ABSTRACT Background: Cleft lip and/or palate are one of the most common congenital craniofacial anomalies that require surgical management. Patients undergoing primary cleft repair are at increased risk of perioperative anesthetic complications due to their young age and anatomical defects. Aim: This study aimed to present the frequency of perioperative airway-related morbidities in the anesthetic management of cleft lip, alveolus, and palate surgeries. Patients and Methods: This study was conducted at Lagos University Teaching Hospital, Nigeria. Patients undergoing cleft lip, alveolus, or palate repair were prospectively studied from January 2015 to December 2019. Data on patient demography, type of cleft, presence of syndromes and other deformities, and intra- and postoperative complications were collected. Results: A total of 150 patients were included, with a median age of 15.5 months, and 67 (44.7%) of the patients were <12 months old. Most patients were female (56%), and the most common type of cleft was lip, alveolus, and palate (36.6%). Sixteen (10.7%) of the patients had associated syndromes. Notably, intraoperative complications were observed in 5 (3.3%) patients, including laryngospasm and difficult intubation. Postoperative complications were rare, with one case of nasal bleeding. Significant associations between presence of other deformities and syndromes and intraoperative complications were noted (P < 0.05). Conclusion: Patients with orofacial clefts and other deformities tend to be predisposed to anesthetic complications. However, the incidence of anesthetic complications in this study was low (3.3%) probably because the current protocol used in the author’s hospital for cleft surgeries was followed and appropriate.

ABSTRACT The objective of nasoalveolar molding is to provide an approximation of lip and palatal segments, to reduce tension in the tissues in a nonsurgical way along with reshaping of gums, lips, and nostrils to give a symmetrical appearance, and help in narrowing the cleft width before surgery. The goal of this case report is to describe the use of a modified MU hook appliance in a case of a bilateral cleft lip and palate. This appliance aids in lengthening the columella and significantly improves the surgical outcome. This report also highlights the benefits, adjustments required, proper training for parents, and clinical management of the appliance.

ABSTRACT Palatal fistula is a complication of cleft palate surgery. It can be due to suture dehiscence, hematoma, infection, or flap necrosis. Palatal fistula treatment is a challenge to surgeons. Treatment of fistula depends on its size, location, and surgeon experience. Because of a paucity of nearby tissue, it usually demands the incorporation of extra tissue from the surroundings for a successful outcome. Tongue flaps and buccal myomucosal flaps can be employed to add tissue from the surroundings. In this study, we describe a patient with a large palatal fistula repaired in stages with a good surgical outcome.

ABSTRACT Context: Craniofacial anomalies (CFAs) are rare congenital anomalies that have a profound impact on social acceptance. Most of the syndromic CFAs are genetic in origin and are the result of alteration in single or multiple genes inherited from parents or de novo. Aims: The main aim of this study was to explore the phenotypic variations and the mutation profiles in the various CFA. Subjects and Methods: This was a retrospective study where records of 20 patients were obtained from electronic medical records for analysis. The numbers provided do not accurately reflect the true prevalence as they only encompass cases referred to our department for testing. Results: The median age in this cohort was 1 year with males 60% and females 40%. Out of 20 cases, 8 cases were classified as CFA-associated craniosynostosis and 12 with orofacial clefts. Disease-causing genes identified were FGFR2, RTTN, ASXL3, IRF6, TP63, POLR1D, TCOF1, KMT2D, KDM6A, LARP1, and C5orf42. Most of these craniofacial syndromes were predominantly autosomal dominant, sporadic, and de novo. We had three autosomal recessive cases (RTTN, LARP1, and C5orf42) and one X-linked dominant case (KDM6A). Two novel variants were identified, one for Van der Woude syndrome and another for Crouzon’s syndrome. Conclusions: Although these syndromes are rare in occurrence, the present study provides a detailed phenotypic spectrum and causative mutation in various CFAs in Indian patients. This is crucial for understanding the genetic basis of these conditions and can potentially lead to advancements in diagnosis, treatment, and appropriate genetic counseling.

