Unilateral complete cleft lip repair: a modern morpho-functional surgical approach
A scientific essay in Medical Sciences
DOCTORAL THESIS defended in public on 17th of November 2010
This thesis attempts to understand the intricacies of unilateral cleft lip defects. There are primarily two reasons why I chose to study the unilateral cleft defect. Firstly, the unilateral defect is a unique defect of the human face where the defect is not placed in the midline but on one side of the face. This causes a great challenge for the surgeon to treat the cleft because he/she has to constantly compare the result of the surgery to that of the non affected side. This comparison will also be done by the patient's friends, colleagues and most importantly by the patient him/herself. The second reason is that the unilateral cleft defect, involves not only the lip but also the nose and maxilla, which makes it a multidimensional high demanding surgical challenge. The disturbance of important anatomical landmarks is a major cause of stigma for the patient even after he/she is operated on for a cleft. In this way, the aim of this thesis can only be an attempt to improve surgical techniques to overcome this stigmata.
Quality of life
Before I chose the topic of unilateral cleft lip repair for this thesis, I did a study to assess the Quality of Life of cleft patients in general. The most interesting observation in this study was that patients with bilateral cleft lips perceived a better quality of life when compared to patients with unilateral cleft lips. This study justified my belief that the unilateral cleft lip repair is more challenging than the bilateral cleft repair because the patient usually compares the result of the treatment on the affected side with that of the unaffected side. I therefore decided that our center needed to improve the surgical techniques to treat unilateral cleft defects.
Surgical aspects for treatment of unilateral cleft lip
The principal surgical goal for the treatment of unilateral cleft lips in my center was to have a treatment method that addressed the main problems of the cleft lip in only one surgery. Within the field of my surgical interest, I studied the technical aspects of cleft lip surgery on one hand and particularly assessed interest to the surgical aspect of the septum on the other hand. With regard to the lip, I first compared two standardized techniques (Millard and Pfeifer). I then combined the advantages of both the techniques to evolve into the Afroze incision which I then compared to the previous two techniques. With regard to the septum I studied the advantages and disadvantages of cheiloplasty with and without septoplasty.
The Afroze incision was developed as a simple incision to provide a single step correction of the unilateral cleft lip irrespective of the width of the cleft or the tissue present lateral to the cleft. Initially I used and propagated the Millard's incision for unilateral cleft lip repair with Delaire philosophy to repair the muscles and mucosa. This technique was what I was trained to do. I used this incision for more than 1000 patients. In 2001, I was introduced to the Pfeifer incision. I used this for two years treating more than 600 patients. Then a surgical technician who had worked for me for seven years and had assisted me for almost all the cleft surgeries that I did, came to me with the idea of combining the two incisions such that the advantages of Millard and Pfeifer incisions could be optimized. Since it was designed by Afroze, the echnician, we decided to call it the Afroze incision. The Afroze incision design addresses the problem of downward rotation of the cupids bow on the non-cleft side and lengthening of the lip on the cleft side respectively. The Pfeifer's incision on the cleft side also ensures easy access to the m. alar nasalis below. To compare the efficiency of the Afroze incision it was compared to the Millard and Pfeifer incision. 1200 patients divided into 3 cohorts, with each cohort treated with Millard incision, Pfeifer incision or Afroze incision were studied. The Afroze incision performed statistically significantly better than Millard and Pfeifer for 6 of the 8 parameters, i.e. White Roll Match, Vermillion Match, Scar appearance, Cupids bow, Lip Length and Nostril Symmetry. With regard to Alar Dome and Base, Afroze did not perform statistically significantly better than Millard and Pfeifer incisions. This proved that the Afroze incision was a good technique for the repair of unilateral cleft lip defects. The Afroze incision is now used as a standard practice to repair unilateral cleft lips in our center.
Unilateral cleft lip nasal deformities are characterized by prominent asymmetry resulting from distorted and displaced structures. It consists of a depressed cleft side dome and splayed ala. The cleft side alar base is also depressed and frequently vertically elevated; at the same time, the alar rim is everted exposing the nasal lining. The septum is pulled to the non-cleft side along with the premaxilla by the muscle imbalance. The nasal dorsum is deviated towards the non-cleft side. These nasal deformities are further compounded by the skeletal base malposition on the cleft side. There are proponents and opponents of early nose repair. Randall noted that patients often were more concerned with their nasal deformity than with their lip deformity. It appears, however, that early repair results in less severe secondary deformity, and many authorities now reposition the cartilaginous nasal framework prior to age 5 or 6 years. Primary correction of the nasal deformity at the same time of lip repair has gained popularity, aimed at early restoration of the symmetry by lifting the alar cartilage and lengthening the columella on the cleft side. Within the rhinoplasty procedures, septoplasty always plays an important role. Ralph Latham, in 1969, proposed a hypothesis that the nasal septum was the key factor in height and anterior posterior dimensions of the face in addition to that of the nose. Based on the evidence provided by literature on one hand and with the Latham-hypothesis in mind on the other hand, I started doing primary cheiloseptoplasty to correct the problem of the alar cartilages and septal deviation. To validate my method of primary septoplasty I compared the results with patients who did not have primary septoplasty. The results of the 2-D photography study indicated that the nostril of the cleft side showed better symmetry in the group treated with septoplasty (significant for Columella-Cupids Bow distance, Nostril Gap Area and Nostril Height, Alar Base Inter Pupillary distance' but not significant for Nostril Width).
The conclusions of all these studies are now included to finally end up with a surgical protocol that is actually used as a standard in our center. Based upon the research of this thesis, our protocol for repairing unilateral cleft lips now includes primary lip repair using the Afroze incision, functional repositioning of all muscles of the lip and nose including m. orbicularis oris and m. alar nasalis, primary septoplasty as well as perioplasty. We call this technique the "Afroze Primary Cheiloseptoplasty". After completing various studies to validate the efficacy of this technique, we firmly believe that Afroze Primary Cheiloseptoplasty is the gold standard for treating unilateral cleft defects in our center.