The role of primary surgery in the management of orofacial clefting

Primary cleft surgery refers to the planned surgical procedure(s) necessary to reconstruct an orofacial defect according to a specified protocol; in the context of a unilateral cleft lip and palate, this would include lip repair (with vomer flap closure of the hard palate), subsequent repair of the residual soft palate cleft and finally, the alveolar bone graft. This paper will provide an overview of the goals of primary surgical reconstruction, including the utility of pre-surgical orthopaedic techniques, including nasoalveolar moulding. The surgical methods of primary lip repair in both unilateral and bilateral clefts will be outlined and the concept of a primary rhinoplasty will be introduced. The principal techniques of cleft palate reconstruction will be delineated for a variety of cleft phenotypes. The final element of the primary reconstructive sequence is the alveolar bone graft using cancellous bone harvested from the iliac crest at approximately 8-10 years of age. The role of optimising oral hygiene prior to bone grafting cannot be over-emphasised and the utility of pre-surgical orthodontic arch expansion is also discussed. In the UK, bone graft outcomes are audited using the Kindelan score, which is evaluated from the six-month postoperative upper standard occlusal radiograph. Key points This paper covers the goals of primary cleft surgery, including the role of pre-surgical orthopaedics and nasoalveolar moulding. Outlines the reconstructive options for a patient with a unilateral cleft lip and/or palate, including contemporary cleft lip repair techniques, vomerine flap closure of the hard palate, and the importance of alveolar bone grafting. Discusses the primary surgery options for a patient with a bilateral cleft lip and/or palate, and summarises the methods of bilateral cleft lip repair.