By D. O. MAISELS, M.B., F.R.C.S.Ed. Senior Registrar, Regional Plastic Unit, PYhiston Hospital, Prescot, Lancs.

Transcription

1 THE TIMING OF THE VARIOUS OPERATIONS REQUIRED FOR COM- PLETE ALVEOLAR CLEFTS AND THEIR INFLUENCE ON FACIAL GROWTI-P By D. O. MAISELS, M.B., F.R.C.S.Ed. Senior Registrar, Regional Plastic Unit, PYhiston Hospital, Prescot, Lancs. WHILE it may be true to say that timing in certain surgical procedures, just as in golf or tennis, depends upon a combination of skill, judgement and experience, this can apply only to a very limited extent in the treatment of complete alveolar clefts. Stockard in 1921 stressed the importance of timing in the production of developmental defects, as opposed to the specificity of the teratogenic agent used, and since birth is but an incident in development, as much attention must be paid to the timing of surgical procedures for the reconstruction of complete alveolar clefts as is given to the choice of operation. Any consideration of this timing must be based upon an understanding of the normal development of the face, the formation of the common clefts and the development of deformities secondary to the cleft. Having established these firm base lines one is in a position to review the known effects of the many surgical procedures for the treatment of alveolar clefts and to examine the aims and influence of orthodontics and orthopaedics in both counteracting and supplementing these effects. Having taken into account all these factors, it becomes possible to hazard a suggested optimal regime in the light of current knowledge. Early Development of the Face and Formation of Clefts.--For brevity's sake attention must be focused on those areas of facial development most clearly related to clefts. During the last decade most authorities have rejected the classical theory of His (1892) propounding fusion of processes lying free in space. In its stead there has been a growing tendency to accept the view that masses of mesoderm migrate between two continuous sheets of ectoderm covering the face and roof of the primitive oral cavity (Veau, 1938 ; Streeter, 1951) and that unless this ectoderm is supported by an intervening layer of mesoderm it will eventually break down and give rise to a cleft (Stark, I954). More recently however Tondury (I964) has cast some doubt on the validity of this newer theory, and Latham (I966a) has drawn attention to some very striking evidence in support of His' original theory. We are thus at a fascinating juncture in the elucidation of the development of the face. What is clear is that the primary palate, from which develop the central lip and premaxillary complex as far back as the incisive foramen (Kernahan and Stark, I958), is formed by five weeks. Should a cleft develop, either as a result of failure of mesodermal penetration with breakdown of unsupported ectoderm, or because of persistence of ectoderm covering the mesodermal processes, such a cleft of the primary palate will be present in the embryo by the fifth week, and will vary in severity from case to case (North, 1964). The secondary palate which extends from the region of the incisive foramen backwards, is formed by fusion of two maxillary palatal processes with each other and with the inferior border of the nasal septum. Lying at first vertically at each side of the 1 Kay Kilner Prize Essay, i

