Surgical Repair Of Cleft Palate Research Articles

Comparison of the Outcomes of Surgical Repair of Cleft Palate Performed by Modified Von Langenbeck and Bardach (Two-Flap Palatoplasty) Methods.

Cleft lip and cleft palate are one of the most common congenital craniofacial abnormalities in the skull and face. We aimed to investigate the prevalence of complications after primary cleft palate repair surgery, performed on patients referred to a children's hospital, and to use the information and results obtained from it to reduce the complications and improve the results of these surgeries. In this cross-sectional-analytical study, using a census sampling method, the medical records of 94 consecutive cleft palate patients treated in Abuzar Hospital in Ahvaz, southern Iran, in the years 2019 to 2021 were studied. The rate of postoperative complications during the first week in terms of wound opening and flap necrosis and one month later in terms of fistula formation after surgery were also extracted from the files. Ninety-four patients with congenital cleft palate (57.4% male and 42.6% female) were enrolled. The gap width in all studied patients was 14 ± 5 mm. The frequency of complications of surgical wound opening, flap necrosis, oronasal fistula and hypernasality in von Langenbeck group was 9.5%, 0.15% and 28.1% respectively, and in Bardach group was 9.5 %, 15% and 33.3% respectively. There were no significant differences between the two surgical methods in terms of postoperative complications. Besides, what is important in choosing a surgical method is the patient's clinical condition, the surgeon's experience and skill, and his choice.

H04 The sign of Leser–Trélat: an eponymous misnomer?

Abstract The sign of Leser–Trélat is a paraneoplastic phenomenon consisting of a sudden eruption of seborrhoeic keratoses. It is credited to two surgeons, Edmund Leser (1853–1918) and Ulysse Trélat (1827–1890), who described cutaneous lesions associated with internal malignancies. Edmund Leser, the author of the Textbook of Special Surgery in 50 Lectures, initially studied law in Bonn before qualifying in medicine in Leipzig in 1880. He became Richard von Volkmann’s assistant at Martin Luther University. He was awarded his chair of surgery in 1894, 10 years after becoming a surgeon, and he practised in Goethe University, Frankfurt. Ulysse Trélat was born in Paris in 1827. His father was a republican political activist, Minister of Public Works and known as the founder of public hygiene in France. Ulysse Trélat was employed as an assistant anatomist in surgery at the ‘École Pratique’ 1 year before graduating high school in 1844. He finished his medical studies in 1854 and became a surgeon in 1857. In 1858, he was running the anatomy course in ‘École Pratique’. He replaced Paul Broca, well known for his research on Broca’s area in the frontal lobe, at Hospital Necker in 1880. In 1884, he was awarded a chair of surgery at ‘Hospital de la Charite’, replacing Leon Athanase Gosselin. Notable among his works is the description of the ‘Baizeau and Trélat method’ of surgical repair of cleft palate, and his book Clinique Chirurgicale. Leser and Trélat independently published papers describing skin lesions associated with mammary carcinoma and visceral malignancies. However, their description of cutaneous lesions was more in keeping with the appearance of senile angiomata or Campbell de Morgan spots. Therefore, the credit should go to Eugen Von Hollander (1867–1932), another German surgeon who accurately described the lesions in a paper published in 1900 titled ‘Contributions to the early diagnosis of intestinal carcinomas’. He observed skin changes associated with internal malignancies consisting of an eruption of flat, shiny, pigmented, glandular, epithelial growths similar to seborrhoeic warts or verrucae seniles in young patients with cancer. He hypothesized that there might be a link between abnormal epithelial proliferation in internal organs and skin keratinocyte proliferation. He is remembered for performing the first facelift, on a Polish aristocrat in 1912. The sign of Leser–Trélat is so deeply embedded in medical literature and the minds of modern practitioners that it is unlikely to ever be erased. However, the contribution of Eugen Von Hollander should not be forgotten.

