华西Sommerlad-Furlow腭裂修复术后腭瘘率的研究

目的 探索华西Sommerlad-Furlow （SF）腭裂修复术后的腭瘘发生率及影响因素。方法 随访四川大学华西口腔医院唇腭裂外科2017年4—12月的385例一期腭裂病例,观察华西SF腭裂修复术后的腭瘘率,并分析可能影响伤口愈合的因素,包括性别、体重、手术年龄、裂隙类型、手术医生资历、术前白细胞计数、术前是否预防性使用抗生素、术后体温。结果 采用华西SF腭裂修复术的总瘘孔率为3.9%（15/385）;在15例腭瘘患者中,1例瘘孔位于牙槽近硬腭,12例位于硬腭,2例位于硬软腭交界。腭瘘的发生与性别、体重、手术年龄、术前是否预防性使用抗生素、术前白细胞计数、术后体温均无关（P>0.05）。在手术医生资历这一影响因素中,正高级职称（3.03%）与副高级职称（2.23%）的瘘孔率之间的差异无统计学意义（P>0.05）,但中级职称的瘘孔率为14.29%,明显高于正高级职称和副高级职称（P<0.05）。双侧完全性腭裂的瘘孔率（20.6%）大于单侧完全性腭裂（3.6%）及硬软腭裂（2.6%）（P<0.05）。结论 华西SF腭裂修复术不做松弛切口,可避免上颌骨的生长抑制,同时并未增加腭裂术后的瘘孔率,其瘘孔发生率与患儿性别、体重、手术年龄、术前是否预防性使用抗生素、术前感染、术后体温等因素关联不大,与术者的年资和腭裂的不同类型有一定相关性。     

Fat grafting in patients with cleft lip and palate: A systematic review

This systematic review aims to compare different fat-grafting techniques for cleft lip and palate repair. A search was conducted in PubMed, Embase, Cochrane Library, gray literature and reference lists of selected articles. A total of 25 articles were included, 12 on closure of palatal fistula and 13 on cleft lip repair. The rate of complete resolution of palatal fistula ranged from 88.6% to 100% in studies with no control group, whereas in comparative studies patients receiving a fat graft showed better outcomes than those not receiving a graft. Evidence suggests that fat grafting can be indicated for the primary and secondary repair of cleft palate, with good results. The use of dermis-fat grafts in lip repair was associated with gains in surface area (11.5%), vertical height (18.5%–27.11%), and lip projection (20%). Fat infiltration was associated with increased lip volume (6.5%), vermilion show (31.68% ± 24.03%), and lip projection (46.71% ± 31.3%). The available literature suggests that fat grafting is a promising autogenous option for palate and fistula repair and for improvement of lip projection and scar aesthetics in patients with cleft. However, to develop a guideline, further studies are needed to confirm whether one technique is superior to the other.     

The buccal flap--a useful technique in cleft palate repair?

OBJECTIVE: To evaluate speech quality and oronasal fistula after primary palate repair using a buccal mucosal flap. DESIGN: Retrospective study cohort of patients with cleft palate. SETTING: Primary care center for treatment of craniofacial congenital anomalies. PATIENTS AND METHODS: One hundred fifty-six nonsyndromic patients underwent palatoplasty with the buccal myomucosal flap by the senior surgeon between 1989 and 2002. The preoperative workup, surgical technique, and other factors that might affect the outcome were identical in every case. Oronasal fistula and variables affecting speech quality were analyzed. RESULTS: The most common type of cleft was unilateral cleft lip and palate (43.5%). The median follow-up was 5.8 years (0.4 to 21 years), and the median age at repair was 6.2 months. The overall fistula formation was 3.6%, decreasing progressively: 1989 to 1994: 2.9%, 1995 to 2002: 0.7% (p <.05). Velopharyngeal incompetence (VPI) occurred in 8.8% of the patients, decreasing from 5.3% to 3.5% in the last years. VPI and oronasal fistulae were observed mainly in unilateral and bilateral clefts of the lip and palate. Velopharyngeal adequacy occurred in 91.1% of the children, and resonance was normal in 91.1 %. None of the patients had severe hypernasality or hyponasality. Articulation was normal in 97.9% of the children. Speech quality was good in 89% of the patients. CONCLUSIONS: The technique presented has been effective, with the advantages of palatal closure without tension, good muscular reconstruction, lengthening of the nasal layer, and palatal closure without raw areas. The technique, early repair, and surgeon's skills were the most important variables for good outcomes regarding speech and fistula formation.     

