Primary Cleft Research Articles

Use of De-Epithalialized Flap for Elevating the Alar Base in Patients With Cleft Lip.

Alar base asymmetry is a common problem in cleft lip patients. Caused by a lack of bone support and soft tissue deficiency, it is one of the problems that must be corrected during cleft lip repair. While it is encountered during primary lip repair, it can also be seen as a secondary cleft lip nasal deformity after repair. This study aimed to provide alar base symmetry with a de-epithelialized muscle-skin flap during the primary cleft lip repair of incomplete cleft lip patients and secondary cleft lip deformity repair. In incomplete cleft lip patients, the tissue under the incomplete part is de-epithelialized and elevated as a superiorly based flap. The flap is rotated and sutured under the alar base for the elevation. In secondary patients, scar tissue to be removed is de-epithelialized and elevated as a superiorly based flap. It is turned over and sutured under the alar base for augmentation. The effect of the surgery is monitored during the follow-up period. There were no complications related to the flap, and no volume loss was observed. Using a de-epithelialized musculocutaneous flap, the augmentation of the alar base and nasal sill can be achieved without additional incisions in patients undergoing primary incomplete cleft lip repair and in patients undergoing secondary cleft lip deformity repair. We think it is an effective and safe method, improving the esthetic outcomes of cleft lip patients.

Is Postoperative Nasal Stenting Necessary After Primary Cleft Lip and Nose Repair?

Is Postoperative Nasal Stenting Necessary After Primary Cleft Lip and Nose Repair?

The Study of Facial and Nasal Symmetry in Patients with Unilateral Cleft Lip Achieved by Primary Cleft Lip Repair with Rhinoplasty Plus Postoperative Nasal Appliance “Nasoform”

The Study of Facial and Nasal Symmetry in Patients with Unilateral Cleft Lip Achieved by Primary Cleft Lip Repair with Rhinoplasty Plus Postoperative Nasal Appliance “Nasoform”

Septoplasty During Primary Cleft Lip Reconstruction: A Historical Perspective and Scoping Review.

Traditional surgical approaches excluded septoplasty at primary cleft lip reconstruction due to concerns about restricted nasal and midfacial growth. Modern opinion in the treatment of cleft lip has increasingly employed primary septoplasty; this scoping review and historical perspective aims to chronicle the evolution of septoplasty in patients born with cleft lip and palate and discuss current evidence. The historical perspective explicitly contrasts American and European perceptions of septoplasty in cleft lip deformity and the competing anatomical theories of the role of the septum on midfacial and nasal growth. For the scoping review, articles were extracted from Embase, PubMed, and Medline, as well as manual searches of reference lists. Results were compiled, grouped, and appraised by date, outcomes, and historical significance. Inclusion criteria consisted of children who underwent primary septoplasty for any indication and were followed up on outcomes of facial growth and nasal function. Literature reviews, opinion articles, case reports, guidelines, or studies not available in English or online were excluded. Evolving anatomical theories relating to midfacial growth in the mid-late 20th century underpinned a progressive ideological shift on the safety and efficacy of septoplasty in children. This is supported by our scoping review, which included 23 articles mutually selected for inclusion by 2 blinded assessors. Several competing methods have been employed to measure endpoints on facial growth and nasal function, but generally indicate primary septoplasty is successful in improving nasal function and preserving midfacial growth. Perceptions towards septoplasty on facial growth in the pediatric population have transformed significantly and suggest a growing acceptance of primary septoplasty techniques in patients born with a cleft lip.

Does Primary Cleft Palate Repair by Furlow Z-Plasty Technique With a Buccinator Myomucosal Flap Change Speech and Middle Ear Outcomes?

