Primary bilateral cleft lip-nose repair: the Tawanchai Cleft Center's integrated and functional reconstruction.

BACKGROUND The repair of a bilateral cleft is more difficult than a unilateral repair because of numerous anatomical challenges, such as difficulty of repairing the skin and muscle overlying the protruded premaxilla and bilateral nasal reconstruction with shortening of the columella. An optimum outcome is achieved when all of the deformities of the primary cleft palate, the problems of scar and secondary deformities have been addressed. OBJECTIVES To propose an integrated and functional reconstruction of the primary bilateral cleft lip-nose repair and to present the preliminary outcomes of this technique and its advantages. MATERIAL AND METHOD An integrated, functional reconstruction process includes: 1) analysis of the bilateral cleft deformities; 2) interdisciplinary management and use of Tawanchai Center's protocol for cleft lip and palate care; 3) pre-surgical orthopedic treatments; and, 4) integrated primary cleft lip-nose repair and post-operative management. This approach to repair includes: 1) design of a prolabial flap and a modified, rotation advancement technique for skin surgery; 2) functional muscle reconstruction; 3) correction of nasal deformities and columella lengthening; 4) reconstruction of the vermillion; and, 5) final skin closure. RESULTS Between 2002 and 2010, this technique was performed and evaluated on 42 patients who received primary bilateral cleft lip-nose repair, including 31complete, 6 incomplete and 5 right complete and left incomplete, 27 males and 15 females. Six parameters (scar, Cupid's bow symmetry, vermillion border symmetry, philtrum anatomic fidelity, muscle function and nasal symmetry) were used for evaluating the results, based on 4 scales (0-3) by 2 plastic surgeons. Among the mean scores better rating scales were achieved in philtrum anatomic fidelity (0.69) and Cupid' bow symmetry (0.76) while the mean of the less satisfactory rating scale was found in scar (1.13) and nasal asymmetry (0.96). These preliminary outcomes showed satisfactory results. Secondary reconstruction is less difficult and may be performed at the age of 4-6 years if indicated. DISCUSSION AND CONCLUSION The authors introduced the Tawanchai Center's integrated concepts and functional reconstruction technique for bilateral cleft lip-nose repair. The technique offers the advantages of an integrated assessment for all of the deformities of the primary cleft palate, the design of an integrated technique together with proper peri-operative care, presurgical orthodontic treatment, and a well-coordinated, holistic, interdisciplinary management. A satisfactory preliminary outcome was demonstrated but more improvement of the outcome can be achieved by: 1) continuing assessment of this group of patients until they reach maturity; 2) refining techniques; 3) improving interdisciplinary care; and, 4) setting benchmarks for the outcome.