PubMed · 11379561
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L T Furlow. 2001-04-15. Cleft surgery in developing nations.. https://doi.org/10.1097/00006534-200104150-00054
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LEARNING OBJECTIVES: After studying this article, the practitioner should be able to (1) describe the common secondary deformities of the cleft lip, (2) determine the appropriate timing for surgical intervention to correct the deformities, and (3) determine the best method of addressing each of the individual secondary deformities of the cleft lip. Secondary deformities are common in children born with a cleft lip and palate. Patients with cleft lip deformity will undergo multiple surgical procedures early in life, so it is imperative to prioritize treatment of their secondary deformities and minimize the number of interventions needed. Of the many approaches used to correct these problems, surprisingly few work well consistently. As with all plastic surgery, the timing and procedure should be predicated on the severity of the deformity.
BACKGROUND: Fetal surgery is defined as prenatal surgical intervention. Such intervention is currently considered in selected cases of fetal malformations that endanger the child's life prenatally or postnatally, such as death or severe impairment. METHODS: Current indications are reviewed, with special emphasis on success rates and complications, including concomitant ethical problems. Data sources are based on personal experience and medical information systems (especially MEDLINE). RESULTS AND CONCLUSIONS: In the head and neck areas, especially the upper respiratory tract, such procedures can be indicated in selected cases. They include exposure and temporary obstruction of the fetal trachea to reduce the viscera and to prevent pulmonary hypoplasia in congenital diaphragmatic hernia, prenatal tracheotomy in laryngeal atresia, and intranatal establishment of an airway in airway-obstructing embryonic tumors. The latter surgery can be performed after delivery of the fetal head and neck and before umbilical cord severance. This method ensures oxygenation of the fetus by the maternofetal circulation until completion of the surgical intervention (so called EXIT procedure = Ex-Utero Intrapartum Treatment). The relatively high surgical risk of fetal surgery, in particular postoperative preterm labor, may be reduced by the use of minimally invasive endoscopic techniques. By reducing operative risks even further, prenatal surgical interventions may even be used in nonlethal conditions. Consequently, more diseases of the head and neck area could thus be included in the spectrum of indications, such as prenatal correction of the cleft lip palate. Because fetal wound healing incurs no scarring up to a certain stage in pregnancy, such fetal surgical correction could be a perspective.
PATIENTS AND METHOD: Clinically discernible vertical deviations of the cleft segments in nasal direction were registered and visualized using model series of 16 patients with unilateral cleft lip and palate. All patients were treated according to the cleft concept of the University of Leipzig, with labioplasty being performed at the age of 4-6 months and palatoplasty at the age of 10-14 months. All patients had a modified Hotz plate inserted until the palate was closed. Casts of a collective of non-cleft infants served as controls. The vertical deviations of the segments from the reference plane, defined by us through the tuber points and the canine point of the non-cleft side, were registered metrically by three-dimensional (3D) measuring of maxillary casts, using a reflex microscope. The registered values were represented three-dimensionally, and the absolute growth was compared with the relative vertical changes. RESULTS: The results show that 3D representation with superimposition of the individual results offers the clinician clear, continuous monitoring of the treatment progress. In comparison with the control group, the cleft patients showed significantly greater vertical deviations in nasal direction in the region of the incisor and canine points at each observation timepoint. A significant reduction in vertical divergences was recorded only in the region of the cleft pole point of the larger segment during the study period. The results furthermore suggest that investigation of absolute changes in segment positions alone in comparison with relative growth changes may lead to misinterpretations.