Primary repair of the alveolar cleft

Nasoalveolar fistula and oropharyngeal fistula of the anterior palatal region are very commonly seen in cases when there are concomitant clefts of the lip and the palate. Absence of adequate tissue in that region complicates the treatment and necessitates new tissue transfers from near or distant tissues. Today, the techniques used for correcting cleft lip cannot successfully solve these 2 problems. In this study, we describe a technique that depends on the principle of using the lip mucosal tissues that remains during the Tennison cleft lip correction technique, with a flap designation, to correct the tissue defect of the cleft between the foramen incisivum and lip and the alveolar region. Twenty-two patients (13 boys and 9 girls), with ages ranging from 3 to 53 months (mean, 24 mo), with unilateral cleft lip and palate underwent surgery with this new technique. In all these patients, clefts in the anterior palatal and alveolar regions were successfully corrected. Fistula was observed in none of these patients in these regions. Through this method, clefts in the anterior palatal and alveolar regions can be corrected during repair of cleft lips.     

The incidence and relationship of cervical spine anomalies in patients with cleft lip and/or palate

The relationship, incidence, and distribution of cervical spine anomalies were assessed in 468 patients with cleft lip and/or palate. The patients were placed into four groups: lip and/or alveolar; complete unilateral or bilateral; isolated palatal; and soft palate or submucous clefts. Cervical anomalies were observed in 22% of the cleft patients and in 7% of the noncleft group. Patients with soft palate and submucous clefts had the highest incidence of vertebral anomalies (45%), whereas patients with cleft lip and/or alveolus had an incidence similar to the noncleft group. Patients with complete unilateral and bilateral clefts also had a higher incidence (15.6% to 19.0%) of anomalies than the noncleft group. Cervical anomalies occurred primarily in the occipital-C1-C2 region. The possible implications of these findings are discussed.     

Evaluation of fistula rates in three cleft palate techniques without relaxing incisions

The aim of the present study was to investigate the incidence of postoperative fistula formation from a hybrid cleft palate repair compared to that from two well-established techniques.We performed a modified technique, Sommerlad-Furlow (SF), which combined the repositioning of the levator veli palatini muscles as described by Sommerlad with the double opposing Z-plasty of Furlow to lengthen the soft palate. A retrospective cohort study was conducted to evaluate patients who underwent cleft palate repair utilizing SF, Sommerlad, or Furlow techniques with the incidence of palatal fistula as the target endpoint.A total of 1,164 patients were included in the present study and underwent the following techniques: 603 cases with SF, 244 cases with Furlow, and 317 cases with Sommerlad. In addition to not requiring relaxing incisions, SF advantages included a consistently lower fistula rate compared to that of the Sommerlad technique, as well as the lowest fistula rate in patients with both hard and soft palate clefts without a cleft lip (OR:2.62 95% CI: 1.35, 5.09). However, the differences among the three techniques did not reach statistical significance in terms of a bilateral or unilateral cleft lip/palate, or in patients with a soft palate only or a submucosal cleft palate(OR: 2.22,95% CI:0.77, 6.37).Based on the results of our study, the Somerlad-Furlow technique should be preferred whenever possible.     