Children with repaired cleft lip and palate may present with middle ear effusion and disturbed speech due to velopharyngeal (VP) insufficiency. Furlow Z-palatoplasty with a buccinator myomucosal flap is one of the effective surgical techniques for primary cleft palate repair and lengthening of the palate. This study aimed to evaluate the effect of Furlow Z-palatoplasty with buccal myomucosal flap as a primary cleft palate repair technique on the VP function during speech and the Eustachian tube function. Forty patients with non-syndromic cleft lip and palate aged 3 to 7 years surgically repaired with Furlow palatoplasty with a buccinator myomucosal flap were assessed. Perceptual speech assessment, nasopharyngoscopic examination, otoscopic examination, and tympanometry were done for all patients to assess the speech and middle ear function. The percentage of mild hypernasality was significant in 22.5% of children with repaired cleft lip and palate, while 77.5% showed no hypernasality. Speech intelligibility was normal in 77.5% and mildly affected in 22.5% of children with repaired cleft palate. Compensatory misarticulations were recorded in 12.5% of children. Nasopharyngoscopic examination revealed adequate VP closure in 75% of children with repaired cleft palate. Twenty-five percent of children with repaired cleft lip and palate had middle ear effusion and required myringotomy with insertion of tympanostomy tubes. Primary cleft palate repair with Furlow Z-palatoplasty with buccal myomucosal flap had beneficial effects on speech outcomes. It was associated with a low prevalence of middle ear effusion, and a low number of tympanostomy tubes were needed.

Longitudinal Speech and Fistula Outcomes Following Primary Cleft Palate Repair at a Single Institution

Introduction Fistula formation and velopharyngeal insufficiency (VPI) are complications of cleft palate repair that often require surgical correction. The goal of the present study was to examine a single institution's experience with cleft palate repair with respect to fistula formation and need for surgery to correct velopharyngeal dysfunction. Methods Institutional review board approval was obtained. Patient demographics and operative details over a 10-year period were collected. Primary outcomes measured were development of fistula and need for surgery to correct VPI. Chi-square tests and independent t tests were utilized to determine significance (0.05). Results Following exclusion of patients without enough information for analysis, 242 patients were included in the study. Fistulas were reported in 21.5% of patients, and surgery to correct velopharyngeal dysfunction was needed in 10.7% of patients. Two-stage palate repair was associated with need for surgery to correct VPI (P = 0.014). Furlow palatoplasty was associated with decreased rate of fistula formation (P = 0.002) and decreased need for surgery to correct VPI (P = 0.014). Conclusion This study reiterates much of the literature regarding differing cleft palate repair techniques. A 2-stage palate repair is often touted as having less growth restriction, but the present study suggests this may yield an increased need for surgery to correct VPI. Prior studies of Furlow palatoplasty have demonstrated an association with higher rates of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be due to the use of the Children's Hospital of Philadelphia modification. This study suggests clinically superior outcomes of the Furlow palatoplasty over other techniques.

Use it or Lose it: Predictors of Compliance and Satisfaction With Postoperative Nasal Stent Therapy After Primary Cleft Lip Repair.

Postoperative nasal stents (NSs) are used to improve esthetic outcomes after primary or secondary cleft lip repair (CLR). Prior studies have utilized anthropometric measurements or physician assessment to determine the efficacy of NS, but data on caregiver-reported outcomes is limited. This study aims to assess caregiver compliance and satisfaction with postoperative NS. The authors designed a survey to collect parent-reported postoperative NS usage outcomes. Parents of infants with cleft lip (CL) who used postoperative NS after primary CLR were approached through social media to complete the survey. Data were analyzed to determine factors impacting compliance, satisfaction, and parent-reported outcomes. Eighty-five parents completed the questionnaire, and 60% reported noncompliance with NS. Parents with male children (odds ratio: 5.08, P = 0.019) and patients with incomplete CL (odds ratio: 5.72, P = 0.006) were more likely to be non-compliant with NS for over a week. Complete CL and use of presurgical molding therapy were each associated with better overall experience with postoperative NS ( P = 0.002 and P = 0.037), higher appearance ratings ( P = 0.005 and P = 0.0008), and greater satisfaction with nostril shape after surgery ( P = 0.016 and P = 0.001). Despite limited literature related to caregiver-reported outcomes after postoperative NS for primary CLR, the authors' results align with what has been published regarding this topic. These results can help guide surgeons in counseling patients preoperatively. Larger, multi-institutional studies are needed to better delineate and address factors associated with compliance and satisfaction after NS therapy.

