Reconstructive Plastic Surgery E-Book

• Herausgeber: Thieme Medical Publishers
• Kategorie: Fachliteratur
• Sprache: Englisch

Veröffentlichungsjahr: 2022

Beschreibung

A reader-friendly, how-to guide on reconstructive plastic surgery from international experts

Reconstructive Plastic Surgery: An Atlas of Essential Procedures edited by esteemed authors, educators, and surgeons Robert X. Murphy Jr. and Charles K. Herman is a comprehensive resource detailing head-to-toe surgical procedures for a broad range of conditions. The senior editors have more than 50 years of collective surgical experience and expertise training hundreds of medical students and plastic surgery residents. A distinguished and diverse group of contributors from more than 15 countries and five continents share clinical pearls throughout the book.

Sixty-seven chapters organized in five sections start with head and neck chapters detailing cleft palate defects and repair, followed by functional rhinoplasty, neoplasms, and trauma. Section two encompasses breast reduction/reconstruction techniques and other breast deformities; and management of trunk ulcers, deep wounds, and defects. The hand and upper extremity section details reconstructive techniques for infections, trauma, and Dupuytren's contracture. The final two sections cover a wide spectrum of nerve-related conditions and syndromes, followed by burns, melanoma, and vascular anomalies.

Key Features

• High-quality illustrations and intraoperative photographs enhance understanding of step-by-step operative procedures
• More than 30 procedural videos provide hands-on guidance on how to perform specific steps in reconstructive plastic surgery
• A broad range of reconstructive techniques cover trauma, tumor resection, burns, congenital deformities, and degenerative conditions
• Consistent chapter formatting includes a clear and concise introduction, discussion of pertinent anatomy, surgical indications, operative techniques, complications, and long-term results

This highly accessible yet comprehensive procedural guide is must-have reading for medical students, plastic surgery residents, and early-career plastic surgeons. It will also benefit veteran reconstructive plastic surgeons looking for a robust refresher with an international perspective.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

Leseprobe

To access the additional media content available with this e-book via Thieme MedOne, please use the code and follow the instructions provided at the back of the e-book.

Reconstructive Plastic Surgery

An Atlas of Essential Procedures

Robert X. Murphy Jr., MD, MS, CPE, FACSProfessor of Surgery Morsani College of Medicine University of South Florida Tampa, Florida, USA; Program Director LVHN Residency in Plastic Surgery and Pool Chair of Community Health Lehigh Valley Health Network Allentown, Pennsylvania, USA

Charles K. Herman, MD, MBA, FACSPlastic Surgeon Department of Surgery Lehigh Valley Hospital-Pocono Lehigh Valley Health Network East Stroudsburg, Pennsylvania, USA

1412 illustrations

ThiemeNew York • Stuttgart • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher.

© 2022 Thieme. All rights reserved.

Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USAwww.thieme.com [phone], [email protected]

Cover design: © ThiemeCover images source: © ThiemeTypesetting by DiTech Process Solutions, India

Printed in USA by King Printing Company, Inc.                            5 4 3 2 1

ISBN 978-1-62623-517-5

Also available as an e-book:eISBN 978-1-62623-518-2

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Hippocratic Oath

“I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making themmy witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To holdhimwhohas taughtmethis art as equal tomy parents and to livemy life inpartnershipwithhim…and to regard his offspring as equal to my brothers… and to teach them this art—if they desire to learn it….”

The editors dedicate this book to their professors who shared with them this art—we truly do stand upon the shoulders of giants!—and to the medical students, residents, and faculty whom they have had the privilege of training.

The desire to provide an accessible yet comprehensive procedural guide for students, residents, and early career plastic surgeons was the impetus behind this project. We hope that they derive as much value from utilizing it in their care of patients as we have had in crafting it.

Contents

Videos

Foreword

Preface

Acknowledgments

Contributors

Section I Head and Neck

Subsection IA Congenital Defects

1.Primary/Secondary Cleft Palate Repair

Thomas D. Samson

2.Cleft Lip and Nose Repair

Jonathan Yun Lee and Joseph E. Losee

3.Velopharyngeal Insufficiency

Mimis Cohen and Ellyn McNamara

4.Velopharyngeal Insufficiency: Pharyngoplasty

Husain AlQattan, Leela S. Mundra, Liann Casey, and Seth R. Thaller

5.Cleft Lip Nasal Deformity Repair

John M. Roberts and Donald R. Mackay

6.Syndromic and Nonsyndromic Craniosynostosis: Surgery of the Vault

Lucie Lessard

7.Ear Reconstruction

David Leshem and Sivan Zissman

8.Otoplasty

Guillermo Echeverria

Subsection IB Functional Rhinoplasty

9.Open Rhinoplasty

Stefania de Fazio

10.Closed Rhinoplasty Techniques

Julio Daniel Kirschbaum Fridman

Subsection IC Neoplasms

11.Treatment of Skin Cancer of the Head and Neck

Rogerio I. Neves and Morgan Brgoch

12.Reconstruction after Neoplasm Resection with Regional Flaps

Rachel Georgopoulos, Christopher Edward Fundakowski, and Sameer A. Patel

13.Reconstruction after Head and Neck Neoplasm Resection with Free Flaps

Cindy Siaw Lin Goh, Michael Ku Hung Hsieh, and Terence Lin Hon Goh

14.Lip Reconstruction

William Y. Hoffman

15.Eyelid Reconstruction

Karen Kaplan, Wrood Kassira, Seth R. Thaller, and Chrisfouad R. Alabiad

16.Nasal Reconstruction

Bharat Ranganath, M. Shuja Shafqat, Randolph Wojcik Jr., and Chetan Satish Nayak

17.Cheek Reconstruction

M. Shuja Shafqat, Bharat Ranganath, and Chetan Satish Nayak

Subsection ID Trauma

18.Mandible Reconstruction

Jason Yoo

19.Upper Midface Trauma

Kant Y.K. Lin, Anthony J. Archual, and Sarah A. Cazorla

20.Nasal Fracture

Amr Reda Mabrouk

21.Treatment of OrbitalWall Fractures

Jong-Woo Choi and Wooshik Jeong

22.Facial Paralysis

Eyal Gur and Daniel Josef Kedar

Section II Breast

Subsection IIA Macromastia

23.Breast Reduction in the Female Patient: General Considerations

Rodney Cooter

24.Wise Pattern, Inferior Pedicle Reduction Mammoplasty

Rodney Cooter

25.Vertical Scar Reduction Mammoplasty

Rodney Cooter

26.Reduction of the Male and Transmale Breast

Paul R. Weiss

Subsection IIB Absent Breast

27.Breast Reconstruction—General Considerations

Melissa Mueller, Emily Grace Clark, and Gregory R.D. Evans

28.Breast Reconstruction with Implants or Tissue Expanders

Melissa Mueller, Emily Grace Clark, and Gregory R.D. Evans

29.Breast Reconstruction with Pedicled Latissimus Dorsi Flap

Logan W. Carr and John D. Potochny

30.Breast Reconstruction with Pedicled Transverse Rectus Abdominis Flap

Steven M. Sultan and Mark R. Sultan

31.Breast Reconstruction with Free Transverse Rectus Abdominis Muscle Flap

Rodney Cooter

32.Breast Reconstruction with Free Perforator Flaps

Edward I. Chang

33.Secondary Procedures of the Reconstructed Breast

Sameer A. Patel, Marilyn Ng, and Douglas S. Wagner

Subsection IIC Other Deformities of Breast

34.Tuberous Breast Deformity

David A. Sterling, Michael Grimaldi, and Charles K. Herman

35.Poland’s Syndrome

Ian C. Sando and Paul S. Cederna

Subsection IID Trunk

36.Treatment of Pressure Ulcers

Mamtha S. Raj and Robert X. Murphy Jr.

37.Treatment of Pressure Ulcers with Flaps

Hyunsuk Peter Suh and Joon Pio Hong

38.Management of Deep SternalWound Infections

Hinne A. Rakhorst

39.Reconstruction of Thoracic and Abdominal Defects

Rei Ogawa

40.Vascularized Lymph Node Transfer

David W. Chang and Rebecca M. Garza

Section III Hand and Upper Extremity

41.Hand Infections

M. Shuja Shafqat, Bharat Ranganath, Nathan Miller, and Robert X. Murphy Jr.

42.Fingertip and Nail Bed Injuries

Sean J. Wallace, Robert M. Teixeira, and Robert X. Murphy Jr.

