A new technique for perioral muscle reconstruction and lip lengthening in complete unilateral cleft lip

BackgroundAdequate skin lengthening and symmetry may not be consistently obtained in unilateral cleft lip repair, especially in patients with complete cleft. The purpose of this study was to present the model of muscle dissection and approximation to facilitate lip lengthening and symmetry.MethodsThe design followed the rotation-advancement (RA) method without skin measurement. A curvilinear skin incision was made from subnasale to the Cupid's bow peak (CBP). Muscle dissection was continued to the contralateral nostril floor beneath the columellar base to facilitate downward rotation in the medial lip. Wide muscle dissection was performed in the lateral lip segment from the nasal mucosa passing the alar base. The lateral lip muscle was advanced and sutured to the medial lip muscle in a Z-plasty fashion. A small skin backcut was made above the CBP. Primary nasal correction was performed. A series of 138 patients with complete unilateral cleft lip and palate were included in this study. Standard photographs were collected for measurement in the nasolabial region.ResultsAdequate lengthening and symmetry of the lip was obtained. The ratio of vertical philtral height was 0.99±0.05 between the cleft and noncleft sides. The C flap was used for supplementary skin lengthening in 58% of cases. Postoperative lip retraction requiring massage occurred in 13%. Overall nasolabial appearance was satisfactory.ConclusionThe new technique of perioral muscle reconstruction facilitated to obtain lip lengthening and symmetry in the repair of complete unilateral cleft lip.     

早期腭裂修复术后瘘的发生率研究

目的 探讨婴儿期腭裂手术后瘘发生的规律。方法 对1995年7月～2001年9月期间施行的2～12个月龄的531例腭裂修复术后瘘发生率进行回顾性分析。结果 全组腭裂术后瘘发生率为4.9%，双侧完全性腭裂术后瘘发生率（7.8%），明显高于不完全性腭裂（4.4%），单侧完全性腭裂（4.3%,P＜0.01），后两组之间无显著性差别（P＞0.05）；术后瘘发生率与年龄，及本组所采用的不同术式无关（P＞0.05）；其中硬腭部瘘占完全性腭裂术后瘘率70%，较其它部位差异有非常显著性意义（P＜0.01）。结论 婴儿期腭裂手术并不会增加瘘发生率，对于双侧完全性腭裂，推荐做术前正畸治疗。     

Frequency of homologous blood transfusion in patients undergoing cleft lip and palate surgery

Aim:

The study aims to determine the frequency of homologous blood transfusion in patientsundergoing cleft lip and palate surgery at the Lagos University Teaching Hospital, Nigeria.

Setting and Design:

A prospective study of transfusion rate in cleft surgery conducted at the Lagos University Teaching Hospital, Nigeria.

Material and Methods:

One hundred consecutive patients who required cleft lip and palate surgery were recruited into the study. Data collected included age, sex and weight of patients, type of cleft defects, type of surgery done, preoperative haematocrit, duration of surgery, amount of blood loss during surgery, the number of units of blood cross-matched and those used. Each patient was made to donate a unit of homologous blood prior to surgery.

Results:

There were 52 females and 48 males with a mean age of 64.4 ± 101.1 months (range, 3-420 months). The most common cleft defect was isolated cleft palate (45%) followed by unilateral cleft lip (28%). Cleft palate repair was the most common procedure (45%) followed by unilateral cleft lip repair (41%). The mean estimated blood loss was 95.8 ± 144.9 ml (range, 2-800ml). Ten (10%) patients (CL=2; CP=5, BCL=1; CLP=2) were transfused but only two of these were deemed appropriate based on percentage blood volume loss. The mean blood transfused was 131.5 ± 135.4ml (range, 35-500ml). Six (60%) of those transfused had a preoperative PCV of < 30%. Only 4.9% of patients who had unilateral cleft lip surgery were transfused as compared with 50% for CLP surgery, 11% for CP surgery, and 10% for bilateral cleft lip surgery.

Conclusions:

The frequency of blood transfusion in cleft lip and palate surgery was 10% with a cross-match: transfusion ratio of 10 and transfusion index of 0.1. A "type and screen" policy is advocated for cleft lip and palate surgery.     