Lifestyle of Cleft Lip/Palate Patients in Korea Before the Introduction of the Millard Technique.

The authors introduce a short story about the lifestyle of a cleft lip woman in Korea, published in 1936, about 2 decades before Dr Millard operated on his first patient in Korea. A short story entitled "Ugly Thing," written by Yao-hsieh Chu, analyzed by Eonnyeon, a girl born in a rural area with a cleft lip and palate who excelled at household tasks such as sewing. Her forehead was bulging, and her eyes were protruding. She had a low-profile nose with wide nostrils. She had a left unilateral complete primary cleft, including an alveolar cleft. There was midface retraction, accompanied by a relatively prominent chin. Her voice exhibited hypernasality. People often laugh when they see Eonnyeon eating her food, exclaiming, "She's eating like a rabbit!" However, she married a young man who deserted her on their wedding night because of her appearance. Subsequently, she moved to an urban area and found work as a housemaid. One day, she was raped by a middle-aged water delivery man, who then fled. Ten months later, she gave birth to a girl who also had a cleft lip. In a moment of despair, Eonnyeon attempted to smother her baby with a pillow but stopped herself. She resolved to raise her daughter despite the challenges ahead. The mockery directed at her could be viewed as an expression of the latent sadism inherent in human nature. It is remarkable to consider the progress made since Millard performed his first cleft lip surgery in Korea in 1954.

Multicenter Pattern of Cleft Surgeries and Factors Associated with Late Primary Cleft Surgery in Nigeria.

This study aimed to analyze multicenter patterns in cleft deformity surgeries and identify factors associated with the timing of primary cleft repair in Nigeria. A cross-sectional study of children managed for clefts from January 2009 to December 2020 at three Smile Train partner tertiary institutions situated in the east (Enugu), west (Ibadan), and northern (Jos) parts of the country using a prospectively collected database. Outcomes were the types of surgery performed, yearly volume of surgeries, methods of repair, and time of surgery (early versus late). Of 1043 cleft surgeries, nearly half (45.7%) involved infants (<12 months). Primary repairs of the lip or palate were performed in 83.4% of cases, with 58.4% for lip repairs and 25.1% for palate repairs. The most common cleft lip repair method was a variant of Millard rotation advancement flap. Over the study years, there was a shift from von Langenbeck palatoplasty to methods such as Bardach's palatoplasty and intravelar veloplasty. Patients with bilateral cleft lip defects were significantly more likely (P < 0.001) to undergo early repairs compared with those with unilateral defects. Late primary cleft lip repairs were significantly (P < 0.001) more common in Enugu. This study highlights the variability in cleft surgery patterns in Nigeria. Late primary cleft surgeries were associated with less severe cleft lip or cleft palate and were more prevalent in Enugu, Southeastern Nigeria. The findings contribute valuable insights for optimizing surgical approaches and resource allocation in the management of cleft deformities in the region.

Incidence of Velopharyngeal Insufficiency after Primary Cleft Palate Repair: A 27-Year Assessment of One Surgeon's Experience.