Speech outcome in complete unilateral cleft lip and palate – a comparison of three methods of the hard palate closure

The aim of this study was to compare the speech in subjects with cleft lip and palate, in whom three methods of the hard palate closure were used. One hundred and thirty‐seven children (96 boys, 41 girls; mean age = 12 years, SD = 1·2) with complete unilateral cleft lip and palate (CUCLP) operated by a single surgeon with a one‐stage method were evaluated. The management of the cleft lip and soft palate was comparable in all subjects; for hard palate repair, three different methods were used: bilateral von Langenbeck closure (b‐vL group, n = 39), unilateral von Langenbeck closure (u‐vL group, n = 56) and vomerplasty (v‐p group, n = 42). Speech was assessed: (i) perceptually for the presence of a) hypernasality, b) compensatory articulations (CAs), c) audible nasal air emissions (ANE) and d) speech intelligibility; (ii) for the presence of compensatory facial grimacing, (iii) with clinical intra‐oral evaluation and (iv) with videonasendoscopy. A total rate of hypernasality requiring pharyngoplasty was 5·1%; total incidence post‐oral compensatory articulations (CAs) was 2·2%. The overall speech intelligibility was good in 84·7% of cases. Oronasal fistulas (ONFs) occurred in 15·7% b‐vL subjects, 7·1% u‐vL subjects and 50% v‐p subjects (P < 0·001). No statistically significant intergroup differences for hypernasality, CAs and intelligibility were found (P > 0·1). In conclusion, the speech after early one‐stage repair of CUCLP was satisfactory. The method of hard palate repair affected the incidence of ONFs, which, however, caused relatively mild and inconsistent speech errors.     

Craniofacial morphological outcome following treatment with three different surgical protocols for complete unilateral cleft lip and palate: a premilinary study

This study compared craniofacial morphology between three groups of children with complete unilateral cleft lip and palate, treated with different surgical protocols. The study included 66 10-year-old children (42 boys and 20 girls) with a complete unilateral cleft lip and palate (22 patients in each of the three groups). Children aged 7 months underwent one-stage surgery, performed by a single surgeon. During surgery, the soft and hard palate and the lip underwent correction. The difference between the groups depended on the hard palate closure. Group I patients had the mucoperiosteal flap elevated on both sides of the cleft. Group II patients had the mucoperiosteal flap elevated on the non-cleft side, and had only a minimal 2–3 mm mucoperiosteal flap elevated on the cleft side. Group III patients had mucoperiostium elevated from the septum vomer to create a single-layered caudally pedicled flap, and had only a minimal 2–3 mm palatal flap elevated on the cleft side. Craniofacial morphology was defined using lateral cephalometric analysis. Significant craniofacial morphological differences were identified between groups I, II and III. Group III demonstrated the most favourable morphology. This indicates that the technique of hard palate closure has significant influence on craniofacial growth and development.     

腭裂术后复裂、穿孔72例手术治疗

目的:探讨腭裂术后复裂、穿孔的手术修复方法。方法:对13例患者行直接剖开缝合;20例患者行两侧松弛切口,剖开裂隙缝合;19例患者施行转瓣手术;20例患者接受了两瓣法腭裂修复术。结果:随访4～6周后,除3例患者于原位出现复裂,其余伤口均愈合良好。结论:除腭垂部及部分软腭部小的穿孔外,多不主张直接缝合,尤其是硬腭部的穿孔多用转瓣及两瓣腭裂修复术,无张力及充分的组织瓣覆盖是保证手术成功的必要条件。     