婴儿期单侧完全性唇腭裂术前正畸治疗的临床研究

目的探讨上颌-鼻软骨整形矫治器在婴儿期单侧完全性唇腭裂术前正畸中的应用与疗效。方法2003年1月~2004年3月,对100例出生后10 d~3个月内单侧完全性唇腭裂婴儿进行上颌-鼻软骨整形矫治器矫治。其中男60例,女40例,健康状况良好。根据矫治起始时间的不同分为观察组(10 d~1个月内)及对照组(1~3个月)各50例,对比两组婴儿正畸治疗前后上唇裂隙、上前牙槽突裂隙关闭程度及唇腭裂联合整复术后3个月鼻翼外观满意度,评价疗效。结果婴儿正畸前后上唇裂隙、上前牙槽突裂隙宽度观察组为5.0±1.6 mm、4.1±2.7 mm,6.9±2.6 mm、6.4±2.9 mm;与对照组7.5±3.1 mm、8.3±3.0 mm,12.5±4.0 mm、10.8±2.6 mm比较,差异均有统计学意义(P<0.05)。两组婴儿正畸前后上唇裂隙、上前牙槽突裂隙宽度自身比较,差异无统计学意义。两组患儿术后鼻翼外观满意度观察组86.3%与对照组62.4%比较,差异有统计学意义(P<0.05)。结论尽早对单侧完全性唇腭裂患儿实施上颌-鼻软骨整形矫治器矫治,可明显改善上颌形态及鼻畸形程度,减小牙槽突裂隙,并有效减小上唇张力,为婴儿期唇腭裂联合手术创造有利条件。     

Speech after repair of isolated cleft palate and cleft lip and palate.

The speech of children with isolated cleft palate (CP) repaired by one surgeon has been compared with the speech of children with some form of unilateral cleft lip and palate (CLP) repaired by the same surgeon. All palate repairs included an intravelar veloplasty. We identified 57 children (5--12 years old) with cleft palates repaired in infancy, of which three patients with other medical problems were excluded. Of the 54 patients, 44 (81%) attended for review (27 CP, 17 CLP). Video recordings were analysed by two speech and language therapists, using the Cleft Audit Protocol for Speech. The CP patients had no evidence of permanent fistulas. Final speech outcomes were similar for CP and CLP patients. Intelligibility was normal in 10 (37%) CP and nine (53%) CLP patients. Mild consistent hypernasality was present in five (18.5%) CP and four (23.5%) CLP patients. No patients had moderate or severe hypernasality or nasal emission. Mild consistent hyponasality was present in five (18.5%) CP and five (29%) CLP patients. Moderate consistent hyponasality was present in one (4%) CP patient. Dysphonia was present in eight (30%) CP and seven (41%) CLP patients. Cleft-type characteristics were noted in 11 (41%) CP and nine (53%) CLP patients. No CLP patients but 10 (37%) CP patients had required a pharyngoplasty (P=0.004, Fisher's exact test). Possible reasons for this (age, cleft type, surgeon and surgery) are discussed.     

Palatal fistulas after primary repair of clefts of the secondary palate

Our aim was to assess whether severity of cleft, age at the time of repair, and the operating surgeon's experience contributed to the development of fistulas in patients with clefts of the secondary palate. We studied 814 children born between 1960 and 1999 with clefts of the secondary palate who had had their primary operation at the Department of Plastic Surgery, Rikshospitalet University Hospital, Oslo, Norway. Data were collected retrospectively from the archives of the Oslo Cleft Team. Palatal fistulas developed in 36 patients (4%), among whom 17 patients required correction (2% of the total). The incidence of fistulas was not related to sex. Patients with clefts of the hard and soft palate developed fistulas more often than patients with clefts of the soft palate only (8% compared with 1%, p<0.001). Patients with submucous cleft palates developed fistulas significantly more often than patients with clefts of the soft palate only (5% compared with 1%, p=0.02). Among patients with clefts of the hard and soft palate, the incidence of fistulas increased significantly with increasing age at the time of palatal closure (p=0.005). The incidence decreased significantly the more experienced the operating surgeon was for treating clefts of the hard and soft palate (p<0.001) but not for submucous clefts. Among patients with clefts of the hard and soft palate who had the palate closed at 14 months of age or later, the incidence of fistulas decreased from 21% when the operating surgeon had little experience to 0 when the surgeon had much experience. The incidence of fistulas was related to severity of cleft, age at palatal closure, and the operating surgeon's experience.     