ABSTRACT Background: Breastfeeding infants with a cleft is difficult due to underlying anatomical deficits. The success of breastmilk feeding in this population is highly dependent on the mother. Nevertheless, the rate and duration of breastmilk feeding are often poor in this population due to early cessation of breastmilk production. These infants are therefore at high risk for “failure to thrive”. Aim: The study aimed to identify the challenges encountered by mothers having infants with cleft in establishing and maintaining breastmilk production. Objective: To explore the factors that impact establishing and maintaining breastmilk production viz., a) Mother-infant separation b) Access to Lactation and Feeding consultation c) Breastmilk expression strategies d) Formula supplementation rate e) Motivating or demotivating factors to breastmilk feeding. Method: This study was a phone survey conducted on 28 mothers who had availed lactation and feeding consultations between 2019 and 2020. Results: Various factors impacting the onset and establishment of breastmilk feeding noted were, separation of mother and infant at birth and the duration of separation, lack of access to professional help in lactation and feeding during stay in hospital, irregular and inappropriate breast milk expression, early formula supplementation demotivation due to various lactation and feeding challenges. Conclusion: Support from healthcare professionals specialized in lactation and feeding consultation for mothers having infants with cleft particularly, Speech Pathologists, Nursing staff and Lactation Consultants is critical to increase the rate and duration of breastmilk feeding. Breastmilk feeding should be thus prioritized and supported to enable infants with cleft to thrive.

Dr. S. Anthony Wolfe (Tony) died peacefully at home on December 26, 2023. He was born in Cleveland, Ohio, on July 30, 1940, to Thomas William Wolfe and Elisabeth Ann Wolfe (née Bobbitt). He attended elementary school and later boarding school in the Midwest and Northeast while his parents lived abroad due to his father's role at the U. S. Embassy as the Air Force attaché. He later rejoined his family and lived in Russia, Germany, and France. As a result, Dr. Wolfe became fluent in Russian. He eventually mastered six languages, which would become useful for academic text translations. He earned his undergraduate degree in 1962 from Dartmouth College and, after 3 years at college, completed Medical School at Harvard University in 1965. During medical school, his class was taken to the Fernald School, originally founded as "The Massachusetts School for the Feeble-Minded," which was closely linked to the American eugenics movement. It was standard practice then to institutionalize patients with severe facial deformities despite normal intelligence. His class was taken to an auditorium and on the stage were paraded a variety of patients with severe craniofacial anomalies, including Apert Syndrome, Treacher Collins, Crouzon Syndrome, Down Syndrome, and other facial malformations. In his senior year of Medical School, he was originally interested in neurosurgery. However, his interest waned after a rotation at the Mass General in neurosurgery, where patients did not seem to wake up. He also developed an interest in plastic surgery in medical school, where Joe Murray was on the faculty at the time. Dr. Wolfe then served in the U. S. Public Health Service from 1966 to 1968 in Dakar, Senegal. He then worked as a resident in Surgery and Plastic Surgery in Boston at the Peter Brent Brigham Hospital and the University of Miami, respectively. In his last year at Brigham, he had already been accepted into a plastic surgery residency and earned a scholarship to travel to Montreal to attend the meeting of the American Society of Plastic and Reconstructive Surgery. This was in 1971 and was the first time Paul Tessier spoke in North America. Dr. Wolfe knew immediately that craniofacial surgery was the type of surgery he wanted to do [Figure 1]. At the University of Miami, he trained under Dr. D. Ralph Millard, Jr., from whom he learned the Principles of Plastic Surgery. Millard had learned the Principles of Plastic Surgery from Gillies and had expanded on them. Dr. Wolfe learned the following principles from Millard, and applied them throughout his career:Figure 1: Dr. Wolfe early in his career, planning for a case at Jackson Memorial Hospital. He frequently drew on skulls and skull models to plan for cases and teach his fellows. While Dr. Wolfe staunchly adhered to the