43.Local Flaps for Finger and Hand Reconstruction

Timothy Shane Johnson and Kavita T. Vakharia

44.Extensor Tendon Injuries and Repair

James Nolan Winters and Brian Mailey

45.Flexor Tendon Repair

Austin Michael Beason, James Nolan Winters, and Brian Mailey

46.Tendon Transfers

Ricardo Galán, Sabrina Gallego-Gónima, Hernando Laverde-Gutierrez, Giovanni Montealegre Gómez, and

Carlos Eduardo Torres Fuentes

47.Nerve Repair

Megan P. Lundgren, Waseem Mohiuddin, and Patrick J. Greaney Jr.

48.Hand Fractures/Dislocations

Randy M. Hauck

49.Dupuytren’s Contracture

Catherine de Blacam, Billy Lane-O’Neill, Patricia A. Eadie, and Seán Carroll

Section IV Nerve Compression

50.Median Nerve Compression

Jarom Gilstrap, Bharat Ranganath, M. Shuja Shafqat, and Robert X. Murphy Jr.

51.Ulnar Nerve Compression fromWrist to Elbow—Cubital Tunnel and Guyon’s Canal Release

Bharat Ranganath and Nathan Miller

52.Pronator Syndrome

Ryan W. Schmucker, James Nolan Winters, and Michael W. Neumeister

53.Radial Nerve Syndrome

Ryan W. Schmucker, James Nolan Winters, and Michael W. Neumeister

54.Arterial Insufficiency, Reconstruction, and Amputation

Ryan W. Schmucker, Alex J. Schmucker, and Michael W. Neumeister

55.Acute Compartment Syndrome

Emily Nicole Perez

56.Arterial Repair, Revascularization, or Replantation of Digit, Hand, or Upper Extremity

Ajul Shah, Brian Le, and David Chiu

57.Rheumatoid Hand

Jessica Billig, Paymon Rahgozar, and Kevin C. Chung

58.Articular Surgery for the Scleroderma Hand: Arthrodesis and Arthroplasty

Erez Dayan and Charles P. Melone Jr.

59.Treatment of Degenerative Arthritis of theWrist: Arthrodesis and Arthroplasty

Steven Michael Koehler and Charles P. Melone Jr.

60.Thumb Reconstruction: Toe-to-Thumb Transfer

Kriya Gishen, Morad Askari, and Harris Gellman

61.Treatment of Tumors of the Hand: Sarcoma

Geoffrey Konopka and Zubin J. Panthaki

62.Congenital Hand Reconstruction

Joshua Michael Adkinson

63.Lower Extremity: Soft Tissue Reconstruction

Eric I-Yun Chang

64.Lower ExtremityWound Treatment with Free Flap

Hyunsuk Peter Suh and Joon Pio Hong

Section V Integument

65.Burn Reconstruction

Nelson Piccolo and Sigrid Blome-Eberwein

66.Lesions of the Integument: Treatment of Cancers of the Integument Including Malignant

Melanoma

Graeme Perks

67.Vascular Anomalies and Congenital Nevi

Arin K. Greene and Jeremy A. Goss

Index

Videos

Video 2.1

Left unilateral cleft lip markings

Video 5.1

Cleft nasal deformity repair

Video 9.1

Access and initial septal dissection (columella vessels, complete dissection with Colorado tip and seasers)

Video 9.2

Severe deviation distal septum-partial extracorp

Video 9.3

Spreader to stabilize septum

Video 9.4

Suturing perf ethmoid plate to septum for straightening-stabilization)

Video 9.5

Septoplasty for deviated septum and splinting L strut with perf ethmoid plate buttress

Video 9.6

Suturing septum to spine in midline

Video 9.7

Rib reconstructed septum (secondary)

Video 9.8

Severe deviation distal septum-partial extracorporeal

Video 13.1

ALT flap harvest

Video 13.2

Free radial forearm flap

Video 13.3

Free fibular osteoseptocutaneous flap

Video 21.1

Transconjunctival approach for orbital floor fracture

Video 21.2

Transcaruncular approach for medial orbital wall fracture

Video 29.1

Preoperative markings

Video 29.2

Isolation of the thoracodorsal nerve

Video 36.1

Debridement of Stage IV sacral pressure ulcer in preparation for bilateral glueteal flaps

Video 37.1

Key procedures of propeller flap for covering pressure ulcer

Video 37.2

Painting the pocket of sore with methylene blue

Video 40.1

Supraclavicular lymph node flap harvest

Video 41.1

Flexor tenosynovitis: Incision and drainage

Video 47.1

End-to-end neurorrhaphy: Ensure adequate length for tension free repair by flexing the joint above the injury

Video 47.2

End-to-end neurorrhaphy: Positioning and exposure of nerve ends, with suturing technique

Video 49.1

Enzymatic fasciotomy with collagenase

Video 50.1

Open carpal tunnel release

Video 55.1

Upper extremity fasciotomy release

Video 61.1

Resection and coverage of epithelioid sarcoma of the hand.

Video 64.1

With conventional angiography, flow of the vessels can be detected

Video 64.2

Key procedures of flap surgery on lower pextremity wound

Video 65.1

Key procedures of flap surgery on lower extremity wound

Video 65.2

Percutaneous contracture band release of the neck

Video 67.1

Circular excision of an involuted hemangioma with purse-string closure

Foreword

I am delighted to write the foreword for this truly international textbook on reconstructive plastic surgery. Doctors Robert X. Murphy Jr. and Charles K. Herman, both recognized as outstanding educators and surgeons, have reached out to their counterparts worldwide, who are equally wellqualified surgeons, to contribute to this work. I commend them for doing so, as colleagues from all over theworld have so much to contribute and so much to teach us. This diverse group of authors, representing five continents, generously share their ideas and clinical expertise within these pages. I find the international authorship of this work not only unique but also one with significant advantages, adding to the contents and clinical value of the book.

As the title suggests, this is a comprehensive text on reconstruction with 67 chapters, the first few of which cover the surgical care of the cleft patients. These early chapters are followed by a “head to toe” inclusive set of chapters covering reconstruction following trauma, tumor resection, burn, congenital deformities, and degenerative conditions.

Each chapter begins with a clear introduction and is followed by a discussion of the pertinent anatomy, surgical indications, operative techniques, concluding with a discussion of complications and long-term results. I found the surgical descriptions easy to follow, especially the clear, high-quality artworks and intraoperative images.

The informative materials from the impressive list of expert contributors from over 15 countries make it a must-read, must-have text. The textbook is a must-have for all who are entrusted with the reconstructive needs of patientsworldwide. Thework belongs not only in the hands of those in training and those looking for a refresher but also in the hands of seasoned surgeons.

Foad Nahai, MD, FACS, FRCS (Hon) Adjunct Professor of Plastic Surgery The Center for Plastic Surgery at Metroderm Emory University Atlanta, Georgia, USA

Preface

The concept for this textbook originated during a dinner a few years ago. The coeditors had been reflecting on how educating multiple generations of plastic surgeons has been one of the most rewarding aspects of their career. During this conversation, they came to the realization that, surprisingly, there were few resources available that could serve as a reference guide to a surgeon looking to walk through an operation, a step-by-step approach, from start-to-finish. Feedback from the medical students and residents over the years confirmed this sentiment.

Each coeditor had returned from an international plastic surgery meeting that reminded them how modern information technology has made knowledge transferable globally and at a speed unfathomable only a decade ago. In particular, plastic surgery has benefited greatly from the contributions of thought leaders from around the world.

As a result, the coeditors became motivated to create this book to address the need for a comprehensive procedural guide and as a means of amalgamating the unique ideas of plastic surgeons from all parts of the world. The coeditors believe that the result is truly greater than the sum of its parts.

This textbook details many of the most essential procedures in the reconstructive plastic surgeons’ toolbox. It is organized by anatomic body area, from the head and neck, to the breasts, to the trunk, and the extremities. The authors of each chapter are experts of their domain, many of whom developed procedures that have become the standard of care. Instead of focusing on surgical philosophy, you will find each chapter to be focused on technique and to be very visual, providing clear guidance on the technical progression of each operation as well as its pertinent surgical anatomy.

The editors are indebted to Dr. FoadNahai, a true innovator and ambassador of plastic surgery not only in theUnited States but also internationally, for the foreword. As an educator of several generations of plastic surgeons around theworld, he embodies the essence of thiswork. The editors are also highly appreciative of the hard work of the staff at Thieme Publishers, who were able to turn our ideas into reality.