Human levator veli palatini muscle: a novel source of mesenchymal stromal cells for use in the rehabilitation of patients with congenital craniofacial malformations

BackgroundBone reconstruction in congenital craniofacial differences, which affect about 2–3% of newborns, has long been the focus of intensive research in the field of bone tissue engineering. The possibility of using mesenchymal stromal cells in regenerative medicine protocols has opened a new field of investigation aimed at finding optimal sources of multipotent cells that can be isolated via non-invasive procedures. In this study, we analyzed whether levator veli palatini muscle fragments, which can be readily obtained in non-invasive manner during palatoplasty in cleft palate patients, represent a novel source of MSCs with osteogenic potential.MethodsWe obtained levator veli palatini muscle fragments (3–5 mm3), during surgical repair of cleft palate in 5 unrelated patients. Mesenchymal stromal cells were isolated from the muscle using a pre-plating technique and other standard practices. The multipotent nature of the isolated stromal cells was demonstrated via flow cytometry analysis and by induction along osteogenic, adipogenic, and chondrogenic differentiation pathways. To demonstrate the osteogenic potential of these cells in vivo, they were used to reconstruct a critical-sized full-thickness calvarial defect model in immunocompetent rats.ResultsFlow cytometry analysis showed that the isolated stromal cells were positive for mesenchymal stem cell antigens (CD29, CD44, CD73, CD90, and CD105) and negative for hematopoietic (CD34 and CD45) or endothelial cell markers (CD31). The cells successfully underwent osteogenic, chondrogenic, and adipogenic cell differentiation under appropriate cell culture conditions. Calvarial defects treated with CellCeram™ scaffolds seeded with the isolated levator veli palatini muscle cells showed greater bone healing compared to defects treated with acellular scaffolds.ConclusionCells derived from levator veli palatini muscle have phenotypic characteristics similar to other mesenchymal stromal cells, both in vitro and in vivo. Our findings suggest that these cells may have clinical relevance in the surgical rehabilitation of patients with cleft palate and other craniofacial anomalies characterized by significant bone deficit.

Cleft palate, treatment and complications

Introduction: The purpose of this study is to determine the incidence of velopharyngeal insufficiency (VPI), fistulae and recurrence development in patients seen by the Isfahan Cleft Care Clinic and also determine the association of gender, age at repair, and cleft type with the incidence of each.
 Methods and materials: In this retrospective study, 320 children who had undergone a primary cleft palate surgery and who had come to the Cleft lip and palate in Isfahan in 2010-2017 were studied based on the medical records and Information about each patient. Then all patients were evaluated by standard speech assessment methods for severity of hypernasalitis and screened for clinical manifestations of fistula and recurrence.
 Results: According to the results of this study, the incidence of velopharyngeal insufficiency after initial repair was 78.1% and most of these patients had severe form. The results also showed that by increasing age at surgery also increased the intensity of velopharyngeal insufficiency, and the severity of this complication has nothing to do with gender. In the case of fistula and recurrence of cleft showed that, in patients who are undergoing the new procedure to be significantly less than other patients.
 Conclusion: According to the study, palatoplasty complications such as velopharyngeal insufficiency, fistula, and recurrence were less common in patients treated with microsurgery, Therefore, it can be concluded surgical repair of cleft palate should be performed before 12 months ages and in microsurgery methods. It seems that follow up of these patients after surgery for monitoring of speech complications is necessary.

Surgical Repair of Orofacial Clefts in North Kivu Province of Eastern Democratic Republic of Congo (DRC).

There is a high prevalence of orofacial clefts in low- and middle-income countries with significant unmet need, despite having 50% of the population younger than 18 years in countries such as the Democratic Republic of Congo (DRC). The purpose of this article is to report on the experience of general surgeons with orofacial clefts at a single institution. This is a retrospective study of patients treated for cleft lip/palate in the province of North Kivu, DRC between 2008 and 2017. A total of 1112 procedures (122/year) were performed. All procedures were performed by general surgeons following training by an international nongovernmental aid organization. A total of 59.2% of patients were male and the median age was 3.4 years (interquartile range: 0.7-13 years). Average distance from surgical center to patient location was 242.6 km (range: 2-1375 km) with outreach performed for distances >200 kms. A majority (82.1%) of patients received general anesthesia (GA) with significant differences in use of GA, age, weight, and length of stay by major orofacial cleft category. Of the 1112 patients, 86.1% were reported to have cleft lip alone, 10.5% had cleft lip and palate, and 3.4% cleft palate alone. Despite this, only 5.3% of patients underwent surgical repair of cleft palate. Multiple factors including malnutrition, risk of bleeding, procedural complexity, and cosmetic results may contribute to the distribution of procedures performed where most cleft palates are not treated. Based on previously published estimates, unmet needs and social burden of cleft lip and palate are high in the DRC.

