Correction of Unilateral Cleft Lip Using Surgeon-Made Nasoalveolar Molding Device

The unilateral cleft of the lip and palate is a very complex deformity. This deformity comprises wide separation of the lip, defect of the ipsilateral columella and distorted nose, wide interalveolar gap due to accompanying alveolar cleft and displacement of the premaxilla. These variable deformities must be treated at the appropriate time. If not, it would result in severe facial mutilation, growth disturbance of the maxilla and functional defect of the teeth. Its ideal correction involves alignment of the dental arch, creation of a growing platform for the lip and nose, joining of the separated lip and correction of the distorted nose. Since McNeil(1950), variable presurgical orthopedic techniques have been evolved by many authors, but there is no uniform consensus. One commonly used appliance consists of an alveolar molding plate made of a hard outer shell and a soft acrylic lining described by Gnoinski. The author treated unilateral cleft lip and palate using presurgical nasal and alveolar molding (NAM) device which was introduced in 1993 by Grayson. In our cases (n=17), the author made the device by himself and performed presurgical nasoalveolar molding for the unilateral cleft lip and palate patients. Presurgical NAM device was applied in the second week following birth, and nasal stent for nasal cartilage molding was applied during nasoalveolar molding process around 6weeks after birth. Presurgical NAM was continued until repositioning of the nasal cartilages and alveolar processes (interalveolar gap <2mm), and lengthning of the deficient columella (mean vertical height of columella in postop 3 months: preop. 1.5mm--> postop 4.5mm). The primary lip-nose repair and gingivoperiosteoplasty were performed within 6months after birth (mean age: 17 weeks). Even though not evaluating the long term follow-up study in our cases, this technique enables a one-stage repair of the lip, nose and alveolus while the three-stage repair was necessary previously: primary lip repair, secondary rhinoplasty and alveolar repair with bone graft. In addition, when presurgical nasoalveolar molding is performed by a surgeon, it can be avoided complications such as meganostril and delaying of operation time. But orthodontic postoperative care should be planned after operation for unilateral cleft lip and palate patient.

Surgical Correction Of Congenital Earlobe Cleft Using Reverse L-Plasty

Congenital earlobe deformity and the presence of the cleft at a site of the earlobe seems to be rare. It is important to well-formed, symmetrically positioned ears as a sign of esthetically pleasing, harmonious facial features. So the patients with cleft earlobe require operative repairs. The surgical techniques for congenital earlobe clefts employed vary from simple closure, Z-plasty, L-plasty, two flap method, triangular flap method, and so on. Among them, Passow-Claus described the classic L-plasty method. We designed the modified method that the L-flap direction faced laterally opposed to that of classic L-plasty and propose to term this method `reverse L-plasty`. Kitayama classified the congenital earlobe cleft into four groups according to the shape of cleft, as longitudinal, transverse, triplelobe or mixed, and defective type. We experienced four cases of congenital earlobe cleft. One patient was a defective type and the others were triplelobe types. There`s no complication in patients. We could obtain the advantages of smooth contour of free border, lack of groove or notching due to scar contracture, and possible in moderate defective type without additional method after long term follow-up. This technique breaks the vertical component of scar contracture, resulting in a smooth lobular border. So we believe that this reverse L-plasty technique offers a better cosmetic result in the repair of the cleft earlobe.

Surgical Correction of Macrostomia

Congenital macrostomia is a result of defective union between the mandibular and maxillary processes and it is a rare deformity seen in every 100 to 300 facial clefts. Ohnizuka1`classified macrostomia into two groups as congenital and posttraumatic. We experienced two cases of acquired macrostomia due to NOMA sequelae(58/F:Lt & 51/F:Rt) and one case of congenital macrostomia (3 months/M:Rt). Many plastic surgeons have developed surgical procedures for repair of this congenital macrostomia. Among them, McCarthy6,11 described the classic commissuroplasty. We could repaired 1 case of congenital macrostomia and two cases of acquired macrostomia due to NOMA sequelae using modified technique of McCarthy,s classic commissuroplasty. McCarthy described new oral commissure 2-3mm laterally for prevention of postoperative contraction, orbicularis oris muscle transposition to restore labial function and a z- plasty cutaneous closure. But some author raise an objection to new oral commissure 2-3mm laterally, and they made new oral commissure at same distance of opposite side normal commissure. And so, we designed the new oral commissure moved 1mm laterally comparing to original commissuroplasty in a congenital case for the prevention of displacement. In cases of acquired macrostomia due to NOMA sequelae, we reconstructed new oral commissure like congenital case, moved 1mm laterally. Orbicularis oris muscle transposition could not be possible because of destruction of muscle, adhesion and atrophy. And so we dissected muscle and just sutured side by side. Acquired macrostomia following NOMA sequelae manifsted facial deformity variably, and reconstruction of the facial deformity is difficult by using simple approach. Other variable reconstructive procedures were needed with commissuroplasty as like Washio flap, rotation advancement flap, bone graft and free radial forarm flap, etc. Postoperative results were relatively good. We propose that macrostomia due to NOMA sequelae must add to Ohnizuka classification of acquired macrostomia.