Robert X. Murphy Jr., MD, MS, CPE, FACS Charles K. Herman, MD, MBA, FACS

Acknowledgments

The editors thank the talented staff at Thieme for bringing this project to fruition. From start to finish, they have shared our vision for the book and made it a reality.

Dr. Murphywould like to thank his family, wife, Meg, and daughters, Margo and Shannon, for their selfless and unwavering love and support. Their love has made every day a blessing. He would also like to recognize his colleagues at the Lehigh Valley Health Network who have supported and nurtured his academic and professional development throughout his entire career.

Dr. Herman appreciates the patience of his family, particularly his wife Olga and son Simon, during the many borrowed hours needed to complete this work.

Robert X. Murphy Jr., MD, MS, CPE, FACS Charles K. Herman, MD, MBA, FACS

Contributors

Joshua Michael Adkinson, MDAssociate Professor of Surgery Division of Plastic Surgery;Adjunct Associate Professor of Orthopedic SurgeryIndiana University School of MedicineIndianapolis, Indiana, USA

Chrisfouad R. Alabiad, MDAssociate Professor of OphthalmologyBascom Palmer Eye InstituteUniversity of Miami School of MedicineMiami, Florida, USA

Husain AlQattan, MDFellowUniversity of Texas Health Science Center at San AntonioDivision of Plastic, Aesthetic and Reconstructive SurgerySan Antonio, Texas, USA

Anthony J. Archual, MDPlastic Surgery ResidentPlastic and Maxillofacial SurgeryUniversity of VirginiaCharlottesville, Virginia, USA

Morad Askari, MDProfessorDepartment of OrthopaedicsHand and Microvascular Surgery Miller School of Medicine;Jackson Memorial HospitalUniversity of MiamiMiami, Florida, USA

Austin Michael Beason, MDResearch FellowMemorial Medical CenterSouthern Illinois University School of MedicineSpringfield, Illinois, USA

Jessica Billig, MD, MSPlastic Surgery ResidentUniversity of MichiganAnn Arbor, Michigan, USA

Sigrid Blome-Eberwein, MDAssociate Director Regional Burn CenterLehigh Valley Health Network;Associate ProfessorDepartment of SurgeryUniversity of South FloridaAllentown, Pennsylvania, USA

Morgan Brgoch, MDAssistant Professor of SurgeryDivision of Plastic Surgery/Hand SurgeryUniversity of Kentucky HealthCareLexington, Kentucky, USA

Logan W. Carr, MDPlastic Surgery ResidentDivision of Plastic SurgeryPenn State Milton S. Medical CenterHershey, Pennsylvania, USA

Seán Carroll, MDPlastic and Hand SurgeonSVUH, DublinAssociate Clinical ProfessorUCD School of MedicineUniversity College Dublin;President of IAPSIrish Association of Plastic SurgeryDublin, Ireland

Liann Casey, MDPlastic Surgery ResidentJackson Memorial HospitalMiami, Florida, USA

Sarah A. Cazorla, MDPlastic and Reconstructive Surgery FellowUniversity of VirginiaCharlottesville, Virginia, USA

Paul S. Cederna, MDChiefSection of Plastic Surgery;Robert Oneal Professor of Plastic Surgery;ProfessorDepartment of Biomedical EngineeringUniversity of Michigan Health SystemAnn Arbor, Michigan, USA

David W. Chang, MD, FACSChief of Plastic and Reconstructive Surgery;Director of Microsurgery Fellowship;Professor of SurgeryThe University of Chicago Medicine & Biological SciencesChicago, Illinois, USA

Edward I. Chang, MD, FACSAssociate ProfessorUniversity of Texas MD Anderson Cancer CenterHouston, Texas, USA

Eric I-Yun Chang, MD, FACSClinical Associate ProfessorHackensack Meridian School of MedicineSeton Hall UniversityInstitute for Advanced ReconstructionPlastic Surgery CenterShrewsbury, New Jersey, USA

David Chiu, MD, FACSProfessor of Plastic Surgery and NeurosurgeryChief of Hand SurgeryDirector of Hand Surgery FellowshipHansjorg Wyss Department of Plastic and ReconstructiveSurgeryNew York UniversityNew York, New York, USA

Jong-Woo Choi, MD, PhD, MMMProfessorDepartment of Plastic & Reconstructive SurgeryCollege of MedicineUniversity of UlsanSeoul Asan Medical CenterSeoul, South Korea

Kevin C. Chung, MD, MSProfessorUniversity of MichiganAnn Arbor, Michigan, USA

Emily Grace Clark, MDAssistant Professor Plastic SurgeryPrisma Health-USC Plastic SurgerySumter, South Carolina, USA

Mimis Cohen, MD, FACSProfessor of SurgeryDivision of Plastic, Reconstructive and Cosmetic SurgeryAnd the Craniofacial CenterUniversity of Illinois, Chicago, USA

Rodney Cooter, MDAdjunct ProfessorMonash UniversityAdelaide, Australia

Erez Dayan, MDHarvard Plastic SurgeryBrigham and Womens HospitalHarvard Medical SchoolBoston, Massachusetts, USA

Catherine de Blacam, MD, FRCSI (Plast)Consultant Plastic SurgeonChildren’s Health Ireland at CrumlinDublin, Ireland

Stefania de Fazio, MDBoard certified Plastic SurgeonInternational Liaison SICPREItalian Society of Plastic ReconstructiveRegenerative and Aesthetic SurgeryRome, Italy

Patricia A. Eadie, MB, FRCSI, FRCSI (PLAST)Consultant Plastic, Reconstructive and Aesthetic SurgeonEccles ClinicDublin, Ireland

Guillermo Echeverria, MDPlastic and Reconstructive SurgeonAcademic DirectorCentro Cirugia Plastica RenovaMember of AGCPER, AMCPER, ASPS, FILACP, ICOPLASTGuatemala City, Guatemala

Gregory R.D. Evans, MD, FACSChairDepartment of Plastic SurgeryUC Irvine HealthSchool of MedicineOrange, California, USA

Carlos Eduardo Torres Fuentes, MDPlastic Surgeon, Hand Surgeon, ReconstructiveMicrosurgeon;Assistant ProfessorHead of Hand Surgery Department;Director of Hand Surgery Fellowship programFundación Universitaria de Ciencias de la SaludHospital de San JoséBogotá, Colombia

Christopher Edward Fundakowski, MDAssociate ProfessorDepartment of Otolaryngology – Head & Neck SurgeryThomas Jefferson UniversityPhiladelphia, Pennsylvania, USA

Ricardo Galán, MDPlastic Aesthetic and Reconstructive Surgeon – HandSurgeon;Former PresidentColombian Society for Plastic Aesthetic and ReconstructiveSurgeryHand Surgeon Hospital Militar Central;Titular ProfessorUniversidad Militar Nueva GranadaBogotá, Colombia

Sabrina Gallego-Gónima, MDPlastic and Reconstructive SurgeonHand Surgeon;Assistant ProfessorPlastic Surgery DepartmentUniversidad De AntioquiaSección Cirugía Plástica U de AHospital Universitario De San Vicente FundaciónIDC – Clínica Las Américas AUNAMedellín, Colombia

Rebecca M. Garza, MDAssistant ProfessorDepartment of SurgerySection of Plastic and Reconstructive SurgeryUniversity of ChicagoChicago, Illinois, USA

Harris Gellman, MDAdjunct Clinical ProfessorUniversity of MiamiDepartments of Orthopedic Surgery and Plastic SurgeryUniversity of Miami School of MedicineCoral Springs, Florida, USA

Rachel Georgopoulos, MDAssistant ProfessorHead and Neck surgeryCleveland ClinicCleveland, Ohio, USA

Jarom Gilstrap, MDAssistant Professor of SurgeryDivision of Plastic SurgeryUniversity of South Carolina School of MedicineColumbia, South Carolina, USA

Kriya Gishen, MDPlastic Surgery ResidentJackson Memorial HospitalUniversity of MiamiCoral Gables, Florida, USA

Cindy Siaw Lin Goh, MDPlastic SurgeonDepartment of Plastic, Reconstructive and AestheticSurgerySingapore General HospitalOutram Road, Singapore

Terence Lin Hon Goh, MDPlastic SurgeonAZATACA Plastic SurgeryRoyal Square Medical CentreNovena, Singapore

