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Mediancleft lipİntroduction : complete or partial lip clefts in the midline ofthe upper lip are defined as median clefts of the upper lip. 1 ın 1974, tessiernumbered the craniofacial clefts from 0 to 14 Counterclockwise in a studyinvolving 336 patients. Upper lip midline clefts are named tessier 0 clefts.2,3 despite the diversity in classifications, upper lip midline cleft are rare.Its incidence Among cleft patiens varies between 0.43-0.73 Percent. 4 ıf themore common forms of cleft Lip and palate are not taken into account, the İncidenceof atypical cleft is estimated at 1/10 5 . 5 median upper lip cleft can bedefined As a cleft that passes vertically through the Midline of the upper lip.These clefts ocur Due to incomplete or complete Nondevelopment of the medialnasal Prominences. 6 In this study, we will share a case Diagnosed prenatallyand referred to our clinic For cleft lip repair.Case: A 55days old patient who was Diagnosed with cleft lip anomaly in the 20th Week ofintrauterine life was admitted to our Clinic. It was learned that she was bornat 37 Weeks of age as the third live birth from the Third pregnancy of a 36year old mother who Had no teratogen exposure or drug use History. There was noconsanguinity in the Parents and no other family history of cleft lip Andpalate. In our examination, cleft lip with Vermillon defect in the upper lipmidline and Bifid frenulum structure were observed. It was Observed that thecolumella was short and the Nose tip was flat. Intercanthal distance was Measuredto be minimally increased and that Was consistent with hypertelorism. The totalLenght and width of the vermillon were Considered normal. (photography 1) Inthe preoperative period, brain mrı Ve ecocardiography were performed fort he Diagnosisof additional anomalies such as Other midline defects. While no problem was Observed in the patient’s ecg, corpus Callosumagenesis and colpocephaly was Detected in brain mrı of the patient. BrainMrıshowed no sign of encephalocele and Meningocele. The departmant of pediatric Cardiologyreported that the patient did not Need endocarditis prophylaxis. The Departmantof pediatric nefrology also Examined the patient and the department did (photography1, preoperative examination) (photography 2, intraoperative examination) Notmake any further recommendations. The patient whose preoperativePreparationswere completed and reached 9200gr, was operated on by us when she was 8 monthsand 27 days old. In the operation, local anesthetic Substance containinglidocaine+adrenaline Was infiltrated on the prolabium and cleft lip Margins.Prolabium was elevated as a Quadriangular flap in order to eliminate Shortnessof the columella and flatness of theTip. Incision was extended in the wet mucosaOf the upper lip to the basis of the frenulum. When it was seen that the lenghtof the wet Mucosa was not sufficient, a small z-plasty Was designed from themucosa to increase its Lenght. Orbicularis oris muscle was dissected From theabnormal attacthment sites on the Cleft margins, with horizontal incisions madeİn the muscle, so the contractions in the Muscle were opened and range ofmotion was İncreased. Orbicularis oris muscle was Repaired in the midline bysuturing with 4-0 Vicryl. One z-plasty designed in the mucosa Were suturedappropriately with 5-0 vicyrl to Form the lip tubercle and the mucosa was Repaired.The prolabium flap that was Elavated at begining of the operation was Suturedto the base of the columella to allow For the elongation of the columella.Lateral Skin flaps were primarly sutured in the midline With 6-0 biosyn.Rifampicin was applied to the Suture lines and suture lines was closed with Steriledressing. Then, the patient was followed up İnpatient for 4 days, suture linewas cleaned With saline daily and the dressing was Renewed by applyingrifampicin. The dressing On the suture line was left open at discharge And thepatient’s skin sutures were removed On the 8th postoperative day. No Complicationswere observed in the Outpatient follow-ups. In the postoperative evaluation,the Results of the patient were satisfactory. Sufficient lenght was provided inthe Columella and the flattened appearance of the Nose tip was eliminated. Vermillocutaneousline was created with Minimal scarring. The vertical scar line was Equidistantfrom the bilateral filtral columns. Cupid bow was formed as desired. İn the Evaluationthe height of the left apex of the Cupid bow was minimally superior to the ContralateralapexDiscussion:Medianclefts of the lip were defined By demyer as two separate groups, including Orbitalhypotelorism and hypertelorism. 