Closure of large oronasal fistulas at the time of secondary bone grafting in patients with cleft lip and palate

Oronasal fistulas often arise after repair of the palate in patients with cleft lip and palate. Those located adjacent to the residual cleft are commonly closed at the time of secondary bone grafting. However, it is not easy to close larger fistulas. We present a method of closing large oronasal fistulas in the anterior palate that are adjacent to the residual cleft at the time of secondary bone grafting, which consists of reducing the size of the inferior nasal turbinate.     

Closure of large oronasal fistulas at the time of secondary bone grafting in patients with cleft lip and palate.

Oronasal fistulas often arise after repair of the palate in patients with cleft lip and palate. Those located adjacent to the residual cleft are commonly closed at the time of secondary bone grafting. However, it is not easy to close larger fistulas. We present a method of closing large oronasal fistulas in the anterior palate that are adjacent to the residual cleft at the time of secondary bone grafting, which consists of reducing the size of the inferior nasal turbinate.     

Height of the palatal vault after two different surgical procedures: Study of the difference in patients with complete unilateral cleft lip and palate

Abstract

The present study compared the height of the palatal vault in dental casts from 320 10-year-old children with unilateral cleft lip and palate (UCLP) operated on with the push-back technique according to Wardill-Kilner (W-K) with patients operated on with delayed hard palate closure (DHPC). The palatal height in patients operated on with the DHPC technique was found to be significantly higher than in patients operated on with the W-K technique. This coincides with better maxillary growth and better speech in the DHPC group.     

Malnutrition in cleft lip and palate children in Uganda

The objective of this study is to investigate the nutritional status of patients with cleft lip and/or palate when compared to non-cleft lip or palate patients. A retrospective analysis was carried out of all patients aged less than 1 year who were operated on in the Comprehensive Rehabilitation Services in Uganda hospital since opening in April 2009 to November 2010. The data was divided into three groups: cleft lip patients; cleft lip and palate patients and non-cleft patients. The WHO anthropometric calculator was used to calculate weight-for-age Z scores on each patient for the initial outpatient appointment and the operation. The demographic data and Z scores were compared using independent T tests. Three hundred and twenty-one patients were identified, 131 patients had cleft lip alone, 112 patients had cleft lip and palate and 78 patients had no cleft. The cleft lip and palate group had significantly lower Z scores for both the outpatient appointment and operation (i.e. were more malnourished) than either the cleft lip group or the non-cleft group. Malnutrition is a well-documented problem associated with cleft lip and palate. Our research confirms this malnutrition but also highlights the severity of the malnutrition. The patients with cleft lip and palate are unable to feed adequately and therefore need intervention. We operate on these patients once they reach a target weight of 3 kg and repair both lip and palate in one operation to enable patients to feed and improve their nutritional status.     

Open tip rhinoplasty along with the repair of cleft lip in cleft lip and palate cases.

This paper is a report on a procedure to perform open tip rhinoplasty at the time of lip repair in unilateral and bilateral cleft lip and palate deformity. A total of 69 patients who had this operation between 1994 and 1997 have been reviewed. Conventionally there is hesitation to do radical nasal correction for the cleft lip patient because of the fear of possible growth retardation. The present technique, while it achieves excellent postoperative results constantly, does not entail any more trauma to the cartilage complex than any of the conventional closed rhinoplasty techniques. Early results obtained by this method appear to be superior to those by closed rhinoplasty techniques.     

Repair of the unilateral cleft lip/nose deformity

Successful surgical repair of the unilateral cleft lip and nose deformity, defined as normal orbicularis oris function and near-perfect symmetry of the repaired lip and nose, demands that the surgeon possess complete understanding of the embryology and anatomy of the midfacial defects. The surgical approach to repair of the unilateral cleft lip/nose should place great emphasis on achieving symmetry, not only with the lip segments but also perhaps even more importantly with the nasal tip. The reconstruction should recreate an intact fully functional orbicularis oris muscle across the cleft and camouflage the scar optimally. We have found that modification of the Millard rotation-advancement flap technique, with particular attention to the primary nasal repair, provides the best outcomes. In patients who have undergone primary repair of the lip and/or nose deformity, secondary rhinoplasty is generally required, regardless of the technique used at the primary repair. The degree of nasal deformity, however, is less severe following primary repair of the asymmetric nasal tip. We have found that the sliding flap cheliorhinoplasty, Wang's modification of the Vissarionov technique, provides excellent results for most secondary cleft rhinoplasties.     