Giovanni Montealegre Gómez, MDPlastic Surgeon, Hand Surgeon, and MicrosurgeonNational University of ColombiaFundación Universitaria de Ciencias de la SaludHospital de San José;PresidentLatin American Association of Microsurgery ALAMBogotá, Colombia

Jeremy A. Goss, MDResearch FellowDepartment of Plastic and Oral SurgeryBoston Children’s HospitalHarvard Medical SchoolBoston, Massachusetts, USA

Patrick J. Greaney Jr., MDNerve RepairDivision of Plastic SurgeryThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA

Arin K. Greene, MDVascular Anomalies and PediatricPlastic Surgery Endowed ChairDepartment of Plastic and Oral SurgeryBoston Children's Hospital;Professor of SurgeryHarvard Medical SchoolBoston, Massachusetts, USA

Michael Grimaldi, MDAttending PhysicianDepartment of Emergency MedicineSt. Luke's University Health NetworkBethlehem, Pennsylvania, USA

Eyal Gur, MDChiefPlastic and Reconstructive Surgery DepartmentTel Aviv Medical CenterTel Aviv UniversityTel Aviv, Israel

Randy M. Hauck, MD, MS, FACSAssociate Professor of SurgeryOrthopaedics and RehabilitationPenn State Hershey Medical CenterHershey, Pennsylvania, USA

Charles K. Herman, MD, MBA, FACSPlastic SurgeonDepartment of SurgeryLehigh Valley Hospital-PoconoLehigh Valley Health NetworkEast Stroudsburg, Pennsylvania, USA

William Y. Hoffman, MDProfessor and ChiefDivision of Plastic and Reconstructive SurgeryUniversity of California, San FranciscoSan Francisco, California, USA

Joon Pio Hong, MD, PhD, MMMProfessorUniversity of UlsanAsan Medical CenterSeoul, Korea

Michael Ku Hung Hsieh, MDPlastic SurgeonDepartment of Plastic, Reconstructiveand Aesthetic SurgerySingapore General HospitalOutram Road, Singapore

Wooshik Jeong, MDClinical Assistant ProfessorDepartment of Plastic SurgerySeoul Asan Medical CenterSeoul, South Korea

Timothy Shane Johnson, MDAssociate ProfessorDepartment of Surgery;Chief, Division of Plastic SurgeryPenn State Cancer InstituteMilton S. Hershey Medical CenterHershey, Pennsylvania, USA

Karen Kaplan, MDPlastic Surgery ResidentDivision of Plastic SurgeryMiller School of MedicineUniversity of MiamiMiami, Florida, USA

Wrood Kassira, MDAssociate Professor of Clinical Surgery;Associate Program Director Plastic Surgery ResidencyProgramDivision of Plastic and Reconstructive SurgeryDeWitt Daughtry Department of SurgeryUniversity of Miami Miller School of MedicineMiami, Florida, USA

Daniel Josef Kedar, MDSenior, Plastic and Reconstructive Surgery DepartmentTel Aviv Medical CenterTel Aviv UniversityTel Aviv, Israel

Julio Daniel Kirschbaum Fridman, MDPlastic SurgeonFormer President of the Peruvian Plastic Surgery Society;Former President of the Iberoamerican Federation of PlasticSurgery;Former President of the International Confederation ofPlastic Surgery Societies (ICOPLAST);Professor of Plastic SurgeryUniversity San Martin de PorresSan Borja-Lima, Peru

Steven Michael Koehler, MDDirectorHand and MicrosurgeryDepartment of Orthopaedic Surgery, SUNY DownstateMedical CenterBrooklyn, New York, USA

Geoffrey Konopka, MD, MPHAssistant ProfessorHand and Upper Extremity SurgeryDepartment of Orthopaedic SurgeryUniversity of Texas Health Science CenterHouston, Texas, USA

Billy Lane O'Neill, MB, MChSurgeonDepartment of Plastic and Reconstructive SurgerySt. Vincent's University HospitalDublin, Ireland

Hernando Laverde-Gutierrez, MDPlastic Surgeon and Hand Surgeon;Former President of the Colombian Association for Surgeryof the Hand;Hand SurgeonThe Police National Hospital;Hand SurgeonColsanitas Health Care Organization;IFSSH Colombian Delegate (2007–2014)Bogotá, Colombia

Brian Le, MDAssistant ProfessorProgram Director of Plastic SurgeryResidency at Virginia Commonwealth UniversityRichmond, Virginia, USA

Jonathan Yun Lee, MD, MPHAssistant Professor of SurgeryBaystate Health SystemUniversity of Massachusetts Medical School – BaystateSpringfield, Massachusetts, USA

David Leshem, MDHeadPediatric & Craniofacial Plastic Surgery UnitPlastic & Reconstructive Surgery DepartmentTel Aviv Sourasky Medical CenterTel Aviv Sackler Medical SchoolTel Aviv UniversityTel Aviv, Israel

Lucie Lessard MD, FRCSC (ENT), FRCSC (Plastic Surgery),FACSFormer Chief, McGill Plastic SurgeryDirector & Founder, McGill Craniofacial FellowshipBoard of Directors, International Confederation of PlasticSurgery Societies (ICOPLAST)Montreal, Canada

Kant Y.K. Lin, MD, FACSProfessorChief Division of Plastic SurgeryUniversity of KentuckyLexington, Kentucky, USA

Joseph E. Losee, MD, FACS, FAAPDr. Ross H. Musgrave Endowed Chairin Pediatric Plastic Surgery;Professor and Executive Vice ChairDepartment of Plastic Surgery;Division Chief, Pediatric Plastic SurgeryChildren’s Hospital of Pittsburgh of UPMCPittsburgh, Pennsylvania, USA

Megan P. Lundgren, MDDepartment of SurgeryThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA

Amr Reda Mabrouk, MDProfessorPlastic and Maxillofacial SurgeryAin Shams UniversityCairo, Egypt

Donald R. Mackay, MD, FACS, FAAPProfessor of SurgeryPenn State Hershey Medical CenterHershey, Pennsylvania, USA

Brian Mailey, MD, FACSAssociate Professor of Surgery;Hand Fellowship Program Director;DirectorBrachial Plexus and Tetraplegia Clinic;DirectorCongenital Head and Neck Anomalies Clinic;Vice Chair of ResearchInstitute of Plastic SurgerySouthern Illinois University School of MedicineSpringfield, Illinois, USA

Ellyn McNamara, MS, CCC-SLPBilingual Speech-Language PathologistAssistive Technology UnitDepartment of Disability & Human DevelopmentUniversity of Illinois at ChicagoChicago, Illinois, USA

Charles P. Melone Jr., MDDirectorHand SurgeryMount Sinai Beth IsraelNew York, New York, USA

Nathan F. Miller, MDAssistant Professor of SurgeryUSF Health Morsani College of MedicineDivision of Plastic & Reconstructive SurgeryDivision of Orthopedic SurgeryLehigh Valley Health NetworkAllentown, Pennsylvania, USA

Waseem Mohiuddin, BSDivision of Plastic SurgeryThomas Jefferson University HospitalPhiladelphia, Pennsylvania, USA

Melissa Mueller, MDAssistant ProfessorDivision of Plastic SurgeryIndiana University School of MedicineIndiana, USA

Leela S. Mundra, MDPlastic Surgery ResidentDivision of Plastic SurgeryUniversity of Miami Miller School of MedicineMiami, Florida, USA

Robert X. Murphy Jr., MD, MS, CPE, FACSProfessor of SurgeryMorsani College of MedicineUniversity of South FloridaTampa, Florida, USA;LVHN Program DirectorResidency in Plastic Surgeryand Pool Chair of Community HealthLehigh Valley Health NetworkAllentown, Pennsylvania, USA

Chetan Satish Nayak, MDPhysicianLehigh Valley Health NetworkAllentown, Pennsylvania, USA

Michael W. Neumeister, MD, FRCSC, FACSProfessor and ChairDepartment of SurgeryElvin G. Zook Endowed ChairInstitute for Plastic SurgerySouthern Illinois University School of MedicineSpringfield, Illinois, USA

Rogerio I. Neves, MD, PhD, FACSProfessor of Surgery, Dermatology, Pharmacology andMedicinePenn State University, Division of Plastic SurgeryHershey, Pennsylvania, USA

Marilyn Ng, MD, MScReconstructive Microsurgery FellowDivision of Plastic and Reconstructive SurgeryFox Chase Cancer CenterPhiladelphia, Pennsylvania, USA