2 TIMING OF OPERATIONS FOR complete ALVEOLAR CLEFTS tongue these palatal folds rise above it when the neck extends and the tongue descends, and then between seven and eight weeks they fuse with each other and with the septum from before backwards, to form most of the hard and all of the soft palate. Failure of fusion, for reasons which are only now beginning to emerge (Latham I966b), will of course result in a cleft of the secondary palate. Secondary Effects of the Cleft.--A complete alveolar cleft will thus be present by the end of the eighth week. During the remaining period of growth and development which extends until maturity, the cleft will exert secondary effects upon the whole of the middle third of the face. An understanding of these secondary effects of the clefts demands further examination of the normal development of the middle third of the face, in particular the part played by the inter-orbital cartilaginous nasal system. It is the growth of this relatively enormous structure which is responsible for much of the forward and downward growth of the maxillae (Scott, I953, I954). Because the maxillae are attached to the nasal septum, they are carried with it, the potential spaces at the surrounding sutures being " filled in " by bone. This relatively passive concept of sutural growth has recently been reinforced by the work of Latham and Burston (I964) and the unequivocal experiments carried out by Sarnat (I964). In a complete unilateral cleft of the primary and secondary palates, the maxilla on the cleft side is separated from the nasal septum. The lesser segment, being thus deprived of the growth impulse, lags in development and is small and retroposed. The premaxilla on the greater segment tends to grow forward and to rotate to the uncleft side, taking the nose tip with it, bending the septum and flattening the ala on the cleft side. A similar set of deformities, usually less marked, may be seen in complete clefts of the primary palate only, andin those rare cases where the cleft of the alveolar and postalveolar portions of the primary palate is submucous and therefore less obvious. Cases of typical cleft lip type deformities of the nose in the absence of overt clefts of the primary palate have been reported. While Brown (I964) attributed this to a primary defect of the alar cartilage and not secondary to the abnormality of the lip or alveolus, Stenstrom and Thilander (I965) and Cosman and Crikelair (I966) have made a good case for it being a microform of a cleft. In the complete bilateral cleft, the unrestrained growth of the septum carries the premaxilla forward, leaving the lateral segments behind. In both unilateral and bilateral clefts there may be some slight collapse of the lateral segments at birth, which appears to increase during the next few months, even in the absence of surgery. This increase in collapse has been the source of much confusion and misunderstanding, but it has been shown by Burston (I96o, I965) to be more apparent than real, because of differential growth rates between maxilla and mandible. A varying degree of retrognathia is always present at birth and as the mandible catches up and grows forward it may well outstrip the maxill~e and because of the altered maxillo-mandibulary relationship, give a false impression of increasing collapse (Fig. I). Because septal growth is maximal during the last six weeks of gestation, premature babies generally show less marked deformities than do full-time babies. After a short neo-natal pause there is another growth spurt for about six months, which accounts for the increasing deformity which may be seen in untreated babies during this period. Thereafter a fairly stable condition is achieved in the upper dental arch affected only in minor degrees by the changing maxillo-mandibular relationship, which becomes established at approximately four months. As pointed out above, this may give the false appearance of increasing collapse. 23I

3 232 BRITISH JOURI~AL OF PLASTIC SURGERY The assumption that all the secondary deformities resulting from a cleft are due to deformities and deficiencies in the bone, the cartilage and the developing tooth elements is to ignore the influence of the soft tissues. Due regard must be paid to at least two factors arising in the soft tissues (Subtelny, I957). In the first place the division of the lip and soft palate has the effect of dividing a muscle sphincter and thereby increasing the divergence of the parts, partly by a direct traction effect and partly by failing to oppose the disrupting effects of the bone and cartilage referred to above. Secondly one A FIG. I To indicate the illusion of increasing collapse produced by forward growth of the mandible. Note that in B, a lateral cross-bite has developed although the maxillary segment has not moved medially. (Maxillary segments in continuous lines, mandibular in broken lines.) B must consider the influence of the tongue which lies contained within the alveolar arch and palatal shelves and which in a cleft is enabled to increase the deformity. Case reports of unrepaired clefts of primary and secondary palates in older children and adults are rare, but the few available illustrate many of these points (Davis, I95I ; Dunn, r952 ; Hyslop and Wynn, I952 ; Glass, I956 ; DeJesus, I959 ; Mestre et al., I96o ; Innis I96I). An aspect of cleft lip deformity which is receiving increasing attention is that of the nose. In many instances, as the nose progresses from the normal infantile snub nose appearance to the adult state the deformity becomes increasingly apparent. The columellar shortage on the cleft side gives rise to the most marked deformity in the bilateral cleft while deviation from the midline in the unilateral cleft becomes increasingly obvious with the passage of years and general increases in size of the nose. General Effects of Surgery.--It is against this background of normal and abnormal development that the effects of surgery must be considered. Before proceeding to a detailed examination of the numerous operations which are or have been employed it seems advisable to make some general observations. Repair of the cleft lip plays a dual role. While on one hand, by the establishment of more

