Unilateral Cleft Lip

Unilateral cleft lip

A unilateral cleft lip is a congenital deformity where there is an opening or gap in the upper lip on one side (either the left side or the right side). It is a problem that arises when upper lip tissues do not meet up appropriately when developing the fetus. It can be isolated as well as concomitant with cleft palate.

Unilateral Cleft Lip Types

• Unilateral cleft lip incomplete: There is no cleft up to the nostril.
• Unilateral cleft lip complete: The cleft extends into the nostril.
• Unilateral cleft lip and alveolar: The gap includes the alveolus when that is involved (the gum which holds the teeth), and sometimes it also involves the development of the teeth.

Unilateral Cleft Lip Repair

Unilateral cleft lip repair is a surgery to close a single sided gap or split in the upper lip. This operation re-establishes lip continuity and enhances the facial aesthetics, and is performed in conjunction with nasal deformity correction and contributes to feeding, speech, and psychosocial development. 

What Is Unilateral Cleft Lip Repair?

Unilateral cleft lip repair (cheiloplasty) entails the repair of the:

• The musculature of the upper lip (orbicularis oris). 
• Skin and vermilion border
• The bow of Cupid and his philtral columns.
• Nares asymmetry on the affected side.
• This is normally the initial significant operation on a child with cleft lip.

The Best Timeframe for Surgery 

Most surgeons follow the 10s rule:

• 10 weeks of age, 
• 10 pounds of weight, 
• 10 g/dL of hemoglobin. 
• Usually done at the age of 3-6 months.

Objectives of Unilateral Cleft Lip Repair

• Reclaim normal lip form and muscle tone.
• Restore the bow and philtrum of Cupid.
• Adequate nasal tip and nostril asymmetry.
• Permit normal eating and speech progression.
• Enhance facial appearance and psychosocial health.

Unilateral cleft lip surgery

Unilateral cleft lip surgery is a cosmetic surgery that is performed to seal a division on one side of the upper lip. It restores a natural look of the lip, recreates normal muscle continuity and corrects nasal deformity due to the cleft. Such surgery is usually the initial one in the long-term-management of a child with cleft deformities.

Preoperative Preparation

• Pediatric assessment and clearance.
• Blood tests
• Evaluation of cleft palate or syndromes.
• Nutrition counselling.
• Elective nasoalveolar maneuvering (NAM) to narrow cleft palate and enhance nasal symmetry.
• Surgical planning preoperative photographs.

Surgical Techniques Used

A number of standard methods assist to obtain aesthetic and functional outcomes:

Millard Rotation-Advancement Technique

• Most popular in the global market.
• Recreates the philtral column using a rotation flap.
• Close the cleft using advancement flap.
• Gives the bow of natural Cupid and good symmetry.

Tennison Randall Triangular Flap Method

• Includes a triangular flap of small size.
• Fits well in wide or anatomically out of line clefts.
• Helps maintain lip length

Modified Techniques

• Mohler modification
• Fisher anatomic subunit method.
• Indicated by the choice of the surgeons and the severity of the clefts.

Primary Nasal Correction

Commonly performed together in order to enhance the shape of the nostrils:

• Positioning of nasal cartilage.
• Alar base correction
• Soft tissue reshaping
• This minimizes the subsequent nasal surgeries.

Procedure

• General Anaesthesia - Baby is sleeping and being monitored. 
• Marking - Accurate lines that are drawn to the height of the lip and Cupid bow.
• Incision - This is done cautiously along natural borders in order to reduce scarring.
• Muscle Repair - Orbicularis oris muscle is pinpointed, undone and sewed back together to work properly.
• Skin Repair & Vermilion Repair - Rebuilt as to create a natural lip contour.
• Nasal Correction - Cartilage is made symmetrical.
• Closure Site closed using delicate multi-layers sutures.
• Postoperative Dressing -Tapes or steri-strips placed.
• Duration of surgery: 1 to 2 hours (approximately)

Healing After Unilateral Cleft Lip Surgery

• Inpatient duration: 24 hours to 2 days 
• Resumes feeding in hours (spoon, cup, or bottle, as recommended by the surgeon)
• Manageable pain using oral drugs.
• Arm restraints (no-no splints) 1-2 weeks.
• Stitches can either be absorbable or taken off after 5-7 days.
• Scar taping or silicone gel with several months of use.
• Periodic follow-up visits to check lip and nose development.

Unilateral cleft lip treatment

Unilateral cleft lip can be corrected by administering a mixture of surgery, feeding, orthodontic and follow-up to regain normal facial appearance, functions and development. A cleft lip is a condition that occurs when the tissues of the upper lip cannot be fused appropriately on one side of the fetus. A cleft care multidisciplinary team is the most effective way to treat it.

Elements of Unilateral Cleft Lip Treatment

Immediately After Birth Feeding Support

Infants with cleft lips will have latching difficulties. Interventions that can be used to feed include:

• Specialized cleft feeding bottle.
• Upright feeding position
• Frequent burping
• Referral to lactation experts.
• Before surgery, it is recommended to monitor weight gain.
• FedEx support is even more urgent in the case of cleft palate.

Pre-Surgical Orthopedics / NAM Therapy (Optional)

Nasoalveolar Molding (NAM) is applied in 1-3 months of age to:

• Narrow the cleft gap
• Align the gums (alveolus)
• Enhance the shape of nasal cartilage.
• Less surgical tension and enhance symmetry.
• Not a must, but very useful in extensive clefts.