Rei Ogawa, MD, PhD, FACSProfessor and ChiefDepartment of Plastic, Reconstructive and AestheticSurgeryNippon Medical SchoolTokyo, Japan

Zubin J. Panthaki, MD, CM, FACSProfessor of Clinical Surgery Division of Plastic Surgery;Professor of Clinical OrthopedicsThe University of MiamiMiller School of MedicineMiami, Florida, USA

Sameer A. Patel, MD, FACSChief, Plastic and Reconstructive SurgeryAssociate Professor, Department of Surgical OncologyFox Chase Cancer CenterPhiladelphia, Pennsylvania, USA

Emily Nicole Perez, MDHand Surgery FellowJackson Memorial Hospital/University of MiamiUM Division of Plastic SurgeryMiami, Florida, USA

Graeme Perks, FRCS, FRACSPlastic SurgeonDepartment of Plastic, Reconstructive and Burns SurgeryNottingham University Hospitals NHS TrustNottingham, England

Nelson Piccolo, MDPlastic SurgeonDivision of Plastic SurgeryPronto Socorro para QueimadurasGoiânia, Goiás, Brazil

John D. Potochny, MDPlastic SurgeonPenn State Hershey Medical CenterHershey, Pennsylvania, USA

Paymon Rahgozar, MDAssistant ProfessorDivision of Plastic SurgeryUniversity of California San FranciscoSan Francisco, California, USA

Mamtha S. Raj, MA, MDPlastic Surgery ResidentDivision of Plastic and Reconstructive SurgeryDepartment of SurgeryLehigh Valley Health NetworkAllentown, Pennsylvania, USA

Hinne A. Rakhorst, MD, PhDConsultant Plastic and Reconstructive SurgeryDepartment of Plastic and Reconstructive SurgeryZiekenhuis Groep Twente AlmeloMedisch Spectrum Twente EnschedeThe Netherlands

Bharat Ranganath, MDAssistant Professor of Plastic SurgeryGeorge Washington UniversityWashington DC, USA

John M. Roberts, MDPlastic Surgery ResidentPenn State Hershey Medical CenterHershey, Pennsylvania, USA

Thomas D. Samson, MD, FACS, FAAPAssociate Professor of Surgery Pediatrics and NeurosurgeryDivision of Plastic SurgeryPenn St. Hershey College of Medicine;Lancaster Cleft Palate ClinicHershey, Pennsylvania, USA

Ian C. Sando, MDClinical Instructor in MicrosurgeryStanford Plastic and Reconstructive SurgeryPalo Alto, California, USA

Alex Schmucker, MDPlastic Surgery ResidentDepartment of Orthopaedic SurgerySumma Health SystemAkron, Ohio, USA

Ryan W. Schmucker, MDAssistant ProfessorDepartment of Plastic and Reconstructive SurgeryThe Ohio State UniversityColumbus, Ohio, USA

M. Shuja Shafqat, MDAssistant ProfessorProgram Director-Reconstructive Microsurgery FellowshipDivision of Plastic and Reconstructive SurgeryDepartment of Surgical OncologyFox Chase Cancer Center/Temple HealthPhiladelphia, Pennsylvania, USA

Ajul Shah, MDPlastic, Reconstructive,Hand and Upper Extremity SurgeonBoard Certified in Plastic and Reconstructive SurgeryBoard Certified in the Subspecialty of Surgery of the HandThe Center for Hand and Upper Extremity SurgeryShrewsbury, New Jersey, USA

David A. Sterling, MDDepartment of Plastic SurgeryUniversity of Kansas Medical CenterThe University of Kansas Medical CenterKansas City, Kansas, USA

Hyunsuk Peter Suh, MD, PhDAssistant ProfessorUniversity of UlsanAsan Medical CenterSeoul, Korea

Mark R. Sultan, MDProfessor of Surgery (Plastic)Mount Sinai School of MedicineNew York, New York, USA

Steven M. Sultan, MDPlastic Surgery FellowMontefiore Division of Plastic SurgeryNew York, New York, USA

Robert M. Teixeira, MDHand, Nerve, and Microsurgery FellowWashington University in St. LouisDivision of Plastic & Reconstructive SurgeryDepartment of SurgerySt. Louis, Missouri, USA

Seth R. Thaller, MD, DMD, FACSProfessor and ChiefDivision of Plastic, Aesthetic, and Reconstructive SurgeryUniversity of Miami School of MedicineMiami, Florida, USA

Kavita T. Vakharia, MDFellow (Hand Surgery)University of New MexicoAlbuquerque, New Mexico, USA

Douglas S. Wagner, MDClinical ProfessorPlastic SurgeryNortheast Ohio Course of MedicineAkron, Ohio, USA

Sean J. Wallace, MDAttending SurgeonDivision of Plastic SurgeryDepartment of SurgeryLehigh Valley Health NetworkAllentown, Pennsylvania, USA

Paul R. Weiss, MDClinical Professor of SurgeryDivision of Plastic SurgeryAlbert Einstein College of MedicineNew York, USA

James Nolan Winters, MDPlastic Surgery ResidentSIU School of MedicineInstitute for Plastic SurgerySpringfield, Illinois, USA

Randolph Wojcik Jr., MD, FACSChief, Division of Plastic SurgeryDepartment of SurgeryLehigh Valley Health NetworkAllentown, Pennsylvania, USA

Jason Yoo, MDPlastic Surgery ResidentDivision of Plastic and Reconstructive SurgeryUniversity of Miami/Jackson Memorial HospitalMiami, Florida, USA

Sivan Zissman, MDPlastic & Reconstructive Surgery DepartmentTel Aviv Sourasky Medical CenterTel Aviv Sackler Medical School, Tel Aviv UniversityTel Aviv, Israel

Section I

Head and NeckSubsection IACongenital Defects

1 Primary/Secondary Cleft Palate Repair

2 Cleft Lip and Nose Repair

3 Velopharyngeal Insufficiency

4 Velopharyngeal Insufficiency: Pharyngoplasty

5 Cleft Lip Nasal Deformity Repair

6 Syndromic and Nonsyndromic Craniosynostosis: Surgery of the Vault

7 Ear Reconstruction

8 Otoplasty

1 Primary/Secondary Cleft Palate Repair

Thomas D. Samson

Abstract

This chapter will focus on the author’s preferred technique for surgical correction of both primary and secondary cleft palates. The strategies for addressing common cleft presentations such as complete, incomplete, and submucous as well as the correction of palatal fistulae and velopharyngeal insufficiency will be reviewed. Postoperative care strategies for cleft palate patients will also be discussed.

Bardach, cleft palate, fistula, Furlow, intravelar veloplasty, palatoplasty, velopharyngeal insufficiency, vomer flap, von Langenbeck

1.1 Introduction

Repair of the cleft palate defect aims to separate the oral and nasal cavities and anatomically reposition the levator veli palatini muscles for functional speech. Surgical repair of the cleft palate is widely regarded to have begun in the 19th century. The advent of anesthesia brought upon varying techniques of cleft palate repair many of which form the basis of the current popular techniques.

1.2 Indications

Palatal clefts can be described using the Veau classification. Many operative techniques have been used over time with the same guiding principles of two-layer closure and repositioning of the velar musculature as the goal. Review of the many techniques of palate repair is beyond the scope of this chapter. However, the most commonly used repairs today include the Furlow double-opposing palatoplasty, the Bardach two-flap palatoplasty, the von Langenbeck palatoplasty, and the Wardill-Kilner V-Y pushback palatoplasty.1,2,3,4,5,6,7,8 It should be noted that the Wardill-Kilner V-Y pushback has fallen out of favor due to long-term maxillary growth restriction.

My preferred techniques for Veau types I and II that are less than 10 mm wide is the double-opposing Z-plasty and for clefts wider than 10 mm, or any Veau III–IV, is the Bardach two-flap palatoplasty with intravelar veloplasty (IVV) with or without vomer flaps. Regardless of the technique, repositioning of the levator musculature in its normal anatomic location is the key to success.9 Surgery is ideally performed at about 12 months of age. Repair prior to 16 months results in better speech outcomes.

In secondary cleft repairs due to fistula, I use the Bardach two-flap palatoplasty with IVV using judicious relaxing incisions. Others have used buccal fat flaps or facial artery myomucosal flaps for larger fistulae. I have used human acellular dermis to augment these repairs in the past but have abandoned the technique after a number of postoperative infections.