腭裂伤口延迟愈合规律的初期研究

目的研究腭裂术后伤口延迟愈合的变化规律。 方法2017年4月至2019年12月在四川大学华西口腔医院唇腭裂外科行一期腭裂整复术,并且术后发生伤口延迟愈合的患者150例,分析腭裂伤口在延迟愈合的情况下,术后6个月内延迟愈合的变化规律及其影响因素。 结果当伤口延迟愈合的部位分别发生在硬腭、硬软腭交界和软腭时,其最终形成的腭瘘分别占各部位延迟愈合总病例数的38.1%、9.8%和6.7%,差异有统计学意义（χ² = 52.962,P<0.001）。当伤口延迟愈合的伤口面积分别为≤0.5 cm²、>0.5~≤1.0 cm²、>1.0~≤1.5 cm²和>1.5 cm²时,其最终形成的腭瘘分别占各伤口面积总病例数的5.6%、14.8%、35.8%和44.9%,差异有统计学意义（χ² = 28.068,P<0.001）。其余相关影响因素如年龄、性别、腭裂类型等,差异均无统计学意义。 结论腭裂术后出现延迟愈合的伤口,其最终是否形成腭瘘受伤口发生部位及伤口大小影响。     

Occurrence of oronasal fistulas in operated cleft palate patients

Oronasal fistulas, a troublesome complication, often occur after cleft palate repair. Seventy-three patients in a series of 346 cases of cleft palate (21%) were found to have fistulas, most located at the junction of hard and soft palate (42%). Langenbeck's method of cleft palate repair resulted in more fistulas than Wardill's method. Fistulas occurred more frequently in bilateral clefts than in the unilateral type. Nasality was found to be the most common symptom in patients with oronasal fistulas. No treatment was needed for 17 patients, 10 were given obturators, and surgical repair was performed in 46. Treatment was totally successful in 56% of the patients and partially so in 34%.     

Investigations on the Palatal Rugae Pattern in Cleft Patients

The characteristics of the palatal rugae zone (number of rugae, relief type, posterior limitation) were investigated on the maxillary casts of 44 patients with unilateral cleft lip and palate and 28 patients with bilateral clefts by means of reflex microscopy, a three-dimensional, computer-assisted, touch-free measuring system for the metrical registration and analysis of the parameters directly on the maxillary casts for the segments of the 2 cleft groups. The features "number of palatal rugae" and "relief type" (primary rugae) were determined both before and after surgical repair of the cleft palate. Both segments in unilateral cleft lip and palate and both lateral segments in bilateral clefts most commonly had 4 to 5 palatal rugae. The number of rugae in cleft patients is thus in a range that other authors have reported for non-cleft individuals. Following palatal cleft repair, the rugae counts per segment decreased significantly in patients with unilateral and bilateral cleft lip and palate but the 3rd rugae was never lost after surgery. The relief type identified in unilateral and bilateral cleft lip and palate was the same as in isolated cleft palates and did not differ from that in non-cleft subjects. The posterior limitation of the palatal rugae zone was determined both in a tooth-defined manner and as an absolute linear distance (at all time points). The most frequent tooth-defined posterior limitation of the rugae zone in unilateral and bilateral clefts was the second deciduous molar, which is also the position identified for non-cleft individuals. The linear distance from the tuberosity line to the rugae zone increased in all segments of unilateral and bilateral clefts during the interval up to palatal cleft repair, indicating sagittal maxillary development in the posterior area of the palate. Surgical repair of the cleft palate resulted in a significant shortening of the distance in both segments of the unilateral cleft, most likely due to the displacement of mucosa and periosteum required to cover the palatal cleft.     

Dental arch relationships following palatoplasty for cleft lip and palate repair

Palatal scarring is assumed to be a primary cause of facial growth derangement in cleft lip and palate. Evidence supporting this hypothesis is confounded by the clinical involvement of various surgeons, and therefore definitive conclusions are not possible. In this study, we investigated the dental arch relationship in two groups, Exposed (47 children; 11.2 yrs) and Unexposed (61 children; 11.2 yrs), with a unilateral cleft lip and palate operated on by the same surgeon. The technique of hard palate repair differed between the two groups. In the Exposed group, palatal bone of the non-cleft side only was left denuded, inducing scar formation. In the Unexposed group, a vomerplasty with tight closure of the soft tissues was applied. Three raters graded the dental arch relationship and palatal morphology using the EUROCRAN Index. The dental arch relationship in the Exposed group was less favorable than in the Unexposed group (p = 0.009). Palatal morphology in both groups was comparable (p = 0.323). This study demonstrates that reduction of denuded bony areas on the palate after palatal repair with a vomer flap had a favorable effect on the dental arch relationship. For palatal morphology, no effect of the type of palatal repair was found.     