Analysis of velopharyngeal function and speech outcomes of Sommerlad palatoplasty combined with sphincter pharyngoplasty in surgical repair of older patients with cleft palate：experience from a major craniofacial surgery centre in eastern China.

We aimed to evaluate velopharyngeal function and speech outcomes of Sommerlad palatoplasty combined with sphincter pharyngoplasty in surgical repair of cleft palate in patients over five years old. Fifty-eight patients were reviewed between the years 2013 and 2017, 31 of whom were treated with Sommerlad palatoplasty combined with sphincter pharyngoplasty, (mean age 15 (range 9 - 22) years), and 27 were treated with Sommerlad palatoplasty alone (mean age 18 (range 10-25) years). Velopharyngeal function was evaluated by radiographic lateral cephalometry and nasoendoscopy. Hypernasality, nasal emissions, and intelligibility were used to assess speech. The rate of velopharyngeal competence was 20/31 in the palatoplasty plus pharyngoplasty group and 7/27 in the palatoplasty alone group after surgical treatment (p=0.003). The improvements in hypernasality (p=0.024), air emission (p=0.004), and speech intelligibility (p=0.004) in the palatoplasty plus pharyngoplasty group was better than that in the palatoplasty alone group. It has been suggested that the surgical approach with the palatoplasty together with the sphincter pharyngoplasty has a higher rate of success in surgical repair of older patients with cleft palate.

The Effect of Cleft Palate Repair on Polysomnography Results.

In view of the risk that surgical repair of cleft palate may induce or worsen obstructive sleep apnea (OSA), the goal of this study was to assess presurgical and postsurgical polysomnography (PSG) results for children who underwent primary palatoplasty. Retrospective case-control series for children with cleft palate repair performed between January 2008 and December 2016 at a tertiary pediatric center. Children underwent PSG before and after surgery. Sixty-four children (53.1% female) with a mean age of 2.0 ± 2.8 years (range 0.6-16.4) were included in the study. Pierre-Robin sequence was the most common comorbidity (67%). Before palatal repair, the mean obstructive apnea-hypopnea index (oAHI) was 3.4 ± 3.9 (range 0-17.9) events/h; this did not significantly change, with 5.9 ± 14.5 (range 0-105.7) events/h after surgery (P = 0.30). However, 34.4% of patients had a worsening of more than 1 obstructive event/h and 18.9% had a worsening of 5 or more obstructive events/h. The presence of a concomitant syndrome (eg, Treacher Collins) was a risk factor for postoperative OSA (odds ratio 4.2, 95% confidence interval 1.1-15.8, P = .03). OSA did not develop or worsen following primary palatoplasty. However, the oAHI increased by 5 or more events/h in approximately 20% of study participants. The presence of a syndrome was the only factor predictive of worsening OSA after palatoplasty. These findings suggest that palatoplasty does not worsen or cause OSA in most patients, and that nonsyndromic children are at low risk for the development or worsening of OSA.

