Abstract
Unrepaired facial clefts are rare. within the literature, only a few articles reported and discussed unrepaired clefts in an advanced age group. Moreover, there are no reported cases in Saudi Arabia and the Gulf countries. Illiteracy, limited access to healthcare along with low socioeconomic status are believed to be the reason for late presentation for cleft repair. This case report represents a unique case of a fifty-two years old Saudi lady who came from a rural village in Saudi Arabia with an unoperated bilateral complete cleft lip.
Interestingly, this facial defect didn’t prevent the patient from living, socializing, getting married, and having children. In fact, our patient was accepted with her facial appearance in her local community. Dealing with unoperated cleft in adult patient is extremely uncommon practice so the surgical feeling and tissue handling is quite different than pediatric; the cleft gap in adult is wider, and the tissues are bulkier and stiffer which may necessitate extensive soft-tissue dissection. This could explain the complexity of the procedure and the prolonged operation time; however, this did not affect the final outcome. Although the case was challenging but the result is satisfactory.
Highlights
- •
Cleft lip and palate (CLP) considered the most common congenital craniofacial abnormality.
- •
The standard of care for (CLP) deformity is complex and require multi-staged surgical interventions in early childhood.
- •
The surgical repair outcome of primary cleft lip in elderly was quite challenging but very satisfactory.
Introduction
Unrepaired facial clefts are rarely seen nowadays. Babies born with clefts in developed countries are managed and followed up by higher healthcare centers. Whereas in undeveloped countries, unrepaired cleft can be still found. This can be explained by the rise of awareness and thus, the advancement in health care [ , ].
It is generally accepted that cleft deformities must be treated early in life based on a team approach. However, late presentation due to ignorance, cultural beliefs, no access to medical facilities, and the high cost of surgical treatment could attribute to the delay in the repair. Unoperated cleft can lead to impair esthetic and psychological status, which can affect the quality of life for these patients [ ].
It is interesting to find untreated adult cleft patient in a well-developed country. In this report, we demonstrate an unusual case of a fifty-two years old Saudi lady with unrepaired cleft lip and the surgical repair outcomes.
Case report
A 52 years old Saudi female married with five children. Known to have diabetes mellitus and hypertension. She presented to our clinic with an unrepaired bilateral complete cleft lip ( Fig. 1 A and B,C). The patient came from a rural village in Saudi Arabia. Neither she nor her family were aware that surgical treatment was possible early in life for such a deformity. Not only had no surgical intervention has been performed but also no dental treatment had been undertaken. She is illiterate and has a low educational background.
The patient presented to the Oral and Maxillofacial Surgery Clinic in Prince Sultan Military Medical City – governmental hospital in Riyadh, Saudi Arabia after she was referred from a primary dental care center near her village. The patient was examined, and a full history was taken, the patient was asked about the reason for finally seeking surgical treatment far beyond the optimum time of surgical repair. As the patient was not delivered in a hospital, and then lived with her parents in old town with poor facility, education, and health care. So they were not aware of the possibility of treating her deformity at that time. Besides, there was no medical center near their area, where they can visit and get the proper guidance and management. Thereafter, the patient faced no problems as she was living her normal life, getting married, and having five children. The patient did not obtain a national ID until her husband died. As it was obligatory to have it in order to follow and get the inheritance. For this reason, she decided to seek treatment to get her photo of the national ID with a better appearance.
Upon examination, A bilateral cleft lip (CL) involving the entire thickness of the lip, the right side of the primary alveolus, and the floor of the nose was detected. There was a prominent distortion of the lip and nose, the alae nasi were flared and displaced laterally with flattening of the nose. Moreover, the columella was short, depressed, and displaced to the left side. The premaxilla was protruded with the two central incisors in a deformed condition, rotated and not well aligned. Skeletally, the posterior dental arch was in a good occlusal relationship and the maxilla was within normal skeletal position. No other physical deformity was detected. Upon history taking, the patient’s speech was assessed with no resonance problems were noticed. Also, the patient didn’t complain from difficulty in swallowing or mastication. This patient presented a good opportunity to study a complete bilateral cleft lip deformity in this age group.
The presurgical planning includes informed consent, routine preoperative laboratory tests, chest radiograph, orthopantomography, cephalometry, and pre-operative photography. The patient was then admitted as a day case after she was cleared by the anesthesiologist. Intubation was done smoothly with an oral Ring-Adair-Elwyn ( ((RAE) endotracheal tube and fixed with tape in the center of the lower lip. Surgery started with extraction of the rotated upper incisors which were directly interfering with the procedure. Lip repair was completed using a modified Millard technique, this method was suggested based on its reliability and easy adjustability. The design of the surgical incision was marked ( Fig. 2 ). A local anesthetic (2% Lidocaine with Epinephrine 1:100,000) was injected. The prolabium skin is first incised then elevation of philtral flap with adequate size and thickness. Lateral to this flap, prolabial flaps (fork flaps) were raised to be used for the reconstruction of the nasal floor. Incision of the lateral lip segment with lateral extension made above the vermilion border. Another horizontal incision made bilaterally, the orbicularis oris muscle and transverse part of nasalis muscle were located, dissected then reoriented medially and reconstructed below the prolabium flap. Although the premaxilla was protruded, no vomerine osteotomy was needed to position it back, in fact, manual pressure of the premaxilla and extensive dissection of the muscles and the periosteum was adequate to mold and align the premaxilla with the lateral maxillary segments. The right alveolar cleft was closed primarily by elevation and suturing of the alveolar periosteal flaps in each side of the defect. No open rhinoplasty was performed; However, nasal correction was achieved by first releasing the lower lateral nasal cartilage then medial mobilization of the alar base. Alar synching was also carried out to decrease the width of the nasal floor. The cupid bow was reconstructed by the vermilion and white roll from the mobilized lateral segments. The entire lip repair was achieved by three layers of reconstruction: oral mucosa, muscle, and skin. The nasal floor was also reconstructed using the lateral prolabium and septal mucosal flaps.