In cases of velopharyngeal insufficiency (VPI), I prefer the use of the Furlow double-opposing Z-plasty as my initial repair because if allows radical dissection and retropositioning of the levator muscles without performing a nonanatomic surgery such as the pharyngeal flap or sphincter pharyngoplasty.10 I have found in my own primarily repaired cleft palate patients that the levator sling has creeped anteriorly even after I have performed what I felt was a radical levator dissection and retropositioning initially. If the repeat Furlow Z-plasty fails, I would perform a pharyngeal flap or sphincter pharyngoplasty. Nasendoscopy can be a very helpful adjunct in determining the correct VPI surgery as it demonstrates the patient’s velar closing pattern. Tailoring the surgery to the closing pattern has been well described.

1.3 Operative Technique

All cleft palate repairs begin with appropriate positioning of the patient and insertion of the Dingman mouth gag. The surgeon must confirm the airway function with anesthesia after insertion of the Dingman.

1.3.1 Furlow Double-Opposing Z-Plasty

●Local infiltration: If the cleft width is less than 10 mm, I will mark the palate for double-opposing Z-plasty. I will identify the hamulus and be sure that my back-cut at the hard and soft palate junction does not extend too far laterally near a potential relaxing incision (Fig. 1‑1). A 1:1 mix of 0.5% bupivacaine and 0.5% lidocaine with epinephrine 1:200,000 is instilled.

●Incision and dissection:

○Left-sided oral myomucosal flap is incised and dissection laterally is limited to allow for a relaxing incision as needed:

–Meticulous dissection of the levator muscle is needed to be sure that the entire muscle is dissected off the posterior edge of the hard palate, freed from the nasal mucosal layer, and radically dissected from the space of Ernst.

–Tensor aponeurotic fibers are stripped from the hamulus allowing medialization of the entire flap.

○Right-sided oral mucosa flap is incised and dissected laterally.

○Left-sided nasal mucosa flap is incised.

○Right-sided nasal myomucosal flap is incised and elevated, being careful not to extend the mucosal incision too far laterally:

–Meticulous dissection of the levator muscle is needed to be sure that the entire muscle is dissected off the posterior edge of the hard palate, freed from the nasal mucosal layer, and radically dissected from the space of Ernst.

–Tensor aponeurotic fibers are stripped from the hamulus allowing medialization of the entire flap.

●Closure: 4–0 and 5–0 absorbable braided suture placed in a horizontal everting fashion. The flap sequence is the right-sided nasal myomucosal flap, the left nasal mucosa-only layer, the right oral myomucosal flap, and finally the right oral mucosa-only flap (Fig. 1‑2).

●Relaxing incisions: I do not routinely use these. If there is any concern for tension along the closure, I will start with a single relaxing incision and not hesitate to make a second incision if needed.

●Nasopharyngeal airway is sized for emergency airway purposes in the postoperative setting. This is placed in a bag on the patient’s chart.

Fig. 1.1 Markings for a Furlow double-opposing palatoplasty.

Fig. 1.2 Closure of Furlow double-opposing palatoplasty.

Fig. 1.3 Markings along the posterior soft palate. Lateral marks indicate location of hamulus with lateral relaxing incisions.

Fig. 1.4 Markings continued on to the hard palate. Note the midline vomer. No markings were made as a vomer flap was not anticipated for this case.

1.3.2 Bardach Two-Flap Palatoplasty with Intravelar Veloplasty

●Local infiltration: I mark relaxing incisions lateral to the hamulus, cleft margin incisions, and superiorly based vomer flaps if needed (Fig. 1‑3and Fig. 1‑4). A 1:1 mix of 0.5% bupivacaine and 0.5% lidocaine with epinephrine 1:200,000 is instilled.

●Incision and dissection:

○Marginal incisions are made with a #12 blade. Relaxing incisions are made bilaterally. The mucoperiosteal flaps on the hard palate are completely incised as unipedicled flaps. This facilitates complete dissection of the greater palatine vessels. If an osseous cuff surrounds the pedicle limiting its medialization, I will carefully osteotimize the bony cuff.

○Dissection of the levator muscle from the oral and nasal mucosa and freeing the musculature from the posterior edge of the hard palate allow for the retropostitioning of the levator to its normal anatomic positioning.

○Dissection in the relaxing incision allows for stripping of the tensor aponeurotic fibers from the hamulus and any lateral attachments to the posterior edge of the hard palate. Separation of the superior constrictor from the levator within the space of Ernst completes the levator musculature dissection (Fig. 1‑5).

○Elevation of the nasal mucosa of the hard palate, especially at the junction of the hard and soft palates, completes the dissection.

●Vomer flap: If I am concerned with the tension of the nasal closure of the hard palate, superiorly based vomer flaps are elevated.

●Closure: I use 4–0 and 5–0 absorbable braided suture in a horizontal mattress fashion to evert the edges. The nasal lining is closed first, including the uvula. The IVV is completed with 4–0 absorbable braided suture in a figure of eight fashion. Careful attention is paid to place an adequate amount of resting tension on the muscle and to position the muscle at the posterior third of the soft palate (Fig. 1‑6). The oral lining is closed (Fig. 1‑7) initially by resuspending the anterior edge of the mucoperiosteum to the alveolar gingiva limiting any exposed hard palate bone. No attempt is made to “close” the alveolus. The relaxing incisions are routinely left open.

●Nasopharyngeal airway is sized for emergency airway purposes in the postoperative setting. This is placed in a bag on the patient’s chart.

Fig. 1.5 Note the freer elevator within the space of Ernst. The levator muscle is retropositioned to its normal anatomic placement. The superior constrictor is lateral and there are no tensor fibers distracting the levator anteriorly.

Fig. 1.6 The nasal mucosa has been approximated. The intravelar veloplasty (IVVP) has been completed with the levator sling sitting in the posterior third of the soft palate.

Fig. 1.7 The oral mucosa is approximated with everting horizontal mattress sutures and the relaxing incisions are left open.

1.3.3 Secondary Palatoplasty for Fistula

●Assessment of the fistula is performed using a freer to gently probe the defect. Once the extent of the communication is identified, the intraoral mucoperiosteum is marked at the edge of the fistula and a 1:1 mix of 0.5% bupivacaine and 0.5% lidocaine with epinephrine 1:200,000 is instilled.

●The fistula edge is incised followed by bilateral relaxing incisions. Bilateral unipedicled mucoperiosteal flaps are elevated, being sure to elevate the mucoperiosteum posterior to the fistula for about 5 mm.

●The fistula tract mucosa is carefully excised. Nasal mucosa is elevated. Superiorly based vomer flaps are elevated. Nasal mucosa closure is vital to bilayer closure and success of fistula repair.

●Everting 4–0 and 5–0 absorbable braided suture in a horizontal mattress fashion is placed to evert the edges. Closure of the anterior extent of the mucoperiosteum to the alveolar gingiva is key to avoiding any exposed palatal bone. I do not close the relaxing incisions.

●If the fistula is confined to the hard palate, once the patient meets discharge criteria, he or she is discharged.

●If the repair extends into the soft palate, the patient is kept overnight to monitor airway.

Postoperatively, the patients remain in the hospital overnight to monitor the airway. The patient has an appropriately sized nasopharyngeal airway with the ideal nare to be used on the chart should any airway issues arise. Others place a tongue suture taped to the cheek for emergency airway purposes as well. Patients must demonstrate the ability to take in liquids prior to discharge. Families are encouraged to bring in sippy cups from home. If there are problems taking oral liquids the use of a syringe or red rubber catheter can be used to encourage oral intake.

Once the patients are taking adequate liquids by mouth and their pain is controlled, they are cleared for discharge. Once home, the patient stays on a soft diet for 3 weeks. Encourage sippy cups with no valves and avoid bottles with nipples and pacifiers. I do not use arm restraints as there has been no literature to support their use with a lower flap failure or fistula rate. Perioperative antibiotics are given for the first day only. I see the patient back in follow-up in 2 weeks.

1.4 Conclusion

Primary or secondary cleft palate repair is challenging and demands a sound operative plan tailored to the patient’s defect.

●Two-layer closure along the length of the cleft with minimal tension is vital to avoid fistula formation.

●Complete dissection and approximation of the levator muscles is necessary to establish correct anatomic positioning and leads to improved speech.

●Establishing a normal resting tension on the levator muscles when approximating is necessary to achieve more normal function postoperatively.

