CLEFT CRAFT
THE EVOLUTION OF ITS SURGERY
D. Ralph Millard, Jr. M.D., F.A.C.S.
I. THE UNILATERAL DEFORMITY
Contents
Foreword J. William Littler XII
I. BASICS
2. Anatomy in Multiple Dimensions 19
3. The Naming and Classifying of Clefts 41
A Note on the Photographic Recording of Clefts 53
4. Incidence of Clefts in the World 57
5. Optimum Time for Cleft Lip Surgery 69
II. THE EVOLUTION
6. Paring and Approximation with Needles and/or Sutures 79
7. Increasing Vertical Length of Cleft Edges 89
8. Full-Thickness Flaps for Vertical Lengthening 101
9. Perfecting the Triangular Flap 105
10. Constructing a Cupid’s Bow 121
11. Preservation of the Cupid’s Bow 139
III. ROTATION-ADVANCEMENT
CONCEPTION
12. Personal Approach to Cleft Lip 165
13. International Presentation 175
14. Application in America 181
16. Early Proponents of the Rotation-Advancement Principle 197
IV. PROGRESS BY ANALYSIS
17. Benefits of a Mathematical Blueprint 21318. The Evolution of the Rotation and the Elevation of Flap c 217
19. The Original Advancement Gradually Changes 229
20. Primary Handling of the Free Border Vermilion 239
21. Primary Nasal Correction 251
22. Dissimilar Similarities 269
V. INCOMPLETE CLEFTS
24. Early Acceptance in Incomplete Clefts 299
25. Genetic Counseling, Parent Guidance and Preoperative Preparation 305
26. Never Underestimate the Importance of Detail 311
27. Incomplete Unilateral Cleft Lip Rotation-Advancement Detail 313
29. Examples of Incomplete Clefts of Varying Degrees 335
VI. COMPLETE CLEFTS
31. The Struggle for Acceptance in Complete Clefts 38333. Final Acceptance, Adaptation and Dissemination 399
33⅓. A Small Chapter on a Millimeter Modification 419
35. Congress Demonstration 431
36. A Preliminary Adhesion 437
37. How to Rotate and Advance in a Complete Cleft 449
38. Examples of Complete Unilateral Cleft Cases 487
VII. SECONDARY SURGERY
39. The Importance of Winning 52740. Secondary Corrections of Lip Scars 531
41. Discrepancies in Muscle Continuity and Philtrum Contour 539
42. Discrepancies in the Cupid’s Bow, Vermilion Free Border and Sulcus 547
43. Secondary Correction of a Straight-Line Closure 557
44. Secondary Correction of Triangular and Quadrilateral Flap Methods 571
45. Secondary Lip Correction after Rotation and Advancement 581
46. Shaping and Positioning the Lip-Switch Flap in Unilateral Clefts 593
47. Anatomy of the Secondary Deformity of the Unilateral Cleft Lip Nose 629
49. Cleft Half Rotation by External Tip Incisions and Excisions 639
50. Intranasal and Marginal Incisions for Correction of Nasal Tip, Alar Rim and Base 653
52. Combined Nasal and Labial Unilateral Cleft Corrections 691
53. My Own Secondary Correction of the Unilateral Cleft Lip Nose 699
A Backward Glance and an Afterthought 733
References 735
Index 773
II. BILATERAL AND RARE DEFORMITIES
Contents
I. PRIMARY DEFORMITY
1. Special Bilateral Cleft Embryology 33. What "To Do or Not To Do" About the Projecting Premaxilla 41
4. Optimum Time for Bilateral Cleft Lip Surgery 81
5. The Surgical Evolution of Bilateral Lip Clefts 89
6. Sliding the Prolabium into the Columella 97
7. Prolabium as the Full Length of the Upper Lip in Straight-Line Closure 107
8. Transposition of Lateral Flaps Below the Prolabium 119
9. Conscientious Objectors 135
10. Interdigitations into the Sides of the Prolabium 143
11. Joining Portions of the Lateral Elements Behind the Prolabium 149
12. Personal Experience and Gradual Evolution 171
13. The Adhesion Principle in Bilateral Clefts 175
15. Adaptation of the Rotation-Advancement Principle in Bilateral Incomplete Clefts 189
18. Other Primary Two-Stage Columella Lengthening Procedures 231
19. The Chances of a Lengthened Columella’s Being Hairy 237
20. No Lip Muscle Union and Delaying the Forked Flap for a Year or Years 239
23. Joining the Lip Muscles and Banking the Fork 281
24. The Making of a Cupid’s Bow and Tubercle 299
25. Bilateral Cleft Game Plan 307
26. Detailed Closure of a Bilateral Incomplete Cleft Lip with Banking of the Fork 313
28. Details of Closing a Complete Bilateral Cleft and Banking the Fork 359
