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PubMed2001

Reconstruction of palatal defect using mucoperiosteal hinge flap and pushback palatoplasty.

This article describes a simple, new surgical technique to provide a complete two-layer closure of palatal defect resulting from a surgical complication of trans palatal resection of skull base chordoma. The nasal layer was reconstructed with triangular shape oral mucoperiosteal turn over hinge flap based on anterior margin of palatal defect and rectangular shaped lateral nasal mucosal hinge flaps. The oral layer was reconstructed with conventional pushback V-Y advancement 2-flaps palatoplasty. Each layer of the flaps were secured with two key mattress suture for flap coaptation. This technique has some advantages: simple, short operation time, one-stage procedure, no need of osteotomy. It can close small- to medium-sized palatal defect of palate or wide cleft palate and can prevent common complication of oronasal fistula, which could be caused by tension.

Child, Preschool↗
PubMed2003

Incidence of cleft lip and palate in the northeast of Mexico: a 10-year study.

In Latin American countries, studies on the incidence of cleft lip and palate are not widely available. A 10-year retrospective study was carried out to determine the incidence of cleft lip and palate at the Autonomous University of Nuevo Leon's University Hospital. The study included data from patients who attended the plastic surgery outpatient clinic from January 1990 to December 1999. The author reviewed 10,843 files from which 376 patients were selected to identify the following variables: time of the year in which the first consultation took place, gender, birthplace, type of cleft, age of both parents, and medications taken during pregnancy. The highest incidence was found in patients aged 1 to 6 months. Ninety-four patients had a primary palate cleft; 76 had a secondary palate cleft; and 206 had primary and secondary palate clefts. The gender distribution of the 206 patients with primary and secondary clefts was 127 boys and 79 girls. The mean parent age was 29.5 years (father) and 25.7 years (mother). The incidence of cleft lip and palate in the cited hospital was 1.1:1000 births. Clefts of the left side occurred more often than of the right. Boys were affected more commonly than girls.

Adult↗
PubMed1994

Effects of 5-fluorouracil on collagen synthesis in the developing palate of hamster.

A study was undertaken to examine the effect of 5-fluorouracil (5-Fu) on collagen synthesis in the developing secondary palate. Pregnant hamsters were given 81 mg/kg 5-FU intramuscularly or 1 ml saline on day 11 of gestation. Control and treated embryonic palates, dissected from hamsters between days 11 and 13 of gestation, were incubated in a growth medium supplemented with [14C]proline. The rate of collagen synthesis, total protein and collagen isotypes were determined. The data showed that in control hamster palate the collagen synthesis peaked between days 12:00 (12 day: 0 h) and 12:04 of gestation, which is the period of shelf reorientation. In 5-FU-exposed hamster palates, the rate of collagen synthesis was lower than controls until day 12:04 of gestation followed by a rise on day 12:12 of gestation. In 5-FU-treated embryos palatal shelf reorientation took place between days 12:16 and 13:00 of gestation. Electrophoresis showed that only type I collagen was synthesized during palate development in both the control and 5-FU-treated hamster embryos. It was suggested that collagen synthesis may play a critical role in shelf reorientation in hamster since (i) new collagen was synthesized in both the control and 5-FU-treated hamster embryos prior to and during the period of normal reorientation, and (ii) in 5-FU-treated hamster embryos, a recovery in collagen synthesis precedes reorientation. Inhibition of collagen synthesis during abnormal development is only a step in the cascade of events of 5-FU-induced effects on protein synthesis.

Animals↗
PubMed1981

Ultrasound diagnosis of cleft lip and cleft palate before birth.