4 TIMING OF OPERATIONS FOR COMPLETE ALVEOLAR CLEFTS 233 correct muscle balance and varying degrees of tension, it tends to correct the premaxillary deformity in both unilateral and bilateral clefts, it may on the other hand tend to perpetuate and even increase the malrelafionship of the lateral segments. Furthermore, if repair of the anterior palate is combined with lip repair, the contraction of the band of scar tissue which is bound to result from the usual single layer closure is felt to be a major factor in this lateral collapse. Severe collapse is not the inevitable result of lip and anterior palate closure, for the degree of movement of the segments is the resultant of the above mentioned forces, the amount of tongue thrust present and the pre-operative size and position of the alveolar segments, all of which will vary from case to case. Bilateral lip repair may result in the premaxilla becoming locked in position anterior to co/lapsed lateral segments as in Wallace's Type I deformity (1963) and it was this problem which led to the controversial and usually undesirable operations of surgical retropositioning or even excision of the premaxilla. In some cases of gross deformity it was only by these means that lip closure could be achieved. In the past, surgery was often blamed for maxillary retrognathism and hypoplasia in patients with repaired clefts. This theory has been examined by Foster (196o ; 1962) Subtelny (1962) and Coccaro and Pruzansky (1965) among others, all of whom agreed that surgery as currently practised does not have this effect. It seems probable that a diminution of maxillary growth potential is an integral part of the cleft deformity. DETAILED EFFECTS OF SURGERY In this section a review of the various surgical procedures will be undertaken, together with their timing and effects on subsequent growth and development. Approaching the problem in chronological order mention must be made of lip repair in the neonate (DesPrez et al., 1964). It would appear that the decision to operate at this time is dictated more by social conditions than consideration of the subsequent growth and development of the face. Lip Adhesion.--Johanson and Ohlsson (I96I), as part of their preliminary procedure carried out at the age of 2 months, approximated the tissues of the upper part of the lip. This facilitated the definitive repair of the lip, which was done some months later together with bone grafting, by improving the muscle balance and converting a complete to an incomplete cleft. Millard (1964) advocated simple closure of the superior third of the lip in the exceptionally severely distorted case for the same purpose, and in 1965, Randall gave the name "lip adhesion" to a variant of an essentially similar operation. Ideally these procedures should be carried out on the neonate but it would seem preferable to achieve the same objectives by non-surgical means. That this is possible will be shown below in the section on early orthopmdic treatment. Repair of Lip and Anterior Palate.win the majority of cases the first operation on the baby with a complete alveolar cleft is the repair of the lip. In many instances the decision to combine this procedure with repair of the anterior palate depends as much upon the skill, training and habit of the surgeon as it does on considerations of the subsequent growth and development of the face. The type of lip repair itself will often have as much bearing on subsequent growth and development, as will the timing of the operation. At one end of the scale we have the Kilner/Rose/Thompson type of operation which often results in a lip which is too tight, especially after secondary repairs necessitating the sacrifice of tissue to obtain adequate length. This tightness, particularly in the lower third of the lip, produces an excessive moulding effect on the alveolar segments

5 234 BRITISH JOURNAL OF PLASTIC SURGERY and contributes to collapse. The nasal deformity being uncorrected at the primary operation, subsequent development of the nose is faulty and secondary correction is frequently extremely difficult. At the other end of the scale are the modern operations, the best of which is undoubtedly that devised by Millard (1955, I964) which not only preserves the natural landmarks of the lip and restores them to their normal position, but also corrects the nasal deformity to a very marked degree. This allows the subsequent growth and development of the nose to proceed normally and should render superfluous all but the most minimal of secondary corrections on the nose. By placing the tension high in the lip it has been noted that the Millard operation has a more favourable effect upon the arch alignment (Joss, 1964). The classical teaching is that the lip should be repaired when the baby weighs IO lb., is thriving and has a hmmoglobin concentration of IO g. This usually results in the operation being undertaken at about 3 months of age, when the baby is not only FIG. 2 To show the real-alignment in a case of unilateral cleft resulting from repair of lip and anterior palate without pre-surgical orthopmdic treatment. in fit condition to undergo surgery, but also the parts are sufficiently large to allow a reasonable degree of precision in the repair. We have already examined the effects this operation has upon subsequent growth and development, especially of the premaxilla and lateral segments. Not infrequently faulty moulding of the maxillary segments results, with the premaxilla impinging against the collapsed lateral segment, and this is more likely to happen if a single layer anterior palate repair has been carried out at the same time (Fig. 2). To counteract this effect, Muir (1966) has devised an elegant refinement of the Burian flap (I957), which is designed to maintain the alveolar gap and allow better arch alignment to be achieved by the moulding effect of the repaired lip. The repair of the complete bilateral cleft of the primary palate is complicated, especially when accompanied by a cleft of the secondary palate, by the problem of the protruding premaxilla. The impossibility of achieving lip closure in the severe cases led in former times to the excision of the premaxilla. The resultant deformity became increasingly obvious as the child grew to adolescence and left the unfortunate victim with a severely retroposed middle third of the face (Fig. 3). A compromise solution to this defect was surgical recession of the premaxilla (Browne, I949 ; Cronin, 1957)

