Patient born with unilateral cleft lip and palate deformity
The patient is a 26-year-old female from Thalassery in Kerala, India. She was born with a unilateral cleft lip and palate deformity. Her parents had been counseled extensively at the time of birth. A plastic surgeon had given them a timetable for the surgeries required by the patient.
Parents had rigorously followed the doctor’s advice. The patient underwent cleft lip surgery at 3 months of age and cleft palate surgery at 9 months of age. There was complete closure of the communication with the nasal cavity at the roof of the mouth. This had been followed by cleft alveolus surgery at the age of 4 years. The three surgeries had been performed at a nearby city.
Immediate period after initial surgical correction of deformities
Her parents had been satisfied with the immediate results of the surgery. The patient had been able to feed well and her speech also developed within normal limits; however, as she grew up, the deformity became more pronounced and evident to others. She had also developed a degree of breathing difficulty and snoring.
Her facial deformity had always drawn unwelcome attention from others. She had faced a certain degree of bullying while in school and college. The patient had always been an extrovert and had excelled in studies and co-curricular activities. She had met all her milestones appropriately and had always been a happy child.
Considering surgical correction of her facial deformities
The patient has been mulling surgical correction of her deformities over the past few years. She and her parents had visited a local facial cosmetic surgeon. He examined her and said that there would be cosmetic and functional improvement with the surgery. The patient and her parents had therefore decided to go forward with getting her deformity corrected.
Her parents persevered to find the best hospital for the surgery. They had made extensive enquiries regarding the best surgeon for this surgery. Our hospital had been widely recommended by many specialists with whom they enquired. They therefore decided to visit our hospital and fixed an appointment.
Initial Consultation and Examination at our Hospital
Dr SM Balaji, facial cosmetic surgeon, examined the patient and obtained a detailed oral history. He then ordered pertinent imaging studies for the patient including a 3D CT scan. Clinical examination revealed that there was a depression on her left nostril. It was also considerably smaller than the right.
Imaging studies revealed a depression in the left anterior maxillary region. The patient also had a congenitally missing left lateral incisor. Augmentation of the maxillary defect would result in elevation of the base of the nose. This would result in proper form to the nose.
The left side of the lip was slightly uneven at the site of the left vermilion border. It was at the site of the previous cleft lip repair. This resulted in a slight asymmetry of the upper lip. Her lips also had some scarring from the previous surgery.
Treatment plan formulated for addressing her complaints
It was explained to her that she would need closed rhinoplasty with insertion of a costochondral cartilage graft. This would result in symmetry of both sides of her nose. An open rhinoplasty was not chosen as it would result in visible scarring at the site of surgery.
It was also explained that the lip revision surgery of the vermilion would establish the Cupid’s bow form to her lips. Cupid’s bow lip surgery would help establish perfect lip contour for the patient. The patient and her parents expressed understanding of the same and consented to surgery.
Surgical correction of the nasal and lip deformities
Under general anesthesia, an inframammary incision was made following which a rib graft was harvested. An intranasal transcartilaginous incision was then made. Rhinoplasty was next performed followed by insertion of a costochondral graft for cosmetic nose correction. This was followed by augmentation of the maxillary defect with the rib graft, which was fixed with titanium screws.
Lip correction of the vermilion border was performed next. Incisions were made followed by excision of the scar tissue and suturing to establish the Cupid’s bow. Anesthesia was reversed and the patient was extubated and brought to recovery room in stable condition.
Successful outcome of surgery with good cosmetic results
The patient and her parents were very happy with the results of the surgery. Her parents stated that her nose and lips were in perfect harmony with her face. It was explained that they should return in 3-4 months for dental implant surgery for replacement of her missing lateral incisor.
An artificial tooth would be placed over the implant at a later date. They expressed their understanding and gratitude to the surgical team.