Real-time ultrasonography in pregnancy can accurately detect gestational age, position of the fetus, position of the placenta, sex of the fetus, and many congenital anomalies before birth. To date, however, there has been no report of detection of a cleft lip-palate deformity by ultrasound. Two cases, in approximately 200 scans, have been found in patients with no previous family history of cleft lip-palate. The first case was a bilateral cleft lip-palate visualized at 28 weeks gestation. The second was a unilateral cleft lip-palate detected at 33 weeks gestation. Diagnosis of cleft lip-palate is dependent on appreciation of facial topography in multiple planes, adequate experience in the technique, and observation of the degree of excursion of the undulating tongue. Detection of the facial clefting in utero by ultrasound has resulted in our formulation of a routine for informing the parents of the deformity and referring them for consultation with a plastic surgeon. This is recommended before birth, so that the parents are well acquainted with what the deformity will look like and the sequential steps necessary for its correction. We encourage plastic surgeons, obstetricians, pediatricians, and ultrasonographers to be aware of the ability to diagnose cleft lip-palate before birth.

Cleft Lip↗
PubMed1987

A T-shaped musculomucosal buccal flap method for cleft palate surgery.

The primary aim of cleft palate surgery is not only to close the cleft palate but to push back the palate by repositioning the levator muscle to ensure that normal speech is obtained. Although the pushback operation using a mucoperiosteal flap is a readily effective method for velopharyngeal closure, postoperative fistula sometimes occurs, especially when the cleft palate is wide. Furthermore, postoperative maxillary deformity, possibly due to elevating the mucoperiosteal palatal flap, is extremely troublesome. For the purpose of pushing back the nasal mucosa, we applied the Kaplan buccal flap method, which is also applicable for reestablishing the levator muscle sling. The other buccal flap is covered on the hinged flap of the pared cleft margins. This results in far less disturbance of maxillary growth. We call it the T-shaped buccal flap method, and we have applied it in over 30 patients with various cleft palates and have obtained satisfactory results.

Cheek↗
PubMed1990

One-stage closure of the entire primary palate.

Timing of the closure of the anterior palate and alveolus is a subject of debate. Late repair of this defect is complicated by high fistula formation and subjects the patient to the problems of palate fistula for extended periods of time. We have utilized a single procedure performed when the child is 3 months of age that completely closes the anterior hard palate and alveolus along with the cleft lip. Our series consisted of 61 consecutive patients with unilateral clefts of the primary and secondary palate. Mucosal turnover flaps from the vomer along with lateral nasal mucosal flaps provide the nasal lining. A buccal sulcus flap with a Veau flap completes the oral repair. Ninety-five percent (58 of 61) of the patients had complete and stable closure of their anterior palate and alveolus after 1 year. The incidence of fistula formation in our series (3 of 61) is much lower than that reported with the utilization of other protocols. Excellent exposure of the anterior palate and alveolar defect during lip repair, early restoration of anatomic relationships, establishment of a good nostril floor and sill, and very low fistula formation are among the benefits of this procedure. The increase in operative time is considered minimal in light of aforementioned advantages.

Cleft Lip↗
PubMed1996

The effect of cleft lip repair on maxillary morphology in patients with unilateral complete cleft lip and palate.

This study was performed to investigate the isolated effects of cleft lip repair on maxillary morphology in patients with complete unilateral cleft lip and palate. We compared 10 adult patients with unilateral cleft lip and palate who had only lip repair in childhood and no palatal repair (group 1) with 30 adult patients with unilateral cleft lip and palate who had both their lip and palate repaired in childhood (group 2). Both groups of patients also were compared with 24 adult individuals who had normal occlusion and no cleft anomalies. Evaluation of lateral cephalograms showed that both group 1 and group 2 had significant degrees of maxillary retrusion compared with normal individuals. The magnitude of maxillary retrusion was not increased by cleft palate repair, and none of the cephalometric measurements were significantly different between groups 1 and 2.

Adult↗
PubMed2001

Short stay after cleft palate surgery.