Background Velopharyngeal insufficiency (VPI) is a major complication of cleft palate repair. The purpose of this study was to evaluate the incidence and predictive factors of VPI after cleft palate repair based on 27 years of one surgeon's experience. Methods Medical records were retrospectively reviewed for 652 patients who underwent cleft palate repair between 1995 and 2021. After exclusion of those with other syndromes or developmental disorders, the study included 374 patients with sufficient follow-up until the age of 4 years, when language evaluation was possible. VPI status was categorized through subjective and objective tests into normal, VPI, and borderline. We analyzed potential differences in VPI incidence by multiple factors. Factors with significance were analyzed to confirm the relationships between subvariables. Results Of the 374 patients, 311 (83.2%) exhibited normal pronunciation, 51 (13.6%) had VPI, and 12 (3.2%) were borderline. Primary cleft palate repair performed after 18 months was associated with a higher incidence of VPI than repair conducted before 18 months ( p = 0.005). The incidence of VPI was higher in cases of submucous cleft palate than in the other types based on the Veau classification ( p = 0.011). However, in the multivariable analysis, only the submucous type showed statistically significant results ( p = 0.026). Conclusion A total of 374 people underwent primary cleft palate repair, and 13.6% of those with VPI required secondary therapy. The incidence of VPI was relatively high among patients with primary cleft palate repair after 18 months and patients with submucous cleft palate.

Evaluation of Vermillion Symmetry and Scar Quality in Unilateral Cleft Lip Repair Using Modified Millard's Technique Versus Fisher's Technique

BackgroundSince the primary goal of cleft lip repair is to achieve a symmetrical, aesthetic lip, several surgical techniques have been utilized. Accordingly, in this study, a unilateral cleft lip was surgically repaired using two techniques: modified Millard's and Fisher's techniques. PurposeThis study was designed to compare the vermillion symmetry and scar quality in the surgical management of patients with unilateral incomplete cleft lip using the modified Millard's and Fisher's techniques. Study design, setting, and sampleWe conducted a prospective randomized controlled clinical study. The study involved 20 patients selected from the Department of Plastic Pediatric Surgery at the Specialized Pediatric Hospital, Faculty of Medicine, Cairo University. The patients included in the study were aged between 2 and 6 months old, had a primary non-syndromic unilateral incomplete cleft lip, and had no other associated anomalies. Predictor variableThe predictor variable was operative management of the cleft lip, and subjects were randomly assigned to either the modified Millard or Fisher techniques. Outcome variablesThe primary outcome, vermilion symmetry, was evaluated by computerized photogrammetric lip analysis with Image J software. Additionally, scar quality, considered a secondary outcome, was assessed with the Vancouver Scar Scale and the Image J software. Every measurement was meticulously recorded in millimeters. CovariatesAge, sex, and cleft side were considered. AnalysesThe study comprised 20 children (12 males and 8 females), with a mean age of 140.5 ± 23.7 days in the Fisher’s group and 137.4 ± 25.6 days in the modified Millard’s group (p = 0.8). No statistically significant differences (p = 0.6) were found in vermillion height and width between both groups at 1 week, 3 months, and 6 months. Similarly, there were no statistically significant differences (p = 0.4) between both groups in terms of scar length and width at the 3- and 6-month follow-up periods. Conclusions and RelevanceThis study found no statistically significant differences in vermillion symmetry and scar quality between the two cleft lip repair techniques. Notably, one patient in the modified Millard group exhibited a notch on the vermillion border, which was not statistically significant.

Long-term results of orbicularis oris muscle reconstruction in primary cleft lip repair using the "basket-weave method".

The basket-weave method is an orbicularis oris muscle reconstruction method used in primary unilateral cleft lip repair. We compared the long-term results of the basket-weave method with those of a conventional method. For primary unilateral cleft lip repair, we compared the long-term results of 7 cases in which the orbicularis oris muscle was reconstructed by use of the basket-weave method, and of 7 cases in which the reconstruction was performed by use of the conventional method. The average postoperative follow-up period was 12 years and 7 months for the basket-weave method, and 11 years and 9 months for the conventional method. Using photographs of the front and elevation angle views, we evaluated the results as good if the philtrum ridge was formed on the fissure side and was almost symmetrical in height; as fair if the philtrum ridge was lower than the normal side; and as poor if the philtrum ridge had disappeared. For the basket-weave method, the results were good in 6 cases (85.7%), fair in 1 case (14.3%), and poor in 0 cases. For the conventional method, the results were good in 2 cases (28.6%), fair in 4 cases (57.1%), and poor in 1 case (14.3%). A significant difference was found between the 2 groups (Mann-Whitney U test, P = 0.0417). The philtrum ridge shape could be reconstructed by use of the basket-weave method, which gave better results in the long-term than did the conventional method for orbicularis oris muscle reconstruction in primary unilateral cleft lip repair.