7 ın 1968, millard defined median lipclefts as Clefts that cross the midline of the upper lip, Regardless of extentand size. Then he dividedİt into 2 classes; the first group includes Agenesisof the frontonasal process and the Second group is defined as the cleft oftheMedian segments. Therefore, the second Group is associated withhypertelorism and Cranial malformations. In our case, corpus callosum agenesis Wasdetected in cranial imaging and Hypertelorism was present in examination. In Thatcase, it is tought that our patient belong To the second group defined bymillard. The Patient was screened for additional midline Defects by us in thepreoperative periods. Due to the scarcity of median cleft lip Cases andresources on this subject, there is No definitive procedure for surgical Managmentof upper lip clefts. Millard Recommended excision of inverted cleft lips in 1968.Then, in his work in 1977, he proposedAn inverted v-shaped excision from the2mm Superior white roll on either side of the cleft. Thus, the skin in themidline of the cupid bow Was elongated. 8 nakamura, tomonari and Goto describedwedge excision at the Wemillon border, but did not provide Sufficientinformation on excision or Manipulation of the orbicularis oris muscle. Manytypes of excision, such as elliptical Excision, have been published by many Authors.In our patient, excision was not Considered due to the short columella and Nasaltip flattening. It was sutured to the base Of the columella by elevating theprolabium as A fasciocutaneous flap, thus providing many Benefits such aselongation of the columella, Elimination of asymmetry in the nostrils, and Correctionof nasal tip. With the dissection And horizontal incision made to theorbicularis(photography 3, postoperative 1st day)(photography 4, postoperative4th month) Oris muscle, tension-free repair of the muscle İn the midline waspossible. By suturing the Skin in the midline without tension, and Performingz-plasty on the mucosa, both the Length of the mucosa was increased and the Liptubercle was formed. In the patient, whoDid not have complications in the Postoperativeperiod, mouth opening was Evaluated as compatible with her peers. Inconclusion, median cleft lip is a very rare Congenital anomaly. Due to the lownumber ofCases and scarcity of resources in the Litarature, a common decisioncould not be Reached in the treatment process.therefore, a Lot of work isneeded on this subject. We Would like to contribute to the literature by Publishingour own procedure.Sources1.Millard dr and williams s. Median Lip clefts of the upper lip. Plast reconstr.Surg.1968;42:4 2. Tessier p. Anatomical classification Offacial, craniofacial, and latero-facial clefts. JMaxillofacsurg 1976;14:69 3. Tessier p.Anatomical classification Of facial, craniofacial, and latero-facial clefts. In:tessier p, ed. Symposium onplastic surgery İn the orbital region. St. Louis: cvmosby,1976 4. Apesos j and anigian g. Median Cleft ofthe lip: ıts significance and surgical Repair. Cleft palate j 1993;30:94–96 5. Kawamoto hk and patel pk. Atypical Facialclefts. In: bentz m, ed. Pediatric plastic Surgery. Stamford: appleton andlange, 1998 6. Johnston mc, sulik kk.Some Abnormal patterns of development in the Craniofacial region. Birth defectsorig artic ser 1979;15:23‑427. Demyer w. The median cleft face Syndrome: differential diagnosis ofcranium Bifidum occultum, hypertelorism, and medianCleft nose, lip, and palate.Neurology.1967;17:961–971. 8. Millarddr jr. Median cleft lip with Hypertelorism. In: millard dr, jr, ed. Cleft Craft:the evolution of ıts surgery. Vol. 2. Boston: little, brown; 1977:727–768. 9. Nakamura j, tomonari h, goto sTrue mediancleft of the upper lip associated With three pedunculated club-shaped skin Masses.Plast reconstr surg 1985;75:727–731Dokuz eylülunivercity hospital plasticReconstructive and resthetic surgery Departmantizmir/turkeyProf.dr.Adnan menderes Dr. Fatih berk ateşşahin Dr. Hasan basri çağlı Dr. Safa erenatalmış Dr. Merve terzi Dr. Tahir babahan |