Although algorithms for the repair of soft and hard palatal clefts continue to be debated, the appropriate length of postoperative stay has not yet been defined. Recent reports of cleft palate repair advocate a 2- to 5-day hospitalization. The plastic surgery service at St. Joseph Hospital frequently uses same-day admission with 23-hour observation postoperatively, with no increase in complications from the reported 2- to 5-day stay. The authors inspected the records for all the cleft palate patients undergoing cleft repair at St. Joseph Hospital Cleft Clinic from August of 1988 through June of 1998. After excluding syndromic patients and secondary or revision surgical cases, 79 patients remained in the study. These 79 patients underwent 104 procedures; all procedures were performed by a single surgeon (E.D.C.) with resident assistance. Short-term morbidity, length of stay, and operation performed were studied. All patients were admitted the day of surgery. Mean age at the time of operation was 13.2 months, with a range of 6 months to 20 years. The length of operation averaged 1 hour and 37 minutes; 94 percent of patients stayed 24 hours or less postoperatively, and 97 percent stayed 36 hours or less. The longest stay was 72 hours, which was related to delay in resuming adequate oral intake. The overall complication rate was 3.8 percent for this cohort, which included two partial palatal dehiscences and two small fistulas. No blood transfusions were needed, and no infections were noted postoperatively. No patients required readmission postoperatively for bleeding, respiratory compromise, or inadequate oral intake. The authors do not advocate a 1-night stay for all cleft palate cases. However, they do think it is safe for a healthy group of patients undergoing routine cleft palate surgery. The decision to discharge a patient early must always be left to the treating physician.

Adolescent↗
PubMed2003

Graft contraction: a comparison of acellular dermis versus hard palate mucosa in lower eyelid surgery.

PURPOSE: To compare graft contraction rates of acellular dermis versus hard palate mucosa when used as free spacer grafts in lower eyelid surgery and to provide clinical outcome data. METHODS: A prospective, nonrandomized clinical trial involving the placement of 19 spacer grafts in the lower eyelids of 14 patients was performed. Indications for spacer graft placement included lower eyelid retraction and mildly contracted socket. Patients with lower eyelid retraction also underwent an endoscopic subperiosteal midface lift. For all procedures, the height of each graft was measured during and after surgery. The amount of contraction was measured for each graft, and a mean was calculated for each spacer material. The clinical success was evaluated for all procedures, based on improvement of the functional concern being addressed. RESULTS: The mean graft contraction rate was 57% for the acellular dermis and 16% for the hard palate mucosal grafts (P <0.005). Of the 7 procedures using acellular dermis for lower eyelid retraction, 6 were considered a success, and 1 was considered a partial success. Of the 6 procedures using hard palate for lower eyelid retraction, 5 were considered a success, and 1 was considered a failure unrelated to the graft. Of the 5 procedures with acellular dermis used for mildly contracted socket, 2 were considered a success, 2 were considered a partial success, and 1 was considered a failure because of graft contraction. The one case using hard palate for mildly contracted socket was considered a success. CONCLUSIONS: Acellular dermis contracts significantly more than hard palate mucosa when used as a lower eyelid spacer graft. Acellular dermis and hard palate mucosa were both associated with a high rate of clinical success in all categories except for patients with a mildly contracted socket who received acellular dermis; more than 60% of these patients (n=5) had only partial success or failure caused by graft contraction.

Adult↗
PubMed2005

Long-term clinical, audiologic, and radiologic outcomes in palate cleft children treated with early tympanostomy for otitis media with effusion: a controlled prospective study.

OBJECTIVES: The role of tympanostomy in the treatment of otitis media with effusion (OME) in children with palate cleft with regard to the otologic and audiologic outcome is controversial. Little is known about the development of the mastoid air cell system (MACS) in these children. STUDY DESIGN: Controlled, prospective. METHODS: All children born in the hospital district area of the Central Hospital of Central Finland during the years 1983 to 1993 with palate cleft were reviewed at the age of 6 months. A total of 39 patients were followed up for 6 years after primary tympanostomy. Otologic and audiologic data were collected, and the MACS size was planimetrically measured. The control group consisted of age-matched children without palate cleft suffering from OME and were identically reviewed. RESULTS: The otologic outcome was similar in the study group, 64.1%, and among the controls, 60.6% were healed. There were no serious otologic complications in the study group. The audiologic outcome was also similar, with a mean pure-tone average (0.5-2 kHz) of 10.5 dB and 10.9 dB for the corresponding groups. The initial size and growth of the MACS did not significantly differ between the groups. CONCLUSIONS: The prognosis of children with palate cleft treated with early tympanostomy is favorable and does not differ from children without palate cleft. Active treatment ensures normal hearing during the critical years of language, speech, and cognitive development and maintains the development of an aerated mastoid. We believe that early tympanostomy is the treatment of choice of OME in palate cleft children.

