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Cleft lip surgery has a rich history that can be traced back to ancient China during the Zhou Dynasty. Early procedures likely involved cutting open the separated lips and stitching them together. Modern cleft lip surgery began in the West around the 1800s, becoming refined after full-body anesthesia was possible.
The evolution of cleft lip surgery methods started with the straightforward linear closure technique. This was followed by the Z-plasty method to reduce scar contraction. Currently, the most widely used approach is the modified Millard rotation-advancement technique, promoted by American surgeon Millard. According to 2005 literature statistics, these three methods are employed worldwide. Today's surgeries achieve symmetrical nasal shapes and visible results.
The primary method in use is the improved Millard rotation-advancement technique, adopted by 85% of cleft lip surgeons globally. Combined with primary rhinoplasty, the improved version places scars in the philtrum and on the affected lip peak, making them less noticeable. Recent refinements allow post-surgical scars to closely match the normal side. The current approach integrates the improved Millard technique with the subunit repair method learned from David Fisher, a popular technique among younger surgeons worldwide. Tissue closure uses Tae Suk Oh's philtrum reconstruction, and nasal refinement employs Mulliken's soft tissue suturing, ensuring minimal scarring, good illumination, and natural nasal shape.
To achieve optimal results, post-surgical care must include scar management and nasal molding. In recent years, surgical design has been tailored to individual patient conditions, with about half opting for Fisher's subunit repair due to its lower tension and minimal scarring—effective even for darker skin tones. Post-operative care is relatively straightforward.
Modern single-sided cleft lip surgery often includes anterior lip closure. Primary anterior lip closure does not harm anterior lip tissues or affect future tooth eruption.
The advantage is that the nasal base can be stitched together, potentially addressing future oronasal fistulas in some infants. Of course, primary anterior lip closure minimizes tissue tension during lip surgery, reducing the incidence of oronasal tubes.
For incomplete cleft lip infants, pre-surgical nasal molding is needed to shape the nose, as the affected side's nasal cartilage is more depressed. Using nasal molding helps normalize the cartilage shape, allowing long-term maintenance after surgical adjustment. The timing for nasal molding in incomplete cleft cases varies by surgeon; personally, full month post-birth is recommended, as some infants have very small nostrils, and immediate molding can cause nasal skin irritation. At full month, nostrils are typically larger, easier to fit, and less prone to injury, reducing parental concerns. Nasal molds are now provided uniformly by foundations, eliminating costs. Tools like scissors and tapes are also available in care kits.
Cleft palate can be categorized into many types, with different approaches for each. Generally, for complete cleft palate (lip, alveolus, and palate separated), orthodontic plates should be worn after birth.
The benefit of orthodontic plates for complete cleft palate patients is easier feeding and reduced alveolar clefting through assistance, improving surgical outcomes. They can also include nasal elevators to enhance nasal shape, especially important for bilateral clefts.
For incomplete clefts, only nasal skin elevators are needed, without orthodontic plates.
Taiwan has advanced orthodontic plate technology globally. Many countries, including the US, lack insurance coverage, so alternatives like nasal clips or elevators are used to maintain nasal shape. The US and Canada use nasal clips, while China uses homemade nasal elevators.
Orthodontic plates are particularly important for bilateral cleft infants. If fitted well, they can elevate the nasal tip, allowing better surgical techniques. Although orthodontic plates require six pre-surgery visits for molding, making, and adjusting, the results are clear and effective for nasal shape maintenance.
After three months of orthodontic plate use, pre-surgery can achieve reduced clefting and elevated nostrils.
Orthodontic plates are crucial for bilateral clefts! Bilateral cleft patients often have rotated frontal bones (frontal lip) at birth. Through orthodontic plate use, the "nasal tip" can be elevated pre-surgery for better outcomes. Although surgery can create a nasal tip using different methods, it may result in scarring and less natural appearance.
European and American countries lack insurance for orthodontic plates, so nasal clips are used, with post-surgical results comparable to plates. Therefore, nasal clips can be chosen if orthodontic plates are not preferred.
The infant in the right image has complete cleft lip and palate, using only nasal clips pre-surgery. Surgery employed Mulliken's nasal cartilage suturing method, with nasal molding for six months post-surgery. By age one, natural nasal shape was achieved with no visible scarring.
Nasal clips are convenient to use, requiring only forehead taping, with quite effective results.
Surgical methods vary based on individual infant conditions, and results differ by person. Scar formation peaks around two to three months post-surgery; with care, scarring improves by six months.
Post-surgical nasal and lip shapes continue to change, with lip scarring stabilizing around nine months and nasal shape requiring over a year. Thus, nasal molding is recommended post-surgery for as long as possible.
Each infant's constitution differs, so scar formation processes vary. It's similar to cesarean scars differing among mothers. Even with the same surgeon and technique, results vary.
Generally, observation for one month post-surgery is advised without massage, allowing wounds to heal well, then deciding based on scarring response.
Typically, scarring is more severe at 2-3 months post-surgery, then gradually softens, but color persists longer—often over a year. Patience in care is important.
Therefore, care should be based on the infant's condition for the best results. Bilateral cleft post-surgery scarring gradually fades after six months.