Development of the residual cleft in the hard palate after velar repair in a 2-stage palatal repair regimen

Delayed closure of the hard palate is believed to improve maxillary growth and facial appearance in cleft lip and palate patients. However, the cleft opening in the hard palate after velar closure might impair speech development. The aim of this investigation was to study the development of the residual cleft in the hard palate after 2-stage palatal repair (TSPR) in children born with complete cleft lip and palate (bilateral [BCLP]; n=7 or unilateral [UCLP]; n=22) or isolated cleft palate (CP; n=9). Moreover, we aimed to investigate whether any morphologic factors before surgery might predict development of the residual cleft. Dental casts obtained prior to velar repair (mean age 7 months) and postoperatively at 1 1/2, 3, 4, 5 and 7 years were analyzed with a Reflex Microscope regarding the width, length and area of the cleft in the hard palate.The palatal cleft varied in size both pre- and postoperatively in all 3 types of cleft patients. The width of the cleft in the UCLP subgroup showed a marked reduction immediately after velar repair, but then, on average, remained stable until final surgical closure of the hard palate. In the BCLP subgroup the initially rather narrow width of the clefts remained unchanged postoperatively. Clefts in the CP subgroup, especially in those with a complete cleft, remained large after veloplasty. In 4 of the UCLP and 2 of the BCLP patients, the cleft width increased gradually. In some other subjects, both in the UCLP and BCLP subgroups, the residual cleft closed functionally with time, but this development could not be foreseen.     

The Furlow Z-plasty in two-staged palatal repair modifications and complications

OBJECTIVES: To report the modifications and complications of the Furlow palatoplasty for two-stage closure of the palate. PATIENTS AND METHODS: Prospective study of a consecutive series of 45 primary closures of the soft palate portion of clefts extending into the hard palate; mean (S.D.) age at repair 12 (2) months; median follow-up 4 years 4 months (range 2 months to 9 years). The hard palatal part of the cleft was closed in 18 patients at the mean age of 3 years 11 months. RESULTS: The main modifications that we made were the use of quilting sutures, lateral V-Y closures, and fibrin glue application, and the omission of lateral releasing incisions. Patients stayed in hospital for a median of 4 days (range 3-8 days). Two patients had postoperative partial obstruction of the airway and were given steroids. In six patients, a smaller portion of the oral layer of the wound broke down; it healed by secondary intention in five, but resulted in partial dehiscence in one. There were no oronasal fistulas in the 18 patients who had delayed closure of the hard palate part of the cleft. Secondary pharyngoplasty was not necessary in any patient. CONCLUSION: Furlow's technique has been modified for use in the two-stage closure of complete cleft palates (with or without cleft lip or alveolus) with an acceptable rate of complications.     

Evidence for cleft palate as a postfusion phenomenon

Some clefts of the lip and palate appear to result from the rupture after fusion has occurred. This possibility is suggested by (1) epithelial remnants found in the palatal shelves, (2) regenerating epithelium found in the palatal clefts of human fetuses older than 13 weeks, (3) immature epithelium visible on the margin of the cleft, (4) nasopalatine ducts cut off by clefts, (5) perforation type cleft found in the hard palate, (6) a Simonart band visible in six cleft mouse fetuses, (7) duplicated upper lateral incisors enclosing a lip-jaw cleft, and (8) rodent cavities in the lip or palate related to cleft formation.     

A salvage procedure in cleft palate repair: suturing nasal mucosa directly to palatine process.