Alveolar Oral Layer Repair by Periosteal Grafts versus Maxillary Flaps and Gingivoperiosteoplasty: Techniques and Follow-up to Adolescence.

Alveolar periosteoplasty during primary repair of cleft lip is still a topic of debate due to the fear exacerbating maxillary retrusion. The authors present their experience with early closure of alveolar clefts. The study aims to analyze gingivoperiosteoplasty (GPP) by comparing the use of locoregional flaps versus distant grafts for reconstruction of the lower layer of the primary palate cleft. Seventeen infants underwent 22 alveolar cleft repairs. After nasal floor repair by nasal mucoperiosteum, the oral layer was repaired by maxillary or gingival periosteal flaps in seven patients with alveolar clefts less than or equal to 6 mm wide, and tibial or pericranial periosteal grafts in 10 patients with wider clefts. At teenage years, crossbites in three flap-GPP and three graft-GPP patients were compared with nine older adolescents without primary GPP. Alveolar clefts were perfectly sealed. Radiographs during the early 3 postoperative years showed new bone formation more posteriorly extended in patients who underwent graft-GPP. Teeth eruption and alveolar rigidity at the mixed dentition age eliminated the need for secondary bone grafting. The anterior crossbites in adolescent patients ranged between -2 and -14 mm; crossing was relatively smaller in patients with a younger age and without cleft palate. The mean crossbite was 7.2 mm in the six teenagers and 9.6 mm in the control cases. Graft-GPP may be a good alternative to flap-GPP, particularly for wide alveolar cleft repair. Maxillary retrusion is aggravated in patients with cleft palate and older age at assessment. GPP may not increase crossbite.

Is Botox or Dermabond Superior in the Appearance of the Lip Scar After Primary Cleft Lip Repair and Revision? A Systematic Review and Meta-Analysis

Background: Cleft lip scar formation is an inevitable consequence of cleft lip repair (CLR) and is exacerbated by the dynamic movement of the middle face. Various methods to correct or prevent these deformities have been described including silicone sheeting, surgical revisions, laser therapy, and more recently, Botulinum toxin-A (Botox) and Dermabond. This study aims to analyze and compare the impact of Botox versus Dermabond on scar appearance after CLR. Methods: Following PRISMA guidelines, a systematic review was performed on Medline, Embase, Cochrane, and CINAHL using the following keywords: “Dermabond,” “botulinum toxin,” and “cleft lip.” Outcomes of interest were the rates of scar hypertrophy, scar width, Vancouver scar scale (VSS), visual analog scale (VAS), Hollander wound evaluation scale (HWES), and complications. Results: Nine studies were included of which 4 articles analyzed Botox and 5 analyzed Dermabond. Forest plots for scar width at the first and second time point supported the use of Botox to achieve a smaller scar width with P &lt; .0001 (95% CI: −1.09 [−1.56 to −0.63] and 95% CI: −0.94 [−1.37 to −0.50], respectively). A significant increase in VAS was observed with Botox (95% CI: 1.66 [1.27-2.05], P value &lt; .0001) and VSS was insignificant. Of the articles that analyzed Dermabond, scar appearance was comparable to the traditional suture closure group. There were no feeding complications for either intervention. Pooled forest plots for VAS comparing Botox and Dermabond supported the use of Botox with improved VAS (95% CI: 1.66 [1.27-2.05], P &lt; .0001) compared to Dermabond (95% CI: 0.07 [ −0.48 to 0.61], P = .80). Conclusions: The current literature supports the use of Botox for scar improvement following CLR or revision. However, there is limited data to support Dermabond’s utility in improving scars in CLR, which highlights the need for further studies.