6 TIMING OF OPERATIONS FOR COMPLETE ALVEOLAR CLEFTS 235 carried out first and followed later by lip repair. Monroe (I959) combined recession with lip repair and there is little evidence to suggest that doing this in one o1 two stages had different effects on subsequent growth and development. Repair of bilateral clefts is often carried out in two stages, the second side being repaired about six weeks after the first. Here again the indications are technical ones and not the result of consideration of their effects on growth and development. Reference has already been made to the tethering effects of the short columella upon the nose tip in bilateral clefts. This has necessitated secondary procedures to lengthen the columella and release the nose tip. Preferably this operation should be carried out at the age of 5 or 6 years, before the nose begins to assume its adult proportion and thus reduce interference with growth. In I958 Millard described his forked flap operation for lengthening the columella and suggested its use in the primary repair. He has recently reported the early results of this procedure (Millard, I967) which in the case tu J.1LI.IIJ.I.J.11~., LJ.II~., ~.I.I.~...L UJ, L11ql~ ~,,.,lll,,il Ull L11~ subsequent growth and development of the nose. Skoog (z965 a) also has incorporated a primary columellar lengthening procedure in his two-stage repair of the bilateral cleft lip. Palate Repair.--The question of interference with growth and development resulting from surgical repair of the secondary palate has aroused the interest of many workers in this field. Herfert (I958) working on dogs noted a reduction of growth, particularly in the lateral dimension of the hard palate, following elevation of muco-periosteal flaps, especially when the greater palatine artery was ligated. Because he had found good maxillary growth and alignment in a number of children over I2 years old who had had lip repairs but no repair of the palate, and perhaps most significant, no anterior palatal repair, he favoured a two-stage repair (I963). Recognising the importance of providing the infant with an intact velum with which to acquire normal speech, he repaired the soft palate only at I4 to I6 months and the hard palate at about 5 years. He points out that this approach was previously adopted by Schweckendiek in I944 and later by Slaughter and Pruzansky (I954).