Tomasz Drobnik (1858–1901)—An Assistant Who Equalled His Masters

Tomasz Drobnik (1858–1901) was a Polish-born practicing surgeon who developed new surgical techniques despite working under adverse political conditions. Having completed his medical studies in Wurzburg, he worked in a few German hospitals, among others in Strasbourg, where he developed new principles of thyroid surgery, particularly a new method of accessing the gland. Beginning in 1887 Drobnik worked in Koningsberg, in Professor Mikulicz-Radecki’s hospital, where he developed a new method of surgical repair of cleft palate, as well as a technique of facial nerve crossover anastomosis, probably the first in the world. He continued his research and practice in Poznan, where he moved in 1890. This is where he laid the foundations of a new branch of medicine, today known as neuro-orthopedics. He was the first to perform a successful tendon transfer, subperiosteal implantation of a tendon, and vascularized muscle transfer. His perception of musculoskeletal system disorders as being dynamic led him to develop a cutting-edge method of club foot treatment. Drobnik achieved all this on his own while working as an assistant in a Poznan Town Hospital devoid of the research facilities of academic medical centers. Alongside his research, he was also engaged in community service. He was equally devoted to his Polish and German patients, even at the time of escalation of national animosities.

Cleft palate repair and variations

ABSTRACTCleft palate affects almost every function of the face except vision. Today a child born with cleft palate with or without cleft lip should not be considered as unfortunate, because surgical repair of cleft palate has reached a highly satisfactory level. However for an average cleft surgeon palatoplasty remains an enigma. The surgery differs from centre to centre and surgeon to surgeon. However there is general agreement that palatoplasty (soft palate at least) should be performed between 6-12 months of age. Basically there are three groups of palatoplasty techniques. One is for hard palate repair, second for soft palate repair and the third based on the surgical schedule. Hard palate repair techniques are Veau-Wardill-Kilner V-Y, von Langenbeck, two-flap, Aleveolar extension palatoplasty, vomer flap, raw area free palatoplasty etc. The soft palate techniques are intravelar veloplasty, double opposing Z-plasty, radical muscle dissection, primary pharyngeal flap etc. And the protocol based techniques are Schweckendiek's, Malek's, whole in one, modified schedule with palatoplasty before lip repair etc. One should also know the effect of each technique on maxillofacial growth and speech. The ideal technique of palatoplasty is the one which gives perfect speech without affecting the maxillofacial growth and hearing. The techniques are still evolving because we are yet to design an ideal one. It is always good to know all the techniques and variations so that one can choose whichever gives the best result in one's hands. A large number of techniques are available in literature, and also every surgeon incorporates his own modification to make it a variation. However there are some basic techniques, which are described in details which are used in various centres. Some of the important variations are also described.

Cleft palate repair and variations

Cleft palate affects almost every function of the face except vision. Today a child born with cleft palate with or without cleft lip should not be considered as unfortunate, because surgical repair of cleft palate has reached a highly satisfactory level. However for an average cleft surgeon palatoplasty remains an enigma. The surgery differs from centre to centre and surgeon to surgeon. However there is general agreement that palatoplasty (soft palate at least) should be performed between 6-12 months of age. Basically there are three groups of palatoplasty techniques. One is for hard palate repair, second for soft palate repair and the third based on the surgical schedule. Hard palate repair techniques are Veau-Wardill-Kilner V-Y, von Langenbeck, two-flap, Aleveolar extension palatoplasty, vomer flap, raw area free palatoplasty etc. The soft palate techniques are intravelar veloplasty, double opposing Z-plasty, radical muscle dissection, primary pharyngeal flap etc. And the protocol based techniques are Schweckendiek's, Malek's, whole in one, modified schedule with palatoplasty before lip repair etc. One should also know the effect of each technique on maxillofacial growth and speech. The ideal technique of palatoplasty is the one which gives perfect speech without affecting the maxillofacial growth and hearing. The techniques are still evolving because we are yet to design an ideal one. It is always good to know all the techniques and variations so that one can choose whichever gives the best result in one's hands. A large number of techniques are available in literature, and also every surgeon incorporates his own modification to make it a variation. However there are some basic techniques, which are described in details which are used in various centres. Some of the important variations are also described.

Chondroitin Sulfate in Palatal Wound Healing

Chondroitin sulfate is up-regulated in granulation tissue during wound healing. To investigate the role of chondroitin sulfate in the wound-healing process after surgical repair of cleft palate, we isolated and cultured rabbit palatal fibroblasts. Treatment with chondroitin-6-sulfate resulted in a dose-dependent increase in cell adhesion and cell proliferation, whereas the reverse effects were seen after chondroitinase degradation of chondroitin sulfate. The biological actions of chondroitin sulfate appeared to be dependent on the presence and position of sulfate groups. Inhibition of glycosaminoglycan sulfation by chlorate treatment led to reduced cell adhesion and cell proliferation and a slower rate of wound closure in vitro. Furthermore, exposure to chondroitin-4-sulfate resulted in a dose-dependent reduction in cell adhesion. Together, these results show that chondroitin sulfate is involved in palatal wound healing.