Surgery for Primary Unilateral Cleft Lip (Cheliloplasty)

• Age: Based on the Rule of 10s (10 weeks, 10 pounds, and 10 g/dl hemoglobin), the surgery is usually performed when the infant is 3-6 months old. 

Purpose:

• Close the lip
• Reconstruct the muscles
• Normally shape and symmetrically re-establish.
• Carry out primary nasal repair.

Techniques commonly used:

• Millard rotation-advancement method.
• Tennison-Randall triangular technique of flaps.
• Mohler or Fisher changes.
• Result: Good cosmetic and functional outcomes ; >95 percent success rate.

Primary Nasal Correction

Cosmetic lip repair is often done together with lip repair to:

• Reshape nasal tip
• Proper displacement of the alar base.
• Improve nostril symmetry
• In postoperative contour maintenance, nasal stents are allowed.

Postoperative Care

• Pain management
• Feeding guidance
• Arm ties (no-no splints) to avoid contact of the surgical area.

Scar management using:

• Silicone gel/sheet
• Scar massage
• Sun protection
• The cleft team should be followed up on a routine basis.

Dental and Orthodontic Surgery, long-term treatment

In case the cleft penetrates the alveolus (gum):

• Alveolar Bone Grafting in 7-9 years.
• To have the teeth aligned orthodontics.
• Tracking of permanent teeth eruption.

Speech Therapy (If Needed)

• Normally only needed in the presence of a cleft palate.

Focus areas:

• Articulation
• Resonance
• Oral airflow control

Correctional Surgery (Secondary, when necessary)

Some of them may require further procedures as the child grows and include:

• Revision of the lip scar
• Secondary rhinoplasty as nose refinement.
• Nares or lip symmetry correction at the teen age.
• They are not so mandatory and are based on the results of growth.

Factors Affecting Unilateral cleft lip surgery cost in India

The following are the critical determinants that affect the cost of the unilateral cleft lip surgery in India:

Severity and type of cleft

• Cost of pure unilateral cleft lip (lip only) is less than cleft involving alveolus (gums) or palate, or bilateral cleft. 
• Extensive repair work = prolonged surgery, materials, follow-up may be increased.

Hospital and city location

• Large associated hospitals are generally priced even higher than small/rural centers. 
• The cost varies with the level of accreditation (e.g., NABH, JCI) and the standard of the facilities. 

Experience and qualifications of surgeon

• The very experienced plastic/craniofacial surgeons will have higher costs.
• Expert on cleft work (interdisciplinary team) is probably expensive but more successful.

Before & After Surgery Care

• Blood tests, anaesthesia testing
• ICU/paediatric ward care, as required.
• The length of stay, medication, wound care, nutrition.

Anaesthesia, OT time and consumables

• The price of general anaesthesia is dependent on age, weight and well-being of the patient.
• Operating time: more complicated or prolonged surgeries are more expensive.
• Consumables (sutures, implants, nasal splints etc) are costly.

Associated procedures

• In case nasal correction is carried out simultaneously.
• In case of the need to perform alveolar bone grafting or any other dental/orthodontic procedure.
• Assuming that there are other syndromic problems or related palate repair.

Hospital stay duration

• The hospitals collect inpatient bed, nursing, meals. Longer stay → higher cost.
• Stay and cost will be enhanced by complications or extra monitoring.

Materials/Technology used

• Special implants, use of sophisticated imaging (3D planning), custom splints increase the cost.
• To versus charitable/non-profit centres: private can employ more premium consumables.

Follow-up and revision surgery

• The initial surgery fee may not be incurred alongside subsequent operations, adjustments, orthodontics, speech therapy.
• Long term care cost must consider the long-term care aspect beyond the first surgery in the family.

Medical tourism and the logistics (where necessary) costs

• In case patient is international visitor or travelling outside his state, include travel, accommodation, translator, visa.
• Other hospitals are providing package prices to international clients that have additional services.

Best hospital for unilateral cleft lip surgery India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Unilateral cleft lip is a very treatable, but very common birth abnormality, which involves the look, functionality, and growth of the upper lip on one side. The children born with this condition can now attain a high quality of cosmetic and functional results with the modern medical development and the integration of a multidisciplinary effort to achieve this outcome. Early diagnosis usually in prenatal ultrasound or right after birth enables families to get a timely advice on feeding, pre-operative treatment, and treatment planning. Primary unilateral cleft lip surgery is the foundation of management and is typically done between 3-6 months of age. With the help of modern methods like Millard and Tennison-Randall repairs, surgeons can make the lip continue, muscle activity, and to make it look natural like in lips and nose. Additional optional options such as Nasoalveolar Molding (NAM) also help in the outcome by narrowing clefts and improving the shape of the nose prior to surgery.

Affordable unilateral cleft lip surgery India GetWellGo

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FAQ

Will my baby require more surgeries?

Some children may require:

• Revision of the scar
• Nasal correction
• Speech therapy
• Orthodontic therapy at developed age
• It is based on the severity of cleft at first.

Do you have problems with feeding prior to surgery?

• Yes. Before surgery, the babies might require special nipples, feeding bottles or aid to facilitate good nutrition.

Are the results permanent?

• Yes. When healed, the restored lip tends to appear normal. Scar enhancement is an ongoing process and revision is seldom necessary.

Will my child speak normally?

• Majority of the children with isolated cleft lip acquire normal speech. In case of cleft palate too, they might require speech therapy.

Is there any prenatal test to diagnose a unilateral cleft lip?

• Yes. Cleft lip can often be seen on a prenatal ultrasound that is done after 20 weeks.