7 236 BRITISH JOURNAL OF PLASTIC SURGERY On the other hand Sarnat (1958) working on monkeys, excised the muco-periosteal flap and ligated the greater palatine artery. In one group of animals he went further and also excised the bony palatal shelf and nasal lining. These experiments showed no significant gross differences in growth and development of the hard palate, maxillary arch, mandibular arch, maxillo-mandibular relationship or total face. This suggests that neither the surgical trauma of raising flaps nor deprivation of blood supply is the cause of maxillary and facial lack of growth, a finding in accordance with Foster's work in humans with complete alveolar clefts (1962). The apparent contradiction in the results obtained by Herfert and Sarnat would occasion some difficulty in arriving at a conclusion on the timing for repair of the hard palate were it not for the recent and important findings of Latham and Burston (I966). Working on human material they have shown that the lateral activity in the mid-palatine suture is greatly diminished by I8 months and has for practical purposes ceased by 2 years of age. This fundamental observation indicates that after 18 months to 2 years lateral growth of the hard palate takes place as a result of alveolar appositional growth only, and not by separation of the parts along the mid-palatine suture. Consequently operation on the hard palate at this time cannot be expected to inhibit growth by tethering the two sides to each other by a sheet of scar. It is widely held, particularly among the British plastic surgeons, that timing of repair of the secondary palate should be dictated by the need for acquiring normal speech rather than by fear of interfering with subsequent growth and development. In support of this view Jolleys (I954) found significantly better speech results in patients in whom the palate had been repaired before the age of 3 than in those in whom operation was delayed until after this age. In practice the palate is usually repaired in Britain at least, at 12 to 18 months, the delayed procedure never having received general acceptance. It is indeed fortunate that this policy is now shown by Latham and Burston to be compatible with normal development. At the same time a more fluid approach may be retained for the timing of repair of the anterior palate where the turning moment upon the lateral segments is greatest. It is perhaps of interest to note that Peer et al. (1964) using cephalometric measurements, found no significant underdevelopment of the maxillm in 94 patients submitted to the Dieffenbach bone flap operation before the age of 2 years, and accordingly carry out the operation, when possible, at between 7 and 14 months. Bone Grafting.--The first successful bone graft to an alveolar cleft is attributed to Drachter (I914) and in recent years a tremendous amount of interest has been aroused in bone grafting. Broadly speaking the objectives are to replace the missing bone in the line of the alveolar clefts thereby preventing lateral collapse and growth deformities, stabilising the premaxilla in bilateral clefts, and also providing tissue in the alveolus into which misplaced teeth may be migrated. The attainment of these objectives demands early or primary bone grafting which accompanies or only briefly precedes lip repair. A second approach is delayed or secondary grafting at about 5 years of age or later in which most usually expansion of the maxillary arch is required prior to bone grafting, in order to correct deformities resulting from the original operation. Both these methods demand pre,surgical orthodontic and orthopmdic management (Brauer et al., 1962 ; Backdahl et al., I964 ; Skoog, I965b) although Pfeifer and Schuchardt (I964) and Schrudde (1965) who are exponents of early bone grafting, have claimed that normal development follows grafting without pre-surgical orthodontic treatment. Early bone grafting combined with lip repair would appear to offer an ideal solution to a very difficult problem, but a note of caution should be sounded here. Both Ohlsson (1964) and Kling (I964) reporting on results of cases treated with Johanson, who has probably had as much experience of this technique as anybody, have recently expressed

8 TIMING OF OPERATIONS FOR COMPLETE ALVEOLAR CLEFTS 237 some reservations regarding the maintenance of good growth and development in spite of early bone grafting. Late bone grafting following orthopa:dic correction of the maxillary segments would appear to offer greater certainty of achieving a good definitive result (Matthews and Grossman, 1964). Secondary Operations.--Reference has already been made to the increasing tightness of the lip which results from secondary operations which sacrifice tissue and to the effects these will have upon growth and development if carried out, as was usually the case, in the pre-school child. Since it is believed that adoption of the Millard technique for unilateral clefts will eliminate the need for secondary procedures of any magnitude, no further discussion on their timing is called for. in size of the prolabiurn. In bilateral clefts with a very small prolabium a tight upper lip may be inevitable. This may readily be overcome by an Abbe flap operation and presumably the earlier this is carried out the less will be the interference with growth and development. The need for an Abbe flap cannot always be predicted at the primary operation, for not infrequently a small prolabium will grow and/or stretch to a remarkable degree in the years following the primary closure (Fig. 4)- Its need will usually be apparent by the age of 4 or 5 years when each case must be judged on its individual merits. A decision is then made on whether the advantages accruing from an Abbe flap will out-weigh the psychological disturbance occasioned in a young child by this procedure. It will usually appear preferable to delay the operation at least until 8 or 9. Columellar lengthening and correction of alar flaring will frequently be demanded in the bilateral cleft as a secondary procedure. This too has been discussed above. Major secondary operations upon the unilateral cleft lip nose should become uncommon in most cases treated by modern methods. Where indicated it is advisable to apply the same rules here as in cosmetic rhinoplasty and to defer surgery until late adolescence. Secondary procedures for improving speech in cases where the functional results of the primary operation have been unsatisfactory, include the pharyngeal flap (Schoen-

