Craniofacial clefts have many varied presentations even with the same Tessier classification within the same anatomic field. While there are no didactic treatment protocols, the author has established general principles based on a retrospective review of the treatment of over 100 cases over a 12 year period. Evolving Plastic Surgical techniques have eclipsed some historic treatments. Cases have been selected to illustrate important treatment philosophies.
-Analyse the skeletal and soft tissue components of the cleft separately.
-Onlay bone graft often resorbs unless loaded.
-Preferentially use costal cartilage for bone contour.
-Repair cartilage donor site to preserve contour & enable reharvest.
-Early cranial harvest for orbital reconstruction in infants.
-Vascularized parietal bone flaps ideal for zygomatic reconstruction in infants.
-Mandibular elongation with rotation-distraction using transmandibular wire & floating
distal device gives good vector.
-Use facial bone growth for tissue distraction by earlier closure of large clefts
-First stage soft tissue closure may be required for bone graft envelopes.
-Sequential fat graft grafting has replaced most indications for free flaps and tissue expanders.
-Vertical facial lengths more critical than horizontal widths.
-Nasal alar- medial canthal length is key for planning nasal correction
-Mid face rotation advancement flaps use vectors of closure to protect eye, prevent ectropian and lengthen the midface.
-Over elevate the medial canthus. Drift occurs vertically and laterally.
-Expand eyelids early to simulate normal eye growth. The orbit can be enlarged at any age.
-Use serial conformers if tissue expanders are ineffective
-Overcorrect bony IOD in hypertelorism correction.
-Adapt skin to the nasofacial groove as excess dorsal skin usually redrapes
-Nasal skin can be progressively expanded to avoid forehead flaps
-Use facial aesthetic units for flaps where possible