OBJECTIVE: Palatal fistulas are among the complications of cleft palate repair requiring additional surgery. Suturing the nasal mucosa and mucoperiosteal flaps together in a tension-free manner to create a double-layered closure in the hard palate is one of the most important points in prevention of dehiscence and fistula formation. In this report, we describe a salvage procedure to repair nasal mucosa that might be lacerated while being freed from the upper surface of the palatal process. METHOD: To restore the nasal lining, an ipsilateral vomer mucoperiosteal flap or the opposite nasal mucosa flap is advanced to the palatine bone and sutured directly to the palatal process in order to guarantee an intact cleft palate repair. RESULTS: This method is an easy, simple, and time-saving procedure. It should be a useful addition to the armamentarium of every plastic surgeon, especially those working as consultants in training units.     

Speech outcomes of early palatal repair with or without intravelar veloplasty in children with complete unilateral cleft lip and palate

We compared the early speech outcomes of 40 consecutive children with complete unilateral cleft lip and palate (UCLP) who had been treated according to different 2-stage protocols: the Malek protocol (soft palate closure without intravelar veloplasty at 3 months; lip and hard palate repair at 6 months) (n = 20), and the Talmant protocol (cheilorhinoplasty and soft palate repair with intravelar veloplasty at 6 months; hard palate closure at 18 months) (n = 20). We compared the speech assessments obtained at a mean (SD) age of 3.3 (0.35) years after treatment by the same surgeon. The main outcome measures evaluated were acquisition and intelligibility of speech, velopharyngeal insufficiency, and incidence of complications. A delay in speech articulation of one year or more was seen more often in patients treated by the Malek protocol (11/20) than in those treated according to the Talmant protocol (3/20, p = 0.019). Good intelligibility was noted in 15/20 in the Talmant group compared with 6/20 in the Malek group (p = 0.010). Assessment with an aerophonoscope showed that nasal air emission was most pronounced in patients in the Malek group (p = 0.007). Velopharyngeal insufficiency was present in 11/20 in the Malek group, and in 3/20 in the Talmant group (p = 0.019). No patients in the Talmant group had an oronasal fistula (p < 0.001). All other outcomes were similar. Despite later closure of the soft and hard palate, early speech outcomes were better in the Talmant group because intravelar veloplasty was successful and there were no fistulas after closure of the hard palate in 2 layers.     

单侧唇腭裂鼻-牙槽骨塑形后同期唇-鼻-牙槽骨整复术

目的:探讨唇腭裂婴幼儿术前鼻-牙槽骨塑形后的同期唇-鼻-牙槽骨整复术的方法与技术,并进行初步疗效评价。方法:对31例单侧完全性唇腭裂婴幼儿进行术前鼻-牙槽骨塑形及同期唇-鼻-牙槽骨整复术。术前鼻-牙槽骨塑形主要包括关闭牙槽骨间隙、唇牵张及鼻矫形;早期同期唇-鼻-牙槽骨整复术,即牙龈-牙周膜-牙槽骨整形术和改良Mohler法单侧唇裂唇鼻畸形同期整复术。采用SPSS10.0统计软件包对所得数据进行t检验。结果:31例唇腭裂婴幼儿经2～3个月术前鼻-牙槽骨塑形,唇裂隙宽度显著变窄(P<0.01),裂隙两侧唇组织适度牵张;鼻小柱延长及鼻塌陷畸形显著改善(P<0.05);牙槽裂隙显著变窄(P<0.01)。术后2例失访,29例患者随访6～30个月,结果显示:上唇和鼻形态俱佳,鼻小柱端正,鼻尖形态改善,双鼻孔、鼻底堤状隆起对称;口腔前庭-鼻腔瘘封闭;27例患者牙槽突裂隙关闭,牙槽骨连续性及稳定性增强并在原牙槽裂隙处有牙萌出,其中13例牙槽嵴高度、宽度及厚度不足;2例仍有1～2mm的牙槽裂隙。结论:单侧完全性唇腭裂患者为了获得理想的唇鼻形态及完整稳定的牙槽骨,术前进行鼻-牙槽骨塑形和同期唇-鼻-牙槽骨整复术是值得采用的序列治疗方法。