9 238 BRITISH JOURNAL OF PLASTIC SURGERY born, 1876; Rosenthal, 1924; Rosselli, I935), Hynes' pharyngoplasty (1951) and the island flap (Millard, 1962) to mention but a few. While Subtelny (1962) has reviewed the work on growth of the velopharyngeal region in both normal and cleft subjects, the effects on subsequent growth of the individual procedures and their timing remain obscured by conjecture and a variety of complicating factors. Finally some consideration must be given to the tinting of surgical correction of mandibular prognathism in patients with complete alveolar clefts. It is well recognised that a varying jaw relationship is found in the non-cleft population manifesting itself as a Class I, II, or III occlusion, and that a similar variation exists in cleft lip and palate patients. In order that the normal pattern of maxillary surface apposition of bone may take place it is necessary to have normal occlusion. Thus if the occlusion is abnormal either because of mandibular prognathism or because of maxillary hypoplasia, this stimulus for appositional growth is absent. It is therefore felt that early correction of mandibular prognathism and the consequent establishment of normal occlusion will produce the necessary stimulus for maxillary appositional growth, and that the optimal time for this correction is when the permanent upper and lower incisors are fully erupted (Knowles, 1966). The same principles must surely apply when the problem is maxillary hypoplasia rather than true mandibular prognathism, and where the solution is maxillary osteotomy (Gillies and Millard, 1957). AIMS-AND INFLUENCE OF ORTHOP2EDICS It was McNeil of Glasgow (1954) who conceived the idea of early or presurgical orthopredic treatment of alveolar clefts, and Burston of Liverpool (1958, 1959, 196o, I964, 1965) who, working from a sound embryological knowledge, has developed it to its present high degree of refinement. The objectives of this treatment are the control and correction of mal-alignment and the development of the alveolar processes in such a manner that the alteration of forces resulting from repair of the primary palate will produce a well-balanced and stable normal maxillary arch in the presence of a normal maxillo-mandibular relationship. The attainment of these objectives carries with it the corollary that the surgeon is presented with a narrower cleft and in bilateral cases a restrained premaxilla on which to operate, which not only facilitates his task but also improves his results (Osborne, 196o ; Forshall et al., 1964; Maisels, 1966). One of the features, indeed one might almost say the sheet anchor of this presurgical treatment is thatby starting it within forty-eight hours of birth, full advantage is taken of the post-natal growth spurt. Together with bone grafting, early orthopmdic treatment forms the subject of a great deal of current thought and controversy in the treatment of complete alveolar clefts, so that an examination of its relationship to the timing of surgery is of the very greatest importance. Burston (1965) drew attention to the four basic problems presented at birth by the skeletal defects of cleft lip and palate. These were : (i) A true deficiency of tissue, (2) an underdevelopment of the affected side or sides of the maxilla, (3a) deviation of the midline in unilateral clefts, (3b) in bilateral clefts, some eversion of the premaxilla on the central stem and an element of overdevelopment of the stem, (4) a varying maxillomandibular relationship. To these must be added a varying degree of soft tissue deficiency, for in the extreme case this may result in an excessively tight lip no matter what the skill of the surgeon or the elegance of the operation of his choice. Acceptance of the principle that a well integrated team approach will produce the best results in treatment of complete alveolar clefts, demands an assessment of the aims and objectives of early orthodontic treatment and the degree to which these objective can usually be expected to succeed.

10 TIMING OF OPERATIONS FOR COMPLETE ALVEOLAR CLEFTS 239 A certain number of complete unilateral clefts will not require pre-surgical orthopaedic treatment at all, except perhaps for the provision of a plate to alleviate feeding problems. These are the cases which are cited by the opponents of early orthopaedics and they may well constitute 3 per cent. of all cases. Extensive experience suggests that the case not requiring treatment will have a well developed lateral segment with minimal tissue deficiency and a good growth potential, minimal displacement of the lateral segment and rotation of the premaxilla and a normal FIG. 5 A unilateral cleft. To show the effect of orthopaedic treatment. (Left column : soon after birth. Right column : immediately before repair of lip and anterior palate.) maxillo-mandibular relationship. Only very exceptionally will this be apparent at birth, even to the experienced eye, but by observing growth and development during the early weeks of orthopaedic treatment the expert will soon recognise these cases (Burston, 1966). As soon as such a case is recognised it is ready from an orthopa:dic point of view for repair of lip and anterior palate and timing of the operation becomes dependent on general considerations. A second type is the case with a less favourable set of circumstances who requires