Surgical Treatment Of Cleft Palate

Abstract

During the period 1958–1985, 230 patients with cleft palate were operated on in the Department of Plastic Surgery, University of Göteborg, Sweden. A modified push-back technique according to Wardill and Kilner was used. The children were operated on at a mean age of 13 months. They were divided into two groups, the first in which the cleft affected the velum only (n = 121) and the other in which it also affected the hard palate (n=109). Postoperative dehiscences and fistulas occurred in 19 (8%) patients, of which 16 (15%) belonged to the group in which the cleft affected the hard palate. Only three (2%) of the 121 patients with a cleft in the soft palate only developed dehiscences. The total number of patients who had to be reoperated on because of dehiscences were 10 (4%) and palatopharyngeal flaps had to be performed in 25 patients (11%) because of speech problems.     

Current status of presurgical infant orthopaedic treatment for cleft lip and palate patients: A critical review

Rehabilitation of cleft lip and palate (CLP) patients is a challenge for all the concerned members of the cleft team, and various treatment modalities have been attempted to obtain aesthetic results. Presurgical infant orthopaedics (PSIO) was introduced to reshape alveolar and nasal segments prior to surgical repair of cleft lip. However, literature reports lot of controversy regarding the use of PSIO in patients with CLP. Evaluation of long-term results of PSIO can provide scientific evidence on the efficacy and usefulness of PSIO in CLP patients. The aim was to assess the scientific evidence on the efficiency of PSIO appliances in patients with CLP and to critically analyse the current status of PSIO. A PubMed search was performed using the terms PSIO, presurgical nasoalveolar moulding and its long-term results and related articles were selected for the review. The documented studies report no beneficial effect of PSIO on maxillary arch dimensions, facial aesthetics and in the subsequent development of dentition and occlusion in CLP patients. Nasal moulding seems to be more beneficial and effective in unilateral cleft lip and palate patients with better long-term results.KEY WORDS: Bilateral cleft lip and palate, long-term results, nasoalveolar moulding, presurgical infant orthopaedics, unilateral cleft lip and palate     

Palatal Fistulae Following Cleft Palate Surgery

The occurrence and treatment of palatal fistulae have been studied in 1108 CLP patients who had their primary operations performed during the years 1954–69. No fistulae were recorded in 263 patients with incomplete cleft of the primary palate only. These patients were excluded, leaving 845 patients for analysis. The Le Mesurier or Millard technique had been used for the primary lip operation, and the von Langenbeck procedure for closure of the palate; in complete clefts, the anterior part of the palate had been closed using Veau's vomer flap operation simultaneously with lip closure. The observation period ranged from 7 to 22 years, during which time each patient was examined at least once and the majority on several occasions by members of the cleft palate team. The overall incidence of fistulae was 18%. Fistulae were recorded in 11.3% of all complete clefts of the primary palate, and in 36.1% of all complete total clefts. In cases of cleft palate only, fistulae were found in 3.5% of the incomplete clefts, and in 20% of the complete clefts. In patients with bilateral complete clefts, closure of both sides of the lip and anterior palate in one operation seemed to have greatly increased the risk of fistula formation. There was a much higher incidence of fistulae in patients operated on during the years 1954–61 than in those treated in the period 1962–69. Fistula symptoms requiring surgical intervention were recorded in 113 patients. Closure of the fistula was achieved in 84.1%. Of 18 patients with a residual fistula. 17 were asymptomatic or had symptoms so slight that they were considered insignificant and not justifying operation.     

鼻黏膜软骨瓣Z成形术修复单侧唇裂继发严重鼻畸形

目的 探讨一种单侧完全性唇裂继发严重鼻畸形的修复方法.方法 根据健侧鼻翼饱满度,于患侧鼻翼凹陷区做Z成形术设计,形成上下两鼻翼黏软骨瓣,通过交错换位,整体延长了短缩的患侧鼻翼软骨瓣的长度,再将重组的患侧鼻翼与健侧悬吊,恢复患侧鼻翼正常的解剖形态,以达到鼻畸形修复的目的.结果 12例单侧唇裂继发严重鼻畸形的患者术后两侧鼻翼饱满、对称,两侧鼻孔形态接近,外形满意.结论 患侧鼻翼黏膜软骨瓣Z成形术,对于修复严重的单侧完全性唇裂继发鼻畸形是一种良好的术式选择.     