●Liberal use of lateral relaxing incisions is utilized to lessen any tension on the midline closure. These incisions are not typically closed.

●When using the Bardach two-flap palatoplasty with IVV you must reapproximate the anterior-most mucoperiosteal flaps to limit exposed bone.

●All patients are kept overnight for airway assessment and continuous pulse oximetry. A nasopharyngeal airway is sized in the operating room and placed in a bag on the chart for use if the patient desaturates.

●Arm restraints are not used postoperatively.11

●Soft diet is maintained for 3 weeks or until the first follow-up.

References

[1]Furlow LT, Jr. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg. 1986; 78(6):724–738

[2]Timbang MR, Gharb BB, Rampazzo A, Papay F, Zins J, Doumit G. A systematic review comparing Furlow double-opposing Z-plasty and straight-line intravelar veloplasty methods of cleft palate repair. Plast Reconstr Surg. 2014; 134 (5):1014–1022

[3]Katzel EB, Basile P, Koltz PF, Marcus JR, Girotto JA. Current surgical practices in cleft care: cleft palate repair techniques and postoperative care. Plast Reconstr Surg. 2009; 124(3):899–906

[4]Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg. 2003; 112(6):1542–1548

[5]Bae YC, Kim JH, Lee J, Hwang SM, Kim SS. Comparative study of the extent of palatal lengthening by different methods. Ann Plast Surg. 2002; 48(4):359– 362, discussion 362–364

[6]van Aalst JA, Kolappa KK, Sadove M. MOC-PSSM CME article: nonsyndromic cleft palate. Plast Reconstr Surg. 2008; 121(1) Suppl:1–14

[7]Woo AS. Evidence-based medicine: cleft palate. Plast Reconstr Surg. 2017; 139(1):191e–203e

[8]Hopper RA, Tse R, Smartt J, Swanson J, Kinter S. Cleft palate repair and velopharyngeal dysfunction. Plast Reconstr Surg. 2014; 133(6):852e–864e

[9]Andrades P, Espinosa-de-los-Monteros A, Shell DH, IV, et al. The importance of radical intravelar veloplasty during two-flap palatoplasty. Plast Reconstr Surg. 2008; 122(4):1121–1130

[10]Nayar HS, Cray JJ, MacIsaac ZM, et al. Improving speech outcomes after failed palate repair: evaluating the safety and efficacy of conversion Furlow palatoplasty. J Craniofac Surg. 2014; 25(2):343–347

[11]Michelotti B, Long RE, Leber D, Samson T, Mackay D. Should surgeons use arm restraints after cleft surgery? Ann Plast Surg. 2012; 69(4):387–388

2 Cleft Lip and Nose Repair

Jonathan Yun Lee and Joseph E. Losee

Abstract

The cleft lip nose deformity has variable presentation, ranging from a unilateral microform cleft lip to bilateral cleft lip with significant nasal deformity. The primary goals of cleft lip repair include: (1) balance Cupid’s bow with an upper lip philtral subunit reconstruction and (2) correct the cleft lip nasal deformity. In order to achieve adequate lip length, rotation-advancement with or without triangular flap techniques can be utilized. Multiple modifications of the rotation-advancement have been described; however, they all require rotating the medial element down via a back-cut and filling the resulting defect with either C-flap or advancement flap from the lateral element. Primary cleft rhinoplasty is also strongly recommended at the time of primary lip repair to optimize outcomes. There are several key technical points that should be followed to ensure proper repair:

●The length of the normal philtral column should equal the length of both the noncleft philtral column and the leading edge of the rotation-advancement flap.

●During incision, preserve tattoo marks to facilitate accurate reapproximation of key landmarks.

●The orbicularis muscle requires full release from abnormal attachments to the maxilla, piriform rim, anterior nasal spine, alar base, and caudal septum.

●Cupid’s bow and the vertical position of the alar bases should be balanced after muscle repair.

bilateral cleft lip, cleft lip nose, incomplete cleft lip, microform cleft lip, minor-form cleft lip, Noordhoff’s point, primary rhinoplasty, rotation-advancement, unilateral complete cleft lip

2.1 Introduction

Cleft lip and nose repair combines reconstructive and aesthetic principles to restore form and function. The history and evolution of cleft lip and nose repair is extensive, ranging from 3rd century China to today’s modifications of Millard’s rotation-advancement technique.1,2,3 During the 19th century, “straight-line” repairs by Rose and Thompson began to be replaced with “Z-like” repairs using local flaps to reduce lip shortening from scar contracture. The application of the “Z” repair was further popularized in the 20th century with the Tennison-Randall4 (triangular flap) and Millard5 (rotation-advancement) techniques. Moreover, these techniques still serve as the backbone for the numerous modifications that are widely used by cleft surgeons today.6,7,8,9,10,11

2.2 Indications

Unilateral and bilateral cleft lips can have varying degrees of deformity, and can be classified as either microform, minor, incomplete, or complete (Fig. 2‑1). A vermilion notch describes both microform and minor clefts; however, minor clefts have a notch greater than 3 mm in height, vertical depression above the notch extending into the nasal sill, and variable nasal deformity.12 The distinction between incomplete and complete clefts is debated, specifically when a soft tissue bridge, often called a “Simonart’s band,”3 is located at the nostril base. In order to clarify classification, the senior author proposes that when evaluating cleft lips, the nasal sill should be separated from the lip using a line connecting the alar-facial groove to the columellar-philtral junction. Presence of tissue below this line indicates an incomplete cleft lip, while presence of tissue at or above the line would still be considered a complete cleft lip.13

Fig. 2.1 Types of cleft lips: (a) right microform, (b) left minor-form, (c) left incomplete, (d) left complete, and (e) bilateral complete.

Preoperative assessment of the cleft-affected patient requires a multidisciplinary team consisting of speech pathologist, otolaryngologist, geneticist, pediatrician, feeding specialist, and social worker. Comorbidities and genetic syndromes are identified. The need for presurgical infant orthopedics (PSIO) (passive—nasoalveolar molding; active—Latham device) or lip adhesion prior to formal repair is determined.14,15

Regardless of the technique, the goals of cleft lip repair remain constant:

●Philtral subunit lip reconstruction with a balanced and well-shaped Cupid’s bow.

●Distinct, continuous, symmetric white roll.

●Normal philtral morphology with full tubercle.

●Symmetric vertical position of nasal ala.

●Functional continuity of orbicularis oris.

●Imperceptible scars.

●Restoration of normal nasal form.

Accomplishing these goals is complicated by cicatricial changes, growth, and type of cleft lip deformity. Secondary repair is indicated when there are deficiencies in the goals after wound maturation. In the revision, the initial repair may need to be taken apart to recreate the defect for significant asymmetries of Cupid’s bow, lip height, or animation. A cross-lip flap (Abbe flap) may be indicated after bilateral cleft lip repair if the philtrum is deficient or a significant whistle deformity is present (Fig. 2‑2).16,17,18

Fig. 2.2 Abbe flap. (a) Patient status post bilateral lip repair presenting with a whistle deformity characterized by a deficiency in the central vermilion and lip tubercle. (b) Markings. (c) Dissection with recreation of the cleft lip defect and transfer of the lower lip flap. (d) Inset of the lower lip flap. (e) At 6-month follow-up after division and inset of the lower lip flap.

2.3 Operative Technique

2.3.1 Unilateral

A modification of the rotation-advancement is the authors’ preferred technique (Fig. 2‑3and Video 2.1). After the patient is prepped and draped, the markings are performed with a fine marker and critical points tattooed with methylene blue. The first set of markings includes the nadir, the noncleft peak, and the cleft peak of Cupid’s bow on the medial lip element. The distance between the nadir and the noncleft peak is translated medially to determine the location of the cleft peak. The cleft peak of Cupid’s bow on the lateral lip element is then marked. This point is also referred to as Noordhoff’s point,19 which corresponds to where the white roll begins to taper and the vermilion is the fullest. The vertical distance between the lateral cleft peak of Cupid’s bow and the cleft alar base should be the same as the distance between the noncleft peak and the noncleft alar base on the medial lip element, in order to ensure symmetric lip height. The advancement flap on the lateral element is marked from the cleft peak, extending along the lateral aspect of the white roll, then transitioning along the nasal sill, but not beyond the alar base. The rotation flap on the medial element is marked from the cleft peak, extending to the top of the noncleft philtral column. This rotation flap incision will become the cleft philtral column; it should form an isosceles triangle with the noncleft philtral column; and it should equal the length of the leading edge of the advancement flap on the lateral lip element. A back-cut along the noncleft philtral column is marked, and its length is limited only by the distance needed to rotate the medial element to level Cupid’s bow and transpose the top of the new philtrum to the midline of the columella. If additional rotation is necessary to balance Cupid’s bow, a small triangular flap (1 mm) from the lateral lip element can be inserted above the white roll of the cleft peak of Cupid’s bow. Lastly, the C-flap is marked on the medial element from the cleft peak, extending along the vermilion border to the nasal sill.

