INTRODUCTION

The presence of unilateral cleft lip is one of the most common congenital deformities.

A broad spectrum of variations in clinical practice exists.

Unilateral cleft lip involves : deformity of the lip in addition to the alveolus and nose.

Patients with deformity require : short-term care and long-term care and follow up from practitioners in multiple specialties.

Cleft lip surgery has evolved from a simple adhesion of paired margins of the cleft to an understanding of the various malpositioned elements of the lip to a more complicated reconstruction using transposition, rotation and advancement flaps

It is still somewhat controversial. Some centers have advocated surgery in the early neonatal period, with an approved benefit in the scar appearance and nasal cartilage adaptability, thus minimizing nasal deformity.

In general however most centers prefer to perform the unilateral cleft lip repair when the infant aged 2-4 months, AS: anasaethesia risks are lower, the child is better able to withstand the stress of surgery, and lip elements are larger and allow for meticulous reconstruction.

Mesenchymal migration and fusion of the primitive somite-derived facial elements (central frontonasal, 2 lateral maxillary, mandibular processes), at 4-7 weeks gestation, is necessary for the normal development of embryonic facial structures. When migration and fusion are interrupted for any reason, a facial cleft develops along embryonic fusion lines.

Normal lip and nasal anatomy is essential for an understanding of the distortion caused by a facial cleft. The elements of the normal lip are composed of: the central philtrum, demarcated laterally by: the philtral columns and inferiorly by: the Cupid's bow and tubercle.

Just above the junction of the vermilion-cutaneous border: is a mucocutaneous ridge frequently referred to as the white roll.

The orbicularis oris muscle in the lateral lip element ends upward at the margin of the cleft to insert into the alar wing.

In cases of incomplete clefting: the muscle does not, as a rule, cross the cleft unless the bridge is at least one-third the height of the lip.

The philtrum :is short.

Two-thirds of the Cupids bow, one philtral column, and a dimple hollow are preserved.

The musculature between the filtral midline and the cleft is hypoplastic.

The overall occurrence of cleft lip with or without cleft palate: is approximately 1 in 750-1000 live births. Racial differences exist, with the incidence in Asians : (1:500) greater than in Caucasians (1:750) greater than in African Americans (1:2000).

The incidence of cleft lip is more in males.

The most common presentation: is cleft lip and palate (approximately 45%),
Followed by: cleft palate alone (35%) and cleft lip alone (approximately 20%). Unilateral cleft lips are more common than bilateral cleft lips and occur more commonly on the left side (left cleft lip: right cleft lip: bilateral cleft lip = 6:3:1).

 Surgical

Therapy

The objectives of surgical repair :

eliminate any notch of the vermilion. correct the drooping or flattened ala. restore muscle continuity with a minimal amount of scarring of the lip.

Parents who suddenly are faced with caring for a child with a facial cleft are overwhelmed.

The

importance of :

spending sufficient time with them to allay their fears. discuss staging and timing of reconstruction. stress the need for involvement of other specialists. instruct them on the importance of long-term and consistent follow-up care from birth through adolescence cannot be overemphasized.

Results

in:

symmetrically shaped nostrils, nasal sill, and alar bases. a well-defined philtral dimple and columns. a natural appearing Cupid's bow with a pout to the vermilion tubercle. In addition, it results in a functional muscle repair that with animation mimics a normal lip. While ideally the lip scars approximate natural landmarks, ultimately the eye first focuses on symmetry and then normal contours of the lip at rest and in animation.

LeMesurier quadrilateral flap repair. Randall-Tennison triangular flap repair. Millard rotation-advancement repair.

While none of the repairs is ideal, each has advantages and disadvantages, and each result in an excellent repair in experienced hands, underscoring the fact that more than a single acceptable technique, rather than a single ideal repair, is available. However, because of the limitations of this article, the authors choose to focus on the repair Millard first described in 1955, as today it is perhaps the most commonly adapted repair of cleft lip.

It advances a mucocutaneous flap from the lateral lip element into the gap of the upper portion of the lip resulting from the inferior downward rotation of the medial lip element.

The repair attempts to: place the lip scars along anatomic lines of the philtral column and nasal sill.

Conceptually, Millard's approach is elegant but it is not always technically easy to accomplish without some modifications to deal with the wide variation in clefts. As with any other repair, consistency in achieving a good result is operator-dependent.

The aim of this work is to:

evaluate the clinical course and operative outcome of primary cleft lip repair in neonates.

Aiming at:

proper and early oral feeding well as the potential psychosocial benas efits to the family of bringing home a child of normal appearance.

The present study will be carried out on 20 neonates patients admitted to Pediatric Surgery Department at Chatby University Hospital ,
in the period from September 2009 to October 2010.

 Patients

photographic images in static and dynamic positions in frontal and submental views were analyzed, after one year follow up:
The ala developed with position maintenance without nasal stenosis in all cases. All the patients had good lip function (100%), There were no growth facial disturbances. Minimal scar (10 cases with good scar) and (10 cases with excellent scar) as reported by parents. No wound infection has been reported.

The height of the repaired side as compared to the non cleft side was equal in: 18 cases (90% of cases). The lip was found to be shorter in: 2 cases by 0.3 mm, the 2 cases was of the complete type.

 The

average width of our 20 cases :

showed an average of 23.1mm for width of the repaired side compared to 23.2 mm of the non cleft side, thus a narrower lip by average of 1 mm.

Flattening of ala nasii leading to a height of the nostril on the repaired side less than the non cleft side was in 3 cases (15% of cases) with average nasal height on the repaired side being less than the non cleft side by 1.4mm in all 20 cases. A wider nostril was seen in 4 cases (20% of cases) on the cleft side, with an average of 1.7mm.

We conclude that the neonatal cleft lip repair can safely be done in a highly equipped and specialized center in neonatal surgery

with all available facilities as regards incubators, specialized nurses, monitors, neonatal anesthesia, warm blankets , highly equipped operating theaters and available blood bank for safe surgery.

We recommend a long term follow up of the cases (one year follow up is not enough).

We recommend increasing the practice of neonatal cleft lip repair in Egypt together with multi specialties team including anesthetist, surgeon, specialized nurse and neonatologist.

 cleft surgeons must be perfectionists Free to aspire Willing to work in millimeters For the best possible results D. Ralph Millard M.D