Acoustic Impedance Tests↗
PubMed2003

A technique for cleft palate repair.

The author has developed a technique of palate repair that combines minimal hard palate dissection with radical retropositioning of the velar musculature and tensor tenotomy. The repair is performed under the operating microscope. Results are reported for 442 primary palate repairs performed between 1978 and 1992 inclusive, with follow-up of at least 10 years. In 80 percent of these palate repairs, repair was carried out through incisions at the margins of the cleft and without any mucoperiosteal flap elevation or lateral incisions. Secondary velopharyngeal rates have decreased from 10.2 to 4.9 to 4.6 percent in successive 5-year periods within this 15-year period. Evidence from independent assessment of speech results in palate re-repair and submucous cleft palate repair suggests that this more radical muscle dissection improves velar function.

Cleft Palate↗
PubMed2004

From birth to maturity: a group of patients who have completed their protocol management. Part I. Unilateral cleft lip and palate.

The optimal management of the cleft lip and palate patient from birth to completion of treatment presents a formidable challenge to the plastic surgeon and the associated health care system. The multidisciplinary team approach for the management of these patients is widely accepted. However, a paucity of literature exists discussing specific protocol management, interventions, and the long-term outcomes of patients who have completed a strict treatment protocol with a consistent multidisciplinary team. The aim of this study was to present the details of the specific management protocol at the Australian Craniofacial Unit for cleft lip and palate patients and to present a group of patients who have completed this specific protocol and discuss the details of their long-term care. During a 28-year period from 1974 to 2002, the records of 337 patients treated for unilateral cleft lip and palate were evaluated. Of these 337 patients, 22 have completed the same specific protocol management. The same surgeon (David, the senior author) has been responsible for performing all operative interventions and for overseeing the care of each of the 22 patients, ensuring that the treatment protocol has been executed appropriately and without deviation. The interventions and outcomes were analyzed on the basis of speech, hearing, nasal airway, occlusion, psychosocial adjustment, and appearance. Because of the large volume of data and potential differences in outcomes, the authors' intention is to present this as part I of a four-part series beginning with unilateral cleft lip and palate. The results of isolated cleft palate, isolated cleft lip, and bilateral cleft lip and palate will be presented as parts II, III, and IV, respectively. Speech results were assessed as normal speech, mild abnormality, or severe abnormality by objective measures, and intervention for velopharyngeal insufficiency was noted. Seventeen patients were rated as having normal speech. Four patients were rated as having mild speech abnormality, one patient was rated as having severe speech abnormality, and seven patients required surgery for velopharyngeal insufficiency. Hearing results were measured objectively, and good hearing results were obtained in 18 cases. Five patients required tympanoplasty. All patients required alveolar bone grafting. The high Le Fort I osteotomy was performed in six cases. Bimaxillary surgery was performed in one case. Of all the patients assessed from birth to maturity, 13 required between three and five surgical interventions, and nine required six operations or more. Further details and photographs of preoperative and postoperative examples are provided.

Adolescent↗
PubMed2005

The thoracodorsal artery perforator-scapular osteocutaneous (TDAP-SOC) flap for reconstruction of palatal and maxillary defects.