Fig. 2.3 Unilateral markings. (a) Markings are first made with a fine marking pen. The cardinal landmarks are then tattooed with methylene blue and a 25-g needle. (b) The skin incisions are highlighted in white. A, rotation flap; B, advancement flap; C, columellar flap; L, cleft nasal lining flap; M, medial element mucosal lining flap.

Video 2.1 Left unilateral cleft lip markings

The markings are incised and the orbicularis oris muscle is dissected from the skin and mucosa, in addition to elevation of the C-flap. Limited dissection from the noncleft philtral column; however, the muscle must be dissected free from its abnormal attachments to the nasal septum and anterior nasal spine to allow sufficient rotation. This dissection also allows for repositioning the caudal septum of the nose into the midline. The rotation flap back-cut can now be performed to balance Cupid’s bow. Proper dissection of the advancement flap requires a buccal sulcus incision in the lateral element in order to dissect the muscle off the abnormal attachments to the piriform aperture and alar base. Extension of the buccal sulcus incision across the piriform aperture and up on top of the inferior turbinate is often needed to mobilize the alar-lip-cheek complex in the supraperiosteal plane and reposition the alar base.

Repair is started with approximating the mucosal lining with 4–0 and 5–0 Chromic suture. The orbicularis oris muscle is repaired next with eversion of the edges with mattress sutures of 4–0 Vicryl to recreate a philtral column. After muscle repair, the skin edges should be in close approximation with a balanced Cupid’s bow and level nasal ala. The skin is reapproximated precisely with buried dermal sutures of 5–0 Monocryl to avoid external sutures. Lip and vermilion height discrepancies can be addressed by insetting the triangular flaps above the white roll and vermilion redline (between the vermilion and mucosa) from the lateral element into the corresponding back-cuts in the medial element. Lastly, the C-flap is tailored and inset to reconstruct the cleft side columella and medial nasal sill (Fig. 2‑4).

Fig. 2.4 Unilateral lip repair. (a) Right unilateral cleft lip with markings. (b) Immediately after unilateral cleft lip and nose repair, demonstrating a balanced Cupid’s bow and alar symmetry. (c) A balanced Cupid’s bow maintained at 6 months follow-up; however, mild alar asymmetry despite nasal stenting.

The senior author also prefers to correct the cleft nose deformity at the time of the primary lip repair (Fig. 2‑5). The technique is a semi-open approach, utilizing a Tajima’s reverse-U incision20 on the cleft side and a marginal alar rim incision on the noncleft side. The fibrofatty tissue is dissected off the lower lateral cartilages, including the nasal tip. A double-dome bind with a horizontal mattress suture of 4–0 PDS is performed to approximate the genu of each lower lateral cartilage to narrow the angle of divergence of the nasal tip as well as to reposition the cleft side lower lateral cartilage. Horizontal mattress sutures starting in the lateral nasal vestibule, exiting and re-entering the same puncture site in the alar-cheek junction on the cleft side, and then tied internally, is used to collapse dead space, efface lateral intranasal webbing, and support the repositioned lateral crus of the lower lateral cartilage. All incisions are then closed with 6–0 fast absorbing sutures.

Fig. 2.5 Primary cleft rhinoplasty. (a) Markings for bilateral Tajima’s reverse-U incisions. (b) Immediately after cleft nose repair, demonstrating improved alar shape and contour with inversion of the Tajima’s incision into the nostril. (c) Silastic nasal stents are fitted (often different sizes between nostrils initially) and the tabs secured to the dorsum of the nose.

2.3.2 Bilateral

In addition to the goals previously mentioned for unilateral cleft lip repair, bilateral repairs need to create an upper labial sulcus and improve columellar length. Furthermore, nasal repair at the time of lip repair is important to reposition the lower lateral cartilages and establish tip projection. The repair described by Mulliken21 is the authors’ preferred technique (Fig. 2‑6). Similar to the unilateral repair, the markings on the prolabium and lateral elements are marked with a fine marking pen and the critical landmarks are tattooed with methylene blue. The width of Cupid’s bow on the prolabium is marked at 4 mm, and the width of the columellar base is marked at 3 mm. Curved vertical limbs connect the two sets of points, forming the philtrum. The peak of Cupid’s bow on the lateral elements are marked where the vermilion is the fullest and where the white roll begins to taper. Points 2 to 3 mm medial to the Cupid’s bow peaks are marked, indicating the leading edges of the white roll flaps from the lateral elements that will be used to reconstruct Cupid’s bow.

Fig. 2.6 Bilateral markings. (a) Markings are first made with a fine marking pen. The cardinal landmarks are then tattooed with methylene blue and a 25-g needle. (b) The skin incisions on the prolabium and the lateral elements are highlighted in different colors, corresponding to the incisions that will be approximated during repair. Black, columellar-nasal sill junction; Blue, philtral column; Gray, discarded skin; Red, vermilion; White, white roll.

Incision of the markings on the prolabium and lateral elements are made. The philtral skin flap is elevated to the level of the columella, and the remainder of the prolabial skin caudal to the nasal sill is excised. The mucosa of the prolabium is elevated and advanced onto the anterior surface of the prolabium to set the height of the labial sulcus. The nasal sill is then reconstructed by approximating the alar base flaps from the lateral elements to the skin flaps from the prolabium cephalad to the nasal sill. Upper buccal sulcus incisions are made to allow dissection of the alar-cheek-lip complexes off the piriform rim and maxilla. The orbicularis oris muscle from each lateral element is dissected from skin and mucosa, ensuring to release any abnormal attachments to the alar base. Both lateral elements should now be fully mobilized toward the midline without significant tension.

The mucosa is repaired first, advancing the upper buccal incisions. The orbicularis oris muscle from each lateral element is approximated to each other across the prolabium. The skin edges of the lateral elements should now be close to the edges of the philtral flap. Cupid’s bow is reconstructed with the white roll flaps from the lateral lip elements. The tubercle is reconstructed with the vermilion flaps from the lateral elements, and the final inset of the lateral elements to the philtral flap is performed precisely with buried dermal sutures to avoid external sutures (Fig. 2‑7).

Fig. 2.7 Bilateral lip repair. (a) Bilateral complete cleft lip with markings. (b) Immediately after bilateral cleft lip and nose repair, demonstrating a balanced Cupid’s bow, alar symmetry, narrow philtrum, and tubercle fullness. (c) Balanced Cupid’s bow, alar symmetry, and tubercle fullness maintained at 6 months follow-up; however, there is mild widening of the philtrum.

The approach and technique to repair the bilateral cleft nose deformity are the same as the unilateral repair described earlier, except bilateral Tajima incisions are utilized. Again, the angle of divergence of the nasal tip needs to be narrowed with a mattress suture, and the lower lateral cartilages need to be fully dissected from the overlying fibrofatty tissue in order for proper repositioning. In both unilateral and bilateral nasal repairs, the use of silastic nasal stents is strongly advocated by the authors. Stents are sized intraoperatively to have a snug fit in the nostril without causing significant blanching of the nasal tip. The stents are secured to the dorsal surface of the nose with an adhesive strip, and the parents are taught how to change and clean the stents daily. Ideally, stenting should be performed for 3 to 6 months.

2.4 Conclusion

The cleft lip repairs described are a modification of the rotation-advancement technique for unilateral clefts and the Mulliken technique for bilateral clefts. The ultimate goals in any cleft lip repair is to (1) balance Cupid’s bow, (2) fully detach abnormal insertions of the orbicularis oris muscle, and (3) re-establish continuity of the orbicularis oris muscle. Primary cleft rhinoplasty is also preferred at the time of the lip repair to maximize outcomes. However, the rhinoplasty requires dissection of the fibrofatty tissue from the lower lateral cartilages under direct vision to allow the proper approximation/shaping of the cartilaginous structures and avoid iatrogenic injury.

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