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Cleft lip with or without palate is the most commonly treated condition seen by craniofacial teams. Patients with cleft lip benefit from a team care approach. Left unilateral cleft lip is more common than right and unilateral is more common than bilateral. Bilateral cleft lips are often asymmetric. Although most of the time the occurrence of a cleft lip is an isolated occurrence, some patients have a syndrome.
A cleft lip forms when the medial nasal prominence fails to fuse with the maxillary prominences. The cleft can range from a minimally perceptible microform cleft to a complete cleft lip. Dentofacial abnormalities are common, particularly when the primary palate is cleft in the case of a complete cleft lip. Even if the mucosa and skin are intact a failure of fusion of the muscle may occur as in the microform cleft. The nasal deformity may be the most notable feature of the cleft lip.
The unilateral cleft nasal deformity has a characteristic appearance. The caudal anterior septum is deviated to the non-cleft side in the case of the unilateral cleft lip. A deviated septum generally becomes more pronounced with growth. Many surgeons have begun to address the anterior septal displacement without affecting the nasal growth center at the time of the cleft lip repair. The nasal deformity also has an inferiorly posteriorly displaced alar base on the cleft side. The lower lateral cartilages are displaced, malformed, or both on the cleft side. The nasal tip is widened and asymmetric and the medial crus on the cleft side is weakened and or deformed. The orbicularis oris muscle is abnormally inserted on the cleft alar base, piriform and nostril sil instead of spanning circum-orally.
Most centers perform lip repairs between 3-6 months. Some surgeons perform the lip repair in the first week of life as the fetal hemoglobin is high and they perceive scarring benefits in early repairs. There are many popular techniques for lip repair inspired by Millard, Randall, Nordoff, Tennison, Le Mesurier, Mohler, and Fisher. These notable surgeons and others have contributed ideas of significant advancement to cleft lip repair surgery. Addressing the nasal deformity at the time of the lip repair has become an important technique to improve the aesthetics of cheiloplasty results for patients with cleft lip. Closure of the nostril floor,
In the patient with a bilateral cleft the anterior nasal spine may be missing or the septum may be displaced. The premaxilla projects forward with unrestrained growth due to detached lateral alveolar segments and orbicularis muscle as well as tongue thrusting. The prolabial skin has no muscle component underneath and no white roll. Nasolalveolar molding or a lip adhesion surgery may be beneficial to reposition the premaxilla more favorably in advance of the lip repair. NAM has the additional benefit of providing columellar lengthening and nasal contouring prior to the lip surgery. Many craniofacial teams have dentists, orthodontists, or other providers who can perform NAM for the patients with a cleft. Patients with a complete bilateral cleft lip benefit the most from NAM. At the time of the lip repair the vermillion and white roll elements should come from the lateral lip segments.
Patients with a cleft are best cared for in a craniofacial or cleft lip and palate team setting. These patients often have dentofacial differences and would benefit from care by plastic and oral surgeons, otolaryngologists, and dental specialists. They may also benefit from evaluations from geneticists, behavioral psychologists, developmental pediatricians, social workers, and speech pathologists. ASMS surgeons can be crucial to providing reconstruction options for the patients with a cleft. Caring for patients with a cleft is a rewarding endeavor for ASMS surgeons.