principles of plastic surgery and craniofacial surgery that he had learned from his mentors throughout his career, he also embraced innovation and new technologies, and adopted virtual surgical planning later in his career for preoperative planning, utilizing it for complex craniofacial reconstruction cases that he performed into his 80s Attention to fine detail. Being able to convince the patient to have one more minor procedure Respect for facial esthetic units Proper documentation with good photography The rotation advancement for unilateral clefts How to make and transfer a tube pedicle. In 1974, he completed a 1-year postresidency fellowship in Paris with Dr. Paul Tessier [Figures 2a-c]. This was a defining professional and personal experience. During this year, he cemented his medical interests in craniofacial surgery and began to innovate on many of the procedures pioneered by his mentors. During this period, he also began to forge lifelong relationships with colleagues, including his lifelong friend, Dr. Henry Kawamoto Jr. While working with Dr. Tessier, Dr. Wolfe learned the importance of the ideas, the principles, and the logic behind reconstructive work. With Tessier, he learned the importance of:Figure 2: (a) Dr. Wolfe observing Dr. Tessier in the operating room with Dr. Henry Kawamoto and Dr. David Matthews. (b) Dr. Wolfe with Dr. Tessier at the retirement celebration Dr. Wolfe arranged for Dr. Tessier. (c) Dr. Wolfe with Dr. Kawamoto at his retirement celebration in January 2023 Wide subperiosteal dissection to expose the facial skeleton Good power equipment and instrumentation and surgical syringes Good rigid fixation with wire, or increasingly, plates and screws The principle of the effective orbit is that the segment of the orbital framework, when moved, takes the globe with it, making possible the correction of vertical and horizontal orbital dystopias The classification of clefts (later to become clefts and ageneses) The forward movement of the midface by Le Fort 1 and 3 osteotomies and the monobloc frontofacial advancement The use of the temporal muscle, among others The importance of the use of autogenous bone in craniofacial reconstruction. In 1975, Dr. Wolfe established his practice in Miami, Florida, where he lived and worked until his retirement only a year ago. He became Dr. Millard's colleague, as Dr. Millard "could use someone to do bones." A variety of craniofacial cases had been collected for Dr. Wolfe while training with Tessier, and he was busy from the start, performing complex intracranial procedures at the very beginning of his practice up until the very end of his career, almost 50 years later [Figures 3a and b]. Dr. Wolfe treated both adult and pediatric patients. He was adept at complex facial and skull surgery in infants, and esthetic surgery in adults. He emphasized the balance between reconstructive and esthetic surgery. His primary commitment was to improve the quality of life for children with craniofacial anomalies. He was the chief of the Department of Plastic and Reconstructive Surgery at Miami Children's Hospital since 1984. Dr. Wolfe took on cases that no one else would take on. He impacted the lives of countless children and their families.Figure 3: (a) At one point early in his career, Tessier is beside him giving him advice, which may have been, "Always use autogenous bone." (b) The last case of his career - with the next generation by his side: Pedro Piccinini, MD, his last craniofacial fellow, now a craniofacial attending at Montefiore, and Erin Wolfe, MD, now a plastic surgery resident at University of Southern CaliforniaDr. Wolfe was accomplished and prolific, writing numerous books and journal publications. He also participated in many medical associations and societies over the course of his career. Dr. Wolfe was a founding member of the International Society of Craniofacial Surgery (ISCFS) in 1983. He served as president of the ISCFS, American Society of Maxillofacial Surgeons (ASMS), and Rhinoplasty Society. He was the recipient of many awards, including the American Association of Plastic Surgery (AAPS) Clinician of the Year Award and the James Barrett Brown Award for Best Paper in "Plastic and Reconstructive Surgery" (with Dr. Tessier). Recognized for excellence in his specialty, he dedicated his life's work to advancing the science and practice of plastic and reconstructive surgery. He kept meticulous records of his own cases and was able to publish results on decades of long-term follow-up in craniofacial patients. He also chronicled the life and