectory to eat/grow and they are gaining weight, the old adage for a cleft lip repair (which is typically the first thing that you do) is 10 weeks, 10 pounds and 10 grams in hemoglobin. Again, that's an old adage. I don't think that adage is necessarily scientifically-based, but in my mind, this is the earliest that you could repair.
I think there are some folks who are pushing that envelope and trying to do it earlier and earlier just because they feel that there's still some of the maternal progesterone and other things in the system that allow the body to heal with less scarring. There is also some orthodontic stuff that can be used. Nasoalveolar molding can bring the separation closer together to make the surgery easier. This requires weekly appointments where they're building a retainer that stretches out the nose and moves the two alveolar ridges (bony line) closer together. You go from trying to close a pretty wide cleft, to closing a very narrow cleft, which obviously is easier to do.
Unilateral & Bilateral Cleft Lip Repair Techniques
The most popular cleft lip repair technique is to recreate the orbicularis oris, the muscular ring around the mouth. Although Dr. Goudy prefers to do a unilateral cleft lip repair when the infant is three or four months old, he waits until the infant is five or six months old to do a bilateral cleft lip repair, a more difficult surgery with strenuous post-operative recovery. Finally, he recommends that ear tubes be placed during the cleft lip repair surgeries to prevent middle ear infections.
[Dr. Steven Goudy]
In general, we're going to fix the lip. If it's a unilateral cleft lip, I operate at three to four months of age. If it's a bilateral cleft lip, I wait until they're five to six months of age. We already said that babies are obligate nasal breathers. If you do a bilateral cleft lip repair, and all of a sudden squash it all up and then sew it together, they can have a hard time breathing. We don't want them stranded in the hospital for a long time figuring out how to breathe and letting the swelling go down.
...The other interesting part is that in the complete bilateral cleft lip, this central part called the premaxilla can stick way out and so that makes it really hard to fix it. Again, that's the embryologic part from the nasal process, and it has the central and lateral incisors. You sometimes have to kind of push that back and pull it together. You can do a lip adhesion, where you sew the tissue together to kind of bring it back and then do a revision surgery down the road. The goal in most of these surgeries is to recreate the muscular ring around the mouth, the orbicularis oris...
...There are some types of repairs, particularly the bilateral ones, that don't incorporate the muscle all the way around. Personally, I think it's important to reconstitute that just because you can pucker your lips and whistle, if you don't get that muscle together all the way then you can have what's called a whistler deformity. This is when you whistle and there's a little notch in your lip and it looks different.
...Also, at the time of cleft lip repair, we'll put in ear tubes. These babies are going to need about three sets of ear tubes in their lifetime, if they have a cleft palate, the tensor veli palatini is not attached to the other side. There's a very high incidence of conductive and sensorineural hearing loss in these patients so their hearing needs to be screened very closely.
Cleft Lip Repair Post-operative Scars
Operating time for a cleft lip repair surgery depends on the width of the lip separation. Although a cleft lip repair surgery scar is inevitable, surgeons can hide the cleft lip scar by creating a philtrum, the two naturally occurring lines between the nose and the lip.
[Dr. Gopi Shah]
Can you tell us a little bit about your pre-op counseling for the initial cleft lip or palate? How do you counsel families? What kind of expectations should they have? How long do they usually stay in the hospital? What kinds of post-op complications should they be aware of?
[Dr. Steven Goudy]
The cleft lip repair generally takes about an hour or an hour and a half. Obviously, the width of separation determines how long the surgery is and what the cleft lip scar will look like. If it's a wide cleft and you're moving a lot of tissue around, there will be more tension that causes more scarring. There is no scarless cleft lip surgery. The goal of the cleft lip surgery is to hide the scars. The philtrum are the two lines that naturally occur under your lips. The goal of the cleft lip surgery is to recreate a scar in a similar line as the philtrum and reshape the nose so that it's not flattened.
Recovery time is a couple weeks. The kids are angry because I put No-No arm restraints on them to keep their arms straight and prevent them from scratching at their face. Certainly, they can take those off when the family is with them.
Podcast Contributors
Dr. Steven Goudy
Dr. Steven Goudy is the Director of Pediatric Otolaryngology and Professor at Emory University. He is also the CEO and Founder Dr. Nozebest.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, April 13). Ep. 20 – Complete Cleft Care & Choosing Your Own Adventure [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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