三维扫描技术对单侧完全性唇裂同期鼻整形并行鼻撑矫形的效果分析

目的：观察单侧完全性唇裂（unilateral complete cleft lip,UCCP）同期鼻整形联合硅橡胶鼻撑或鼻模（Nasal Split,NS）矫形的临床效果,为单侧完全性唇裂同期鼻整形联合硅橡胶鼻撑矫形的可行性提供临床依据。方法：选取2007年1月～2008年2月我院手术治疗单侧完全性唇裂患儿72例,根据有无同期进行鼻整形联合硅橡胶鼻撑矫形分为实验组（同期鼻整形联合硅橡胶鼻撑矫形）及对照组（未行同期鼻整形联合硅橡胶鼻撑矫形）,每组36例,利用三维扫描仪（Three Dimensional Sensing System,3DSS）,对每组患儿进行面部可见光三维扫描采集鼻部形态数据,进行统计学分析。结果：两组在鼻翼长度、鼻基部长度、鼻孔高度、鼻孔宽度、鼻尖偏斜度方面具有明显统计学差异性,而在鼻偏曲度、鼻翼口角距、鼻翼唇峰距方面无明显统计学差异。结论：实验组与对照组在鼻翼长度、鼻基部长度、鼻孔高度、鼻孔宽度、鼻尖偏斜度方面的改善上明显优于对照组,单侧完全性唇裂同期鼻整形联合硅橡胶鼻撑矫形的方法能够减轻继发鼻畸形的程度,为鼻畸形二期整复创造条件。     

Septopalatal Protraction for Correction of Nasal Septal Deformity in Cleft Palate Infants

OBJECTIVE: It is proposed to test the practicality of septopalatal protraction in the unilateral cleft palate infant for purposes of straightening the nasal septum and thus relieving nasal airflow obstruction and its detrimental sequelae. METHODS: Alternate infants affected with complete unilateral palatal clefts had septopalatal protraction for a period of 6 to 8 weeks (protraction group; n = 4). Septal deviation was measured by a standardized technique that used computed tomography scans. The remaining infants had no protraction and served as controls (nonprotraction group; n = 5). Septal deviation was measured in the nonprotraction group from palatoseptal dental molds. RESULTS: A total of 9 patients were studied. All patients in the nonprotraction group had worsening of nasal septal deviation over a period of 8 weeks compared with the protraction group, which had complete nasal septal straightening. Differences in septal angle deviation between the protraction group and nonprotraction group at the end of the study were statistically significant (P < or = 0.01) as measured by the paired Student t test. CONCLUSIONS: Septopalatal protraction in the newborn appears to provide a means for correcting nasal septal deviation in complete unilateral cleft palate infants. Septopalatal protraction in the newborn is relatively easy and safe.     

Difficult laryngoscopy in cleft lip and palate surgery

We studied prospectively 800 paediatric patients undergoing repair of cleft lip and palate to determine the predictors of difficult laryngoscopy. The incidence of difficult laryngoscopy (Cormack and Lehane grade III and IV) was 2.95% in patients with unilateral cleft lip, 45.76% in bilateral cleft lip and 34.61% in patients with retrognathia. Tracheal intubation was successful in 99% of patients in whom laryngoscopy was difficult. There was a significant association between age and laryngoscopic view (P < 0.01).      

单侧唇裂手术前后唇鼻部外观变化的数据分析

目的获得单侧唇裂患儿术前唇鼻形态的数据资料,根据唇鼻畸形特征设计手术修复方案,通过术后临床观察,评价手术效果。方法单侧唇裂患儿85例,分为单侧完全性唇裂组、单侧不完全性唇裂组。术前、术后6个月分别测量裂隙两侧唇长、唇高、人中嵴高度、鼻底宽度和鼻小柱高度,采用配对t检验来比较各组患儿裂隙两侧测量值的差异。结果单侧唇裂患儿术前裂隙两侧唇鼻部各项参数均有统计学意义（P〈0．01）;短期术后随访表明,两组1岁以内患儿在健一患侧唇长和鼻底宽度方面具有统计学意义（P〈0．01）,裂隙侧唇长较健侧小,鼻底宽度较健侧大。完全性唇裂组患儿术后半年患侧鼻小柱高度小于健侧。1～2岁患儿在健一患侧唇长、唇高、人中嵴高度、鼻底宽度和鼻小柱高度方面差异无统计学意义。结论测量单侧唇裂患儿唇长、唇高、鼻底宽度、鼻小柱高度和人中嵴高度,对术前手术设计和术后对称性评估有很大的帮助。短期随访表明,1岁以内单侧唇裂患儿患侧唇长变短,鼻底增宽,在今后的唇裂修复中,需要通过改进手术方法来解决。