work of his two teachers, Dr. Millard, the master of soft-tissue surgery, and Dr. Tessier, the master of surgery of the craniofacial skeleton. Millard was a prolific author of books and publications. However, Dr. Tessier, because he was so self-critical, wrote very little. His early work, for instance on the treatment of enophthalmos, was in French, and therefore unknown and unappreciated by the English-speaking audience. Dr. Wolfe translated "The Report of the French Society of Ophthalmology", from French so that it was available to others. He also translated the work of Dr. Limberg, "The Planning of Local Plastic Operations on the Body Surface," which delved deep into local flaps in ways that few other surgeons ever have. His other books included Plastic Surgery of the Facial Skeleton, Facial Fractures, and various other translations on different areas of facial plastic and reconstructive surgery. His most meaningful work, to him, was his 2011 monograph on Paul Tessier, "A Man from Héric: The Life and Work of Paul Tessier." In his last year of life, we wrote a book together, "A Tale of Two Teachers," which he considered his swan song. It can also be considered a tale of three teachers, as it is a hybrid, both biographical and autobiographical. It documents the influence Millard and Tessier had on the specialty of plastic surgery, as well as on his career as a teacher from the generation that learned from the prior and broadened and deepened the scope of the specialty. Dr. Wolfe trained almost 80 craniofacial fellows and numerous plastic surgery residents and observers from around the world. His career goal was to pass on to the next generation what he learned from Millard and Tessier. He frequently espoused the use of autogenous bone and insisted that whenever possible artificial implants be avoided. He also built on Millard's work with his innovations in cleft lip and palate repair. One of the technical innovations he was most passionate about was his technique for staged bilateral cleft lip and repair, which left patients with a normal-looking nose and good midface growth at mixed dentition and skeletal maturity, reducing the need for subsequent Le Fort I advancement. Dr. Wolfe's knowledge, and the knowledge of his teachers, will live on through his fellows. Many of those he trained continued his expertise and teachings. Dr. Wolfe considered his biggest legacy his craniofacial fellows. He learned from his fellows as much as they learned from him. As Millard once said to younger surgeons in a video interview Dr. Wolfe made of him in 2000, "Plastic Surgery now remains in your hands." His advice for trainees was as follows: The training of a Plastic Surgeon is a long process, and who your teachers were will have a lot to do with your capabilities, but having your own experience is capital. In the introduction of his book, "Plastic Surgery of the Facial Skeleton," he relays advice to the reader that was given to him by his grandfather, Maxwell Ray Bobbitt, a urologist: "Son, make sure you get the best training that you can, no matter what field you decide to go into" Textbooks on Plastic Surgery are helpful, and watching another surgeon operate can be instructive A Good Plastic Surgeon will be sure that he has the best possible instruments, and that they are kept in ideal condition, and sharpened regularly. A Good Plastic Surgeon is highly critical of his or her own work, rarely content, and always trying to improve the Field For craniofacial surgery, in particular: pursue dental training. Dr. Wolfe would have preferred having 1 year of dental school to 5 years of general surgery training. When he was the president of the ASMS, in his presidential address, he discussed the nature of maxillofacial surgery. He had asked this question of Hugo Obwegeser, who responded that maxillofacial surgery is a medical specialty closely aligned with dentistry. Dr. Wolfe was adamant that plastic surgeons who perform orthognathic surgery require a strong background in dentistry. He advocated for incorporating 3 months of dental school into training for those pursuing craniofacial surgery, to learn dental anatomy, growth and development, and gnathology, as well as orthodontics, which is not taught in dental school. On Dr. Millard's gravestone is his epitaph: "Principles, Discipline, Family." Dr. Wolfe adhered to these principles throughout his life. He operated following principles he had learned from his teachers, continued to innovate and expand on them, and passed this knowledge on to his trainees. He was highly disciplined