30. Personal Cases of Complete Cleft Lip Closure and Fork Banking 379
II. SECONDARY BILATERAL
CLEFT DEFORMITIES
33. Correction of Secondary Muscle Discrepancies 427
34. Philtrum Contouring and Cupid’s Bow Construction 439
35. Deformities of the Free Border Vermilion in Bilateral Clefts 453
36. Creating the Upper Labial Sulcus 469
37. The Anatomy of the Secondary Bilateral Nasal Deformity 477
38. Lengthening the Columella with Central Lip Tissue 481
39. Columella Lengthening by Vertical Scar Flaps Including the Forked Flap 491
40. Forked Flap Craftsmanship 523
41. Other Odd Ways of Lengthening the Columella 539
43. Nasal Skin Shifting by External Incisions 551
44. Free Composite Grafts to the Columella 559
46. A Note on Vestibular Lining Shortage 571
48. Outline of My Approach to Secondary Bilateral Cleft Lip Rhinoplasty 585
49. The Lip-Switch Flap Principle 593
50. Shaping the Abbe Flap for Secondary Bilateral Deformities 607
51. Composite Free Graft Lip-Switch 619
III. RARE CLEFTS
56. Median Clefts of the Upper Lip 727
57. Median Cleft Lip with Hypotelorism 735
58. Median Cleft Lip with Hypertelorism 745
III. ALVEOLAR AND PALATAL DEFORMITIES
Contents
I. BASICS
3. Growth in the Normal and the Cleft Palate Patient and the Effect of Surgery on Growth 51
4. Cooperation of Plastic and Dental Teams is Vital 79
Cleft Palate and the Face in Which It Exists contributed by Samuel Berkowitz 81
5. Ear Disease and Hearing Loss in Cleft Palate 121
6. Anesthesia in Clefts (Gas, Tubes and Gags) 141
with sections by S. MacMahon and A. Freeman7. Preoperative and Postoperative Care, Including Feeding 159
II. SURGICAL CLOSURE OF THE CLEFT
8. Cautery or Paring and Suturing the Edges of the Cleft Palate 167
9. Relaxing Incisions and Mucoperiosteal Dissections 177
10. Eversion of Flaps for Closure of Palate Clefts 195
11. Uranoplasty, Bone Flap and Osteotomies 203
13. Uranoplasty by Maxillary Compression 223
14. Early Soft Palate and Later Hard Palate Closure and Lip Adhesion 231
15. Nasal and Labial Flaps for Alveolar and Hard Palate Closure 249
16. Presurgical Maxillary Orthopedics 263
17. Early Maxillary Bone Grafting 299
18. Choice of Bone and Its Fate 325
20. Periosteal Flaps and Grafts—or “Boneless Bone Grafting” 355
21. Standard Lip and Palate Closure—and Let the Segments Go Where They May 375
22. The Perceptive Passavant and His Controversial Pad 383
III. LENGTHENING THE PALATE
23. Lengthening of the Cleft Edges of the Uvula and Soft Palate 393
24. Palate Extension by Union of the Posterior Pillars 399
25. Early Crude Palatal Pushbacks; Transverse Releasing Incisions 411
26. Refining the V-Y Palate Retropositioning 419
27. Oral Mucoperiosteal Flap Transpositions for Palate Lengthening 449
28. Pushback of Palate with Horseshoe-Shaped Incision 453
29. Methods of Handling the Neurovascular Bundles 467
30. The Nasal Defect After Pushback 473
31. Mending the Misplaced Muscles 497
32. Development of the Palatal Island Flap for Nasal Lining 525
33. Other Surgeons Accept The Island 543
34. Use of the Palatal Island Flap for Ablative and Other Defects 579
IV. PHARYNGEAL FLAP ATTACHMENT TO THE VELUM
36. Velopharyngeal Synechiae with Various Pharyngeal Flaps 605
37. Superior Versus Inferior Base 633
38. Primary Pharyngeal Flap 639
39. Forward Projection of the Pharyngeal Wall by Flaps 651
40. Search for Dynamic Pharyngeal Flaps 663
41. Combining Palate Pushback with Pharyngeal Flap 671
42. Complications and Failure of a Pharyngeal Flap and Its Secondary Surgery 689
V. HODGEPODGE
43. Congenital Velopharyngeal Incompetence and Submucous Cleft Palate 707
45. Closure of Total Cleft in One Operation 745
46. Personal Palatal Evolution 753
VI. FISTULAE AND FAILURES AND THEIR MANAGEMENT
48. Palatoplasty with Other Tissues Within the Mouth and Nose 825
49. Distant Skin Flaps for Palatal Defects 833
50. Tube Pedicles to the Palate 841
51. Flaps and Free Grafts of Distant Muscle, Tendon and Fascia 859
52. Implantation of Material into the Retropharyngeal Space 867
VII. JAWS
VIII. EVALUATION AND HABILITATION