Upper Esophageal Sphincter Dysfunction in Children with Type 1 Laryngeal Cleft after Failed Primary Cleft Repair.

Changes in pharyngeal and upper-esophageal-sphincter (UES) motor dynamics contribute to swallowing dysfunction. Children with type 1 laryngeal clefts can present with swallowing dysfunction and associated symptoms which may persist even after the initial endoscopic intervention. This study sought to characterize pharyngeal and esophageal motor function in children with type 1 laryngeal clefts who had persistent presenting symptoms after their initial therapeutic intervention. We retrospectively analyzed high-resolution esophageal manometry studies of children ≤ 18 years old with type 1 laryngeal clefts who had an esophageal manometry study performed for persistent symptoms after an initial repair. A total of 16 children were found to have significantly increased UES resting pressure, UES pre- and post-swallow maximum pressures, and duration of UES contraction during swallows in comparison to nine age-matched controls of children without pharyngeal anatomical abnormalities. There was no difference between UES residual pressures or pharyngeal dynamics between the two groups. UES resting and residual pressures did not correlate with VFFS in penetration and aspiration scores of children with type 1 laryngeal clefts status post repair. Our study is the first to identify specific changes in UES motor function in patients with type 1 laryngeal cleft post initial repair.

Esthetic Outcomes of Primary Cleft Lip Repair Utilizing 2-Octyl Cyanoacrylate Liquid and a Self-adhesive Polyester Mesh Tape

Background: The method of epidermal closure during cleft lip repair is important to consider, as it may affect complication rates, cosmetic outcomes, and patient comfort levels. Historically, this has most commonly been performed with permanent suture that requires subsequent removal, which is not well tolerated in infants. The purpose of this study is to compare the outcomes between 2-octyl cyanoacrylate liquid with a self-adhesive polyester mesh tape (2-OPMT) and typical suture closure techniques, which to our knowledge has never previously been investigated. Methods: In nine consecutive cleft lip repairs, the epidermal closure was performed with permanent suture, and in the subsequent nine consecutive cleft lip repairs, the epidermal closure was performed with 2-OPMT. Complication rates were compared between the groups. Esthetic scar outcomes were investigated via post-operative photograph analysis utilizing the Manchester Scar Scale. Statistical significance was determined with Fischer Exact Tests and Wilcoxon Rank-Sum tests. Subsequently, scar scores for 30 cleft lip repairs performed with 2-OPMT in our practice were compared to previously reported scores in the literature for 30 cleft lip repairs performed with typical suture technique. Results: Three patients in the permanent suture group had documented scar-related complications and one patient in the 2-OPMT group had documented scar-related complications. No statistically significant difference was found in complication rates between the two groups. No statistically significant difference was found in esthetic scar scores between the two different closure techniques either within our practice or in comparison to reports in the literature. Conclusions: Overall, the use of 2-OPMT offers comparable esthetic outcomes and complication rates to the use of permanent suture in epidermal closure of cleft lip repairs.

Enhancing Airway Strategies in Treacher Collins Syndrome Infants during Primary Facial Cleft Closure

Enhancing Airway Strategies in Treacher Collins Syndrome Infants during Primary Facial Cleft Closure

A Scoping Review of Adjuvant Perioperative Therapies for Primary Cleft Lip Repair