Despite technical advances over the past 3 decades, subtotal, total, and extended total maxillectomy defects remain challenging reconstructive problems. In particular, postoncologic resection of the maxilla results in complex 3-dimensional defects of the midface, which cause severe functional and esthetic deformities. Such defects generally require composite tissue flaps for reconstruction. Rebuilding the palate and maxilla is especially challenging because it requires reconstitution of the facial buttresses, occlusion, replacement of bony hard palate, and the thin intraoral and intranasal lining which normally constitute the soft palate. Various methods of reconstruction have been applied to this area in search of an ideal soft tissue-bone flap to restore the bony framework of the maxilla and palate while providing an internal lining. Osteocutaneous and osteomuscular flaps such originating from the scapular, iliac, peroneal, and radial vascular systems have been attempted with good success. We devised an osteocutaneous flap based on the scapular vascular system, which provided bone and soft tissue to successfully reconstruct the palate and maxilla in 2 patients. The skin paddle received its blood supply from the major perforating vessels of the thoracodorsal artery, and the scapular bone was nourished by the angular vessels. Although free tissue transfer using thoracodorsal perforator flaps has been described, this flap has not been previously reported in the literature as an osteocutaneous tissue transfer. With the use of rigid fixation, excellent results have been obtained with this technique for palatal and maxillary reconstruction.

Adolescent↗
PubMed2006

Palatal fistula repair using acellular dermal matrix: the University of Florida experience.

Palatal fistulas represent a challenging problem for surgeons caring for patients with cleft palate. The purpose of this study was to examine the rate of fistula closure using conventional surgical techniques (Group 1) versus a newer technique (Group 2) employing the use of acellular dermal matrix (AlloDerm). We reviewed the charts of all patients who underwent palatal fistula repair between July 1994 and February 2005. The surgical techniques in Group 1 varied and were considered a historical control. In the second group, a piece of dermal matrix was interposed between the nasal and oral mucoperiosteum after closure of these layers. The primary fistula closure rate for Group 1 was 83.3% (10/12 patients). Fistula closure was obtained in 100% of the patients in Group 2. There were no complications noted other that the failure of the 2 patients in Group 1. The use of AlloDerm in palatal fistula repair has reduced our failure rate from 16.7% to 0%. The use of AlloDerm during palatal fistula repair is safe, effective over time, and has the potential to reduce palatal fistula recurrence rates.

Child↗
PubMed2006

Short-stay cleft palate surgery with intraoperative dexamethasone and marcaine.

The perioperative management of cleft palate surgery remains controversial. Early literature supported hospital stays of 2-5 days, but more recent reports have supported 24-hour admissions in carefully screened patients without congenital syndromes. We retrospectively reviewed 65 cleft palate repairs performed by the senior author from August 1992 through November 2003. Procedures included repairs of the soft palate (n = 25), hard palate (n = 4), or combined hard and soft palate (n = 36). All repairs were performed using a Furlow double, opposing Z-plasty technique. Nine patients (14%) had associated congenital syndromes. Prior to January 1995, patients (n = 15) received perioperative antibiotics and local injection of lidocaine with epinephrine prior to incision. The average operative time to first oral feeding was 13 hours, and the average length of stay in this group was 2.4 days. Previous oral surgery literature has demonstrated the reduction of pain, edema, and trismus with the use of dexamethasone. As part of our recent operative protocol, all patients (n = 50) after January 1995 received perioperative antibiotics, local injection of a 50/50 mixture of 1% lidocaine with epinephrine, and 0.5% Marcaine with epinephrine prior to incision and 4 mg of intravenous dexamethasone perioperatively. The average time to first feeding was 7 hours and the average length of stay was 1.1 days. Postoperatively, patients from both groups were maintained on a liquid or soft diet, depending on their age without the use of bottles. There were no differences in the use of antibiotics or pain management between the 2 groups. Patients were assessed by the surgical team for evaluation of the surgical site and oral intake prior to discharge. Patients in the steroid/Marcaine group had earlier oral intake (P < 0.05) and shorter length of stay (P < 0.05). Of those patients receiving dexamethasone and Marcaine, 43/50 (86%) were discharged within 24 hours. Patients requiring longer hospitalization had initially inadequate oral intake. One patient required readmission for dehydration secondary to rotavirus. In conclusion, short-stay cleft palate surgery is safe, given adequate oral intake, competent parents, and a safe home environment.