and never gave up on his "Impossible" cases. He continued to see patients in clinic and provide clinical advice after retiring from operating at the age of 81 years. The family was of the utmost importance to him. Dr. Wolfe forged lifelong relationships with his patients and took care of them as if they were his own children. Dr. Wolfe loved being a father, and it is fitting that his life's work enabled his patients to live normal lives, becoming parents and pursuing successful careers themselves. He loved children, which was evident as he had ten children of his own. He once visited his son's elementary school class and taught the class about plastic surgery, craniofacial surgery, and cleft lip repairs. He was always passing on his knowledge to the next generation and the generation after that. A force of nature both in and out of the operating room, Dr. Wolfe devoted himself to his career. Somehow, he made time for diverse personal interests. He was a true Renaissance man. In addition to being a prolific writer, Dr. Wolfe was an avid reader. He consumed knowledge ravenously. He was rarely seen without a book in his hand if he was not in the operating room unless he was completing the crossword, swimming, or cooking. He had a penchant for cooking, and once wrote, "There are many similarities between Surgery, in particular Plastic Surgery, and Cooking. Both specialties strive to make something beautiful, that will be savored and appreciated, particularly by the ones we love." Dr. Wolfe frequently experimented in cooking cuisines from around the world and enjoyed traveling. He was extremely physically active and enjoyed traveling for both work and leisure, often visiting his colleagues, friends, and family around the country and world. He took on new hobbies throughout his life, including artistic pursuits such as sculpting and photography. Dr. Tessier once said of craniofacial surgery: "I don't know if it is artistry. We are trying to make people, children, normal." Dr. Wolfe did pursue artistry and perfection, though he was often self-critical of his results. He was always motivated to innovate, create, and improve. Dr. Wolfe was able to make time for work-life balance, by "hurrying up in the afternoon, so (he) could get out in time to see (his) kids." He is remembered by his children, Andrew Wolfe (Hie Jung Yoon; Freddy and Henry), Julia Wolfe (Eric Moore; Theo and Naomi), Johanna Wolfe (Thorsten Wagner; Dahlia and Caleb), Olivia Wolfe (Neel Shah; Louisa and Bruno), Erin Wolfe, Thomas Wolfe, Laura Wolfe (Erika Parjus), Conor Wolfe, Anthony Wolfe, and Maxwell Wolfe, as well as his sister Ellen Brewerton and brother Tim Wolfe. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

ABSTRACT Objective: The objective of this study was to compare the incidence of palatal fistula formation between cleft palate (CP) repair with collagen matrix graft and conventional repair without collagen matrix graft. Patients and Methods: This was a preliminary randomized controlled study of patients with CP who underwent primary palatoplasty (two-flap palatoplasty technique) at the Lagos University Teaching Hospital. Patients were randomly allocated to either the test group (palatoplasty with collagen graft) or the control group (palatoplasty without collagen graft). The primary outcome was palatal fistula, and secondary outcomes were wound dehiscence, surgical site inflammation, surgical site infection, and surgeon satisfaction up to 3 months postoperative (PO). Results: Ten patients were recruited, five in each group. Only one patient in the control group developed a palatal fistula at 1 month PO on the soft palate which extended to the junction of hard and soft palate at 3 months PO. Eight patients developed wound dehiscence, five in the test group and three in the control group. Surgical site inflammation persisted up to at least 7 days PO in nine patients (five in the test group and four in the control group). All persistent wound dehiscence and surgical site inflammation resolved at 3 months PO. No patient developed surgical site infection. No significant difference was seen between the study group and wound dehiscence, surgery time, and difficulty of the procedure (P > 0.05 for all associations). Conclusion: Collagen graft may have a protective effect against fistula formation without significantly increasing surgery time and difficulty. However, due to the small sample size, the study failed to draw definite conclusions. Results from this study may inform future designs of larger randomized controlled studies.