Background:To date, there is little guidance regarding current adjuvant therapies for primary surgical repair of cleft lip. There are studies on the effect of botulinum toxin type A, revision fat grafting, silicone gel and sheeting, intense pulsed light, and carbon dioxide lasers to ameliorate contracture and hypertrophic scar formation, but a comprehensive review of these options is lacking. The aim of this scoping review is to examine adjuvant techniques and therapies that modulate scar outcomes for primary cleft lip repair outcomes in the perioperative period. Methods: PROSPERO, PubMed/MEDLINE, SCOPUS, Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrial.gov were searched for studies that evaluated adjuvant therapies for primary cleft lip repair. Results: The initial search resulted in 688 studies, with 48 studies including relevant key terms in the title and abstract screening. After the full-text screening, 11 studies were included in the final scoping review. These included 3 studies about use of botulinum toxin injection, 2 studies about fat grafting, 2 studies about nasal stents, and 4 studies about various topical treatments. In the Jadad quality index evaluation and MINORS assessment of the methodological quality of the included papers, there was a strong level of agreement among the 2 raters respectively (weighted κ = 1, κ = 0.817, both P-value &lt; .0001). Conclusion: From this scoping review, adjuvant therapies such as utilizing botulinum toxin and immediate fat grafting intraoperatively and nasal stents and topical treatments including antibiotic ointment, lidocaine, hydrogen peroxide, and silicone gels postoperatively are worthwhile to consider as a combination of adjuvant treatments to prevent adverse scar formation in patients undergoing primary cleft lip repair. The most robust evidence lies with botulinum toxin use.

Treatment Modalities to Achieve Nasal Symmetry in Unilateral Cleft Lip/Nasal Deformity: An Objective and Comparative Evaluation.

Primary cleft lip repair techniques do not address the nasal deformity adequately resulting in nasal asymmetry. Maneuvers employed to minimize this have varying degrees of success. To assess the outcome of different treatment modalities employed to establish nasal symmetry in unilateral cleft lip. 100 patients with complete unilateral cleft lip/ palate operated for primary cheiloplasty with modified Millard's rotation advancement technique were divided into five groups. Group 1: lip repair alone, Group 2: NAM followed by lip repair, Group 3: lip repair followed by placement of conformers, Group 4: NAM followed by lip repair and placement of conformers, Group 5: lip repair with semi-open rhinoplasty. Objective assessment was done using measurable parameters after 12months post-operatively on a 1:1 standard photograph. Group 5 showed statistical significance in all parameters assessed. Progressive improvement in nasal symmetry was noted from Group 1 to Group V. In our study, group V, i.e., modified Millard's repair with semi-open rhinoplasty improved the results in terms of all the objective parameters assessed. The results of the other groups showed improvement though not consistent in all parameters. Naso-alveolar molding is an effective adjunct. Additionally, nasal conformers proved to be of great value in retaining the results obtained post-surgery.

Buccal Fat Pad in Primary and Secondary Cleft Palate Repair: A Systematic Review of the Literature.

To review the evidence supporting the use of buccal fat pad (BFP) in primary and secondary cleft palate repair and its short- and long- term clinical outcomes. Systematic review conducted by 2 independent reviewers following PRISMA guidelines. Articles were identified from three databases (Pubmed/Medline, Embase and Web of Science). Search terms included "cleft palate", "palatoplasty", "palate repair", "buccal fat pad". Use of BFP in primary and secondary cleft palatoplasty. Primary outcomes were immediate postoperative complications, postoperative fistula, and maxillary growth. Secondary outcomes were palatal length, speech, and donor site morbidity. Ninety-one reports were retrieved after excluding duplicates. Twenty-three studies were included (13 case series and 10 comparative studies). Overall level of evidence was low. Randomized and non-randomized studies had a high risk of bias. In primary palatoplasty, BFP was more frequently used filling lateral relaxing incisions(57.4%), or in the hard-soft palate junction and covering mucosal defects(30.1%). In these patients, post operative fistula incidence was 2.8%. Two studies found wider transverse maxillary dimensions after BFP use. No higher incidence of bleeding, infection, dehiscence, or flap necrosis was reported. In secondary palatoplasty, no recurrent fistulas were reported for patients undergoing BFP for fistula repair. BFP appears to be associated with a favorable impact in fistula prevention and management, as well as in transverse maxillary growth. However, there is a high heterogeneity among studies, high risk of bias and overall low quality of evidence. More high-quality research with long-term follow-up is warranted.