11 240 B R I T I S H J O U R N A L OF P L A S T I C S U R G E R Y pre-surgical treatment. Again, close and practised observation by the orthodontist will recognise the optimal time for surgery. If the response to treatment is favourable not only as regards the position of the alveolar segments but also the growth of the lateral segments and the maxillo-mandibular relationship, a stage will be reached at 3 to 4 months when the baby is ready for synchronous repair of lip and anterior palate (Fig. 5). FIG. 6 A bilateral cleft. T o s h o w t h e effect o f orthopmdic t r e a t m e n t. (Left c o l u m n : soon after birth. R i g h t c o l u m n : i m m e d i a t e l y before repair of lip a n d anterior palate.) There is however a group of cases in which for a variety of reasons, many of them still completely unrecognised or only poorly understood, response to treatment is less favourable. By 6 months of age the alignment may still be defective or the growth of the lateral segments grossly inadqeuate and the decision is taken to repair the lip. In order to avoid the excessive pull resulting from single layer closure of the anterior

12 TIMING OF OPERATIONS FOR COMPLETE ALVEOLAR CLEFTS palate and to facilitate post-operative orthopzedic treatment, the anterior palate is left unrepaired in these cases. This policy may result in the alveolar processes coining together, often with a normal maxillary arch form, but almost always with an abnormal maxillo-mandibular relationship, the maxillary arch lying within the mandible. Reexpansion of the maxillary arch at the age of about 5 and insertion of a bone graft between the alveolar ends will establish normal maxillo-mandibular relationship and occlusion. The reasons for the adoption of this policy in Liverpool in preference to early bone grafting have been clearly stated by Burston (I965). On the other hand a proportion of cases will develop a balanced occlusion with an alveolar gap if single layer anterior palatal repair is omitted. Here again a bone graft can be inserted at the age of 5, to fill the gap and allow migration of a neighbouring tooth into the graft. In bilateral clefts, if orthopaedic treatment has been successful, repair of the lip and anterior palatal defects can usually be effected at 3 to 4 months (Fig. 6). This will fix and confirm the position of the parts. Failure to repair the anterior palate in these cases has on occasion resulted in the continued forward growth of the premaxilla. In other words, the tension resulting from the lip repair alone, may be insufficient to restrain the central stern (Fig. 7). 24I Fro. 7 To show how the premaxilla may grow away from the lateral segments if the anterior palate is not repaired. A, After orthopaedic treatment at time of repair of lip only, aged 4 months. B, Eight months later. C, Aged 2½ years. Finally there is a small group of bilateral clefts in which pre-surgical orthopsedics has failed to control the protrusion of the premaxilla and in whom surgical retroposifioning becomes necessary. In Liverpool this group constitutes six out of seventy-six bilateral cases. The procedure, which is carried out at the time of lip repair, entails sectioning the vomer behind the suture line and retroposing the premaxilla, without interfering with the cartilaginous septum, by an amount carefully determined from cephalograms and a consideration of the growth pattern already displayed in the early post-natal months. The series of cases is small and the follow-up still too short to be certain of the effects this operation will have on growth. It is hoped that by avoiding damage to the septal cartilage, suppression of growth will be minimal. CONCLUSIONS Having taken into account all the factors discussed above, it would seem obvious that every baby born with a complete alveolar cleft should have orthopmdic treatment instituted within forty-eight hours of birth. While in perhaps 30 per cent. of cases such treatment will in the subsequent growth pattern prove to have been unnecessary, to date 3B

