Art and Science of Cleft Lip and Cleft Palate Repair Girish N Amlani
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Historical PerspectiveCHAPTER 1

 
HISTORY OF CLEFT LIP
Cleft lips have been present from time immemorial, but the attitude and reaction of society have been varied greatly. It has been said that in certain societies, a cleft was once considered a mark of beauty. However, in other eras, cleft children were not so fortunate, and in accord with certain tribal customs, all deformed children were discarded or sacrificed.
An unnamed Chinese surgeon repaired a cleft lip in 4th century AD. The result must have been reasonably successful since his patient, Wei Yang-Chi, became a Governor-general of six Chinese provinces.1
The early surgery consisted of simple denudation of the cleft lip edge, and a V-excision as described in the Saxon Leech Book of Bald, written in the later part of the 10th century.
In 13th century Europe, Jehan Yperman, a Flemish surgeon described repair of cleft lips. Ambroise Paré (1510–1590) discussed closure of cleft lip with needles and wax threads which were wrapped around the ends of the needle in figure of eight fashion (Fig. 1.1).
Velpeau (1839) stated that Celsus and other ancient surgeons in addition to paring harelips made relaxing incisions on the inner surface of the cheek prior to suturing.
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Fig. 1.1: Ambroise Paré (1510–1590) described closure of cleft lip with needles and wax threads
2Franco (1561) is also credited with recommending freeing of the soft part of the cheek from the maxilla prior to closure.2
A step forward from the simple paring of cleft edges (actually a V-excision) several men recommended curving or angulating the denuding incision, thus providing for increasing length of the sutured lip. Graefe in 1825 attempted to overcome subsequence notching by curving this incision.
Mirault of Anger,3 France 1844, described repair of total cleft lip and partial cleft lip by turning down tiny vermilion flaps from either side of the cleft and then cutting one of them off where he approximated the edges. Mirault when wrote his original paper, had woodcuts which poorly illustrated this technique (Fig. 1.2A).
In 1891, Rose of London employed curved incision from the nostril floor to the vermilion border of the lip so as to give a line of union sufficiently long yet not discarding good tissue at the mucocutaneous line (Fig. 1.2B). Thompson in 1912 described a similar curving of the incised wound edges, first making careful and accurate measurements with calipers (Fig. 1.2C).
In order to prevent contraction of the postoperative scar, several methods were devised which resulted in an irregularly outlined scar. The procedure described by Owen (1904) resulted in an angulated scar running laterally. Unfortunately much of the lateral vermilion border was discarded.
The Koenig operation (1898) also introduced tissue from the medial side of the cleft laterally.
It had become apparent to other surgeons4-6 that instead of moving inadequate medial tissue laterally, a transplanting of some of the full lateral tissues into the deficient medial portion of the cleft was desirable.
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Figs 1.2A to C: (A) Mirault (1844) described repair of total cleft lip and partial cleft lip by turning down tiny vermilion flaps; (B) Rose (1891) employed curved incision from nostril floor to vermilion border of the lip; (C) Thompson (1912) described a similar curving of incised wound edges, first making measurement with calipers
3Hagedorn in 1892 described a procedure which had been considered the forerunner of the present day rectangular flap. This procedure produced a desirable fullness at the vermilion border. Veau in his Bec De Lievre (1938) gave credit to Jalanguier who in 1910 described and illustrated a procedure bringing some lateral tissue to the area of the deficiency medially. As noted in his illustrations, however, he discarded more mucous membrane from the lateral portion of the lip than one would do today.7-9
Blair and Brown in their original article in 1930 described a lateral flap, one-half length of the lip. To these authors went the credit for insistence upon production of pouting lip in these infants. They also paid attention to the correction of the deformed nostril.
About this time Lemesurier10-12 of Toronto became aware of the possibilities of modification of the Hagedorn principle for some 13 years before presenting this work in 1948 (Fig. 1.3).
The Tennison method,13,14 using a triangular flap originally outlined with a bent wire stencil, was introduced in 1952 that impressed many surgeons with its good cosmetic results and its relative simplicity. One of its selling point was preservation of normal looking cupid's bow on the medial lip segment, a landmark, largely ignored before (Fig. 1.4).
Marks in 1953 further clarified the techniques of the triangular flap but essentially along Tennison's line.14 Randall (1959)15 and Hegarty 1958 have added modification of the triangular flap insert (Figs 1.5 and 1.6). Skoog16 1958 described the breaking up straight line by introduction to smaller triangles giving credit in principle to Trauner and Gillies.