Anesthetics, Local↗
PubMed2005

Prevalence of cleft lip and palate in a hospital-based population in the Sudan.

UNLABELLED: Cleft lip and palate represents one of the most common developmental deformities seen in oral surgery clinics. It is usually associated with problems which include not only cosmetic and dental abnormalities, but also speech, hearing and facial growth difficulties. OBJECTIVES: The purpose of the present study was to determine the prevalence of cleft lip and palate in births taking place in hospitals in the Sudan. METHODS: The records of 15,890 Sudanese new-borns delivered at three hospitals during the period from 1997 to 2000 were examined. RESULTS: Thirteen cases of cleft lip and palate were found, demonstrating a prevalence of 0.9 per 1000. There were more girls than boys, with a male:female ratio of 3:10. Fifty-four per cent of the cases had cleft lip with cleft palate, 30% had only cleft palate and the remaining 16% had cleft lip alone. CONCLUSIONS: The present study was confined to hospital-based births in one city, and the true incidence of cleft lip and/or palate in the Sudan is not yet known. Findings differ from reports from other countries in terms of suggesting a higher incidence in girls.

Cleft Lip↗
PubMed1992

Cleft palate and complex chromosome rearrangements.

Two of three unrelated children with de novo congenital complex chromosome rearrangements (CCR) with more than four chromosome breaks had cleft lip and palate as one of several congenital anomalies. In patient 1, unilateral complete cleft of the primary and secondary palates accompanied severe ectrodactyly, bilateral posterior choanal atresia and several minor congenital anomalies. Karyotypes of peripheral lymphocytes and skin fibroblasts showed five derivative chromosomes with six break points. There were two translocations, t(2;5), t(3;11) and an interstitial deletion, del(13)(q12q14). Patient 2 had a bilateral complete cleft of the lip and palate, in addition to slow pre- and postnatal growth and minor congenital anomalies. Peripheral lymphocytes and palatal mucosa fibroblasts karyotypes showed five derivative chromosomes with six break points. A partial deletion of 10p, two translocations, t(2;3), t(7;18) and an inversion of the derivative chromosome 2 were present. In both patients, a "major catastrophe" of unknown etiology in one of the parental gametes appeared to be the event leading to the stable CCR without evidence of persistent chromosome instability. All four parents had normal karyotypes. The presence of palatal clefts in these patients indicates that dysmorphologists and pediatricians have to consider CCR whenever taking care of a patient with cleft palate, particularly if additional anomalies, no matter how subtle, are present. The detection and interpretation of the latter anomalies are essential for the diagnosis and management of these patients. Accurate cytogenetic diagnosis determines the short- and long-term prognosis and facilitates genetic counseling in regard to life-span, quality of life and reproductive plans of patients and parents.

Abnormalities, Multiple↗
PubMed1994

Reduction of craniofacial and palatal narrowing in very low birthweight infants.

Many infants born preterm have positional moulding of the head and palate. This study investigates whether specially designed, foam pressure dispersing pads (PDP) worn throughout the neonatal hospital course, were not only effective in reducing craniofacial flattening, but also in lessening palatal narrowing in very low birthweight (VLBW) infants. The study was conducted in two phases. Twenty-three consecutively born VLBW infants were randomly selected to act as a comparative group. The next 31 VLBW infants born comprised the intervention group, and wore PDP during hospitalization. The two groups were similar in birthweight and gestational age. The groups were compared for changes in craniofacial and palatal parameters at three time intervals during hospitalization. Results indicated a significant increase in growth of craniofacial width, palatal width and palatal area of infants wearing PDP compared to those infants not wearing them. These findings suggest that craniofacial and palatal narrowing observed in VLBW infants may be reduced by the wearing of PDP during hospitalization.

Analysis of Variance↗