13 242 BRITISH JOURNAL OF PLASTIC SURGERY nobody can predict at birth which case falls in this 3 per cent. Moreover the orthopaedic treatment can never do harm and the presence of the plate in itself will do much to prevent the feeding problems so often a worrying difficulty presented to an already distressed mother. Having accepted this premise the actual timing of the primary operation on lip and/or anterior palate will be decided by the orthodontist as a result of regular and frequent observation of the growth pattern and response to treatment. Thus the decision has largely been taken out of the hands of the surgeon who none the less still has the responsibility of producing an acceptable cosmetic and functional result. Such a result is most likely to be achieved through a team approach by surgeon and orthodontist, and indeed this combined approach should continue until full growth of face, nose and jaws has taken place. The detailed conclusions regarding the timing of the procedures for repair of the secondary palate and of the various other operations which are on occasion necessary for the treatment of complete alveolar clefts, are embodied in the discussions above. The pervading message is that an attempt should be made wherever feasible to design their nature and timing with due regard to the normal pattern of growth and development of the face. It is with great pleasure that I record my debt to numerous colleagues, both surgical and dental, in Liverpool and elsewhere, who have contributed so much of their time, knowledge and experience, in stimulating my interest in the cleft problem. I am especially grateful to Dr. IV. R. Burston, Mr. R. P. Osborne, Mr. L. B. Scott and Mr. A. H. M. Littlewood, for their help and encouragement in the preparation of this paper and for allowing me to use illustrations of their cases. My thanks are also due to Mr. M. Bayliss, Medical Photographer at IVhiston Hospital, for the illustrations, and to Mr. C. G. Elliott, Maxillo-facial Technician. REFERENCES BACga)AHL, M., NORDIN, K., NYLEN, B., and STROMBECK, J. (I964). Trans. int. Soc. plast. Surg., 3rd Congr., I963, p. I93. Amsterdam : Exerpta Medica Foundation. BRAUER, R. O. (I965). Plastic reconstr. Surg., 35, I48. BRAUER, R. O., CRONIN, T. D., and REAVES, E. L. (I962). Plastic reconstr. Surg., 29, 625. BROWN, R. F. (I964). Br. ft. plast. Surg., I7, I68. BROWNE, D. (1949). Ann. R. Coll. Surg., 5, I69. BURIAN, F. (I957). Trans. int. Soc. plast. Surg., ISt Congr., I955, P ~ Baltimore : Williams & Wilkins. BURSTON, W. R. (x958). Dent. Pracmr., 9, 4I. BURSTOr, W. R. (I959). Ann. R. Coll. Surg., 25, 225. BtrRSTON, W. R. (I96o). Trans. int. Soc. plast. Surg., 2nd Congr., I959, P. 28. Edinburgh : E. & S. Livingstone Ltd. BURSTON, W. R. (r964). Br. dent. ft., x x6, 288. BxmsroN, W. R. (x965). Pro. R. Sac. Med.,58, 767. BtrRSTO~r, W. R. (x966). Personal communication. COCCARO, P. J., and PRUZANSKY, S. (r965). Cleft Palate J., 2, I. COS~N, B., and CRmELAm, G. F. (I966). Plastic reconstr. Surg., 37, 334. CRONIN, T. D. (1957). Plastic reconstr. Surg., x9, 389. DAvis, A. D. (r95i). Plastic reconstr. Surg.~ 7, 482. DEJ~us, J. (I959). Am. ft. Orthod., 45, 6r. DEsPrtEz, J. D., KmrrN, C. L., and MAGID, A. (I964). Plastic reconstr. Surg., 34, 483. DRACHTER, R. (I914). Z. Chit., i3x, 39. DtrtcN, F. S. (I952). Plastic reconstr. Surg., 9, IO8. FORSHALL, I., OSBORNE, R. P., and BURSTOr~, W. R. (I964). In: " Early Treatment of Cleft Lip and Palate," p. 68. Ed. R. Hotz. Berne : Huber. FOSTER, T. D. (I96O). Trans. int. Soc. plast. Surg., 2nd Congr., r959, p. 36. Edinburgh : E. & S. Livingstone Ltd. FOSTER, T. D. (I962). Br. ft. plast. Surg., I5, 182. GILLIES, H. D., and MILLARD, D. R. (I957). " The Principles and Art of Plastic Surgery," p. 34o. Boston : Little, Brown & Co.

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