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Fig. 1.3: Lemesurier (1940) described rectangular flap from full lateral tissue into the deficient medial portion of the cleft
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Fig. 1.4: Tennison (1952) used a bent wire stencil to outline incisions
4
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Fig. 1.5: Randall (1958) added modification of the triangular flap insert
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Fig. 1.6: Hegarty's unilateral cleft lip repair (1958): Hegarty modified triangular flap technique. All points and incisions are based on mathematics
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Fig. 1.7: Rotation and advancement technique introduced by Millard (1955): recolonized surgical lip repair
The rotation and advancement technique introduce by Millard17 in 1955. The Millard rotation advancement technique revolutionized surgical lip repair (Fig. 1.7). The Z plasty type of scar thus produced is also evident in other lip repair (Fig. 1.8). Clifford and Pool (1959) review the Z plasty principles in cleft lip surgery.5
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Fig. 1.8: Mohler (1986) modified rotation and advancement to produce scar line mimic normal philtrum column by extending rotation incision into the columella
 
HISTORY OF CLEFT PALATE
Cleft palate was initially confused with defect caused by tertiary syphilis. In early 19th Century first cleft palate repair was done and with introducing of anesthesia cleft palate repair become common. Von Graefe was the first surgeon to perform cleft palate before 1819. Philibert Roux18 described cleft palate repair around same time in Paris. John Collins Warren was first in America is report cleft palate repair in 1920 in Boston.
Dieffenback19 (1792–1847), Berlin passed multiple silver or lead wires through punch holes to bring both palatal bones together. Von Lagenback20 used bilateral mucoperiosteal flaps for cleft palate closure. Double opposite Z-plasty, Dorrence's pushback and veaus palatal muscles dissection are quite significant in recent times.21
REFERENCES
  1. Boo-chai K. An Ancient Chinese text on a cleft lip. Plast Reconstr Surg. 1966;38:89–91.
  1. Barsky AJ. Pierre Franco, father of cleft lip surgery. His life and times. Br J Plast Surg. 1964;17:335–50.
  1. Blair VP, Brown JB. Mirault operation for single hare lip. Surg Gyn Obstet. 1930;51:81.
  1. Brown JB, McDowell F. Simplified design for repair of single cleft lip. Surg Gyn Obst. 1945;80:12–26.
  1. Rogers BO. History of cleft lip and palate treatment. In: Grabb WC, (Ed). Cleft lip and palate. Boston: Little, Brown;  1971.
  1. Washio H. History of cleft lip surgery. In: Stark RB, (Ed). Cleft palate: A multidisciplinary approach, New York: Hoeber Medical Division. Harper and Row,  1968.
  1. Schultz LW. Bilateral cleft lips. Plast Reconstr Surg. 1946;1:338–43.
  1. Veau V. Operative treatment of complete double harelip. Ann Surg. 1922;76:143–56.
  1. Veau V. Division Palatine. Paris: Masson,  1931.
  1. Bauer TB, Trusler HM and Glanz S. Repair of unilateral cleft lip. Advantage of LeMesurier technique use of mucous membrane flap in maxillary clefts. Plast Reconstr Surg. 1953;11:56–8.
  1. Le Mesurier AB. Hare-Lips and their Treatment. Baltimore: Williams and Wilkins.  1962:120-43.
  1. LeMesurier AB. A method of cutting and suturing the lip in the treatment of complete unilateral clefts. Plastic Reconstr Surg. 1949;4(1):1–12.
  1. Brauer RO. Comparison of Tennison's and LeMesurier technique of lip repair. Plast Reconstr Surg. 1959;23:249.
  1. Tennison CW. The repair of unilateral cleft lip by stencil method. Plast Reconstr Surg. 1952;9:115–20.
  1. Randall P. A triangular flap operation for primary repair of unilateral clefts of lip. Plast Reconstr Surg. 1959;23:331.
  1. Skoog T. A design for repair of unilateral cleft lip. American Journal of Surgery. 1958;95:223–5.
  1. Millard DR Jr. Rotation-advancement principle in cleft lip closure. Cleft Palate J. 1964;1:246–52.
  1. Efin MA. Dr Roux's first operation of soft palate in 1819: A historical vignette. Cleft Palate Craniofac J. 1999;36:27–9.
  1. Goldwyn RM, Johann Friedrich Dieffenback (1794–1847). Plast Reconstr Surg. 1968;42:19–28.
  1. Goldwyn RM, Bernhard Van Lagenbeck. This life and legacy. Plast Reconstr Surg. 1969;44:248–54.
  1. Stephenson J. Repair of cleft palate by Philibert Roux in 1819. Plast Reconstr Surg. 1971;47:277–83.