ABSTRACT Background: Cleft lip chelioplasty can be approached with a wide array of different techniques. The ultimate goal of all techniques is to restore sphincter competence and aesthetically favorable outcome. Dr.C. Balakrishnan of Government medical college,Nagpur devised an original triple wedge technique,a form of three triangular flap,that was evolved independently of the triangular flap technique. Unfortunately he did not publish his technique,even today many of his 4th and 5th generation trainees perform triple wedge technique for cleft lip repair.[1-3] The history of cleft lip repair in Nagpur and it’s growth can not be dissociated from modern plastic surgery in India by the father of modern plastic surgery in India Dr. C.Balakrishnan himself,who established the first department of plastic surgery in India at GMC Nagpur,credited it with a new classification of cleft lip and palate, a new technique of cleft lip repair and propagated the principles of comprehensive cleft care. In our institute triple wedge repair for cleft lip is the repair of choice since 1950, although many modifications have been done in original technique since then. I was trained in KEM hospital,Mumbai and learned Millard’s repair there. After coming to Nagpur,I joined the department as lecturer under respected Dr S.M. Kale sir and I got the opportunity to learn triple wedge technique from him. Over the last 20 years I have added few modifications like changing the orientation of triangles,using the mucosal element for anterior palate repair which used to be discarded in original triple wedge technique and primary rhinoplasty. Aims and Objectives: In this original article we are describing the original triple wedge technique invented by father of modern plastic surgery in India Dr.C. Balakrishnan 2 and its evolution since then in the first department of plastic surgery in India. Materials and Methods: Patients operated in last 50 years at Government Medical college,Nagpur and data available in department. Results: Early and late postoperative pictures showing result of the technique. Conclusion: The purpose of this article is illuminating unpublished work of legend of plastic surgery in India Dr. C. Balakrishnan.

ABSTRACT Background: Presurgical orthopedics (PSO) can be used to treat patients with cleft lip and palate. PSO is a powerful tool for changing nasolabial and palate structures during the 1st months of life, helping improve the restoration of form and essential functions. Materials and Methods: This preliminary retrospective pilot study evaluated treatment efficacy with a nasal PSO protocol using the Rhinoplasty Appliance System (RAS) in seven centers in Mexico that specialize in managing children born with cleft lip and palate. Twenty-five unilateral cleft lip and palate patients (UCLP) (9 females and 16 males) were treated by an orthodontist trained in the RAS system. The severity of the cleft, treatment time, the number of devices used during treatment, and clinical complications were documented using a survey. The results were measured using standardized submental view two-dimensional photographs. Two independent investigators evaluated one angular variable and two lineal variables before and after treatment. The columella deviation angle was measured. On the affected side, between the line in the middle of the columella from anthropometric points Sn-Prn and reference line between Sn-Sbal. The lineal variables that compare the healthy and cleft sides were measured as ratios. The lineal variables were nostril width (this measurement is taken from all are anthropometric points to the columella on the horizontal plane) and nostril height (from the nasal base plane to the upper part of the nostril). All relevant data are within the paper and its supplementary information files. Results: The resulting data were analyzed using a paired t-test (P < 0.05). The results of nasal symmetry showed a statistically significant decrease in the nostrils’ midline deviation and horizontal symmetry and a statistically significant increase in unilateral patients’ vertical symmetry and tip-base angle. Of the reported complications, 36% of orthodontists did not express any concerns. Meanwhile, 32% experienced skin irritation on the cheeks, 16% faced challenges with treatment attachment, 12% encountered difficulties in applying the correct tractions on the rubber bands, and 4% required a larger device from the system. Conclusions: In these preliminary results, the Rhinoplasty Appliance System (RAS) streamlines procedures, enhances reproducibility, and offers a practical solution for nasal protocols in managing cleft lip and palate in infants. RAS improves nasal symmetry, displaying promising outcomes in holistic care for infants with UCLP conditions. This research highlights the potential of three-dimensional printing and innovative digital approaches to revolutionize presurgical interventions for pediatric patients, particularly in infant nasal PSO.