Maxillary dental arch and occlusion in repaired clefts of the secondary palate: influence of surgical closure with minimal denudation of bone.

A change in the method of surgical repair of cleft palate initiated this study of 64 patients with various degree of clefts of the secondary palate. Study casts were obtained at different ages. Certain measurements were taken and compared with those made in a previous investigation of similar patients operated on by the so-called "push-back" technique. Growth in the width of the maxillary dental arch and occlusion had improved, but there were significant differences only for the patients with velar clefts.

Ethical Issues in the Case of Surgical Repair of Cleft Palate

Ethical Issues in the Case of Surgical Repair of Cleft Palate

Ethical issues in the case of surgical repair of cleft palate.

There are some advantages to prospective randomized clinical trials (PRCT) to resolve some limited clinical problems. But, when this method is used to determine the best surgical procedure to close the palatal cleft space, there are strong ethical considerations that cannot be overcome. There are two basic problems. The first is having the surgeon perform surgical procedures which he/she does not believe is the treatment of choice or that can be performed as skillfully as others, even after demonstrations. Secondly, this method does not consider the theoretical aspect that many clefts within the same cleft type are different in the relative size of cleft space to size of soft tissue available for closing the cleft space, thereby creating different degrees of scarring. Different outcomes to the same surgery must, therefore, result irrespective of the surgeons' skills or treatment plans. Retrospective research studies, whether they involve one or more institutions, have been and are still very valuable in improving the knowledge base of all areas of cleft palate habilitation.

Non cardiogenic pulmonary edema as consequence of upper airway obstruction.

Non cardiogenic pulmonary edema is a rare complication of upper airway obstruction. Its etiology is controversial, but probably can be explained by the Starling's law, when the large negative intrathoracic pressure generated exceeds the intravascular and interstitial pressures, shifting fluids from capillaries to interstitium and alveoli. In addition, alteration of capillary permeability potentiates fluid migration. We present herein, a case of non cardiogenic pulmonary edema following relief of upper airway obstruction in a 14 years old girl underwent surgical repair of cleft palate. Cardiogenic pulmonary edema could be excluded by a normal CVP, wedge pressure and four chamber echocardiography. The edema fluid: plasma protein ratio greater than 0.7 can indicate an increased capillary permeability. Mendelson's syndrome could be ruled out by the rapid improvement seen and the soft clinical course.

Surgical repair of cleft palate in the horse.

Surgical repair of a cleft palate was carried out in three horses. Mandibular symphisotomy allowed adequate exposure of the defect. The first subject, a young foal died from inhalation pneumonia but the other two made satisfactory recoveries. The problems of closure of the lip and symphysis are discussed.

Surgical Repair of Cleft Palate

There are three major objectives in cleft palate surgery: to produce normal speech, to produce anatomic closure, and to minimize maxillary growth retardation and dental alveolar deformity. Any discussion of cleft palate surgery must be related to these objectives.

Surgical repair of cleft palate: With special reference to lengthening the soft palate

The best result is obtained if the operaation for the surgical repair of a cleft palate is postponed until the child is between eighteen months and two years of age, or even older. The tissues are then in better condition to withstand the necessary manipulation and the mortality following operation is much lower than when performed at an earlier age. Early operation is of no advantage from the standpoint of speech improvement. The so-called “cleft palate speech” represents the inability of the child to prevent air from passing into the nose, especially in the articulation of consonants. From the anatomical and physiological standpoint, the von Langenbeck procedure with modifications, is the operation of choice to close the palate cleft. The soft palate should also be immobilized by the lead ribbon or tension relief wire, as an important requirement of the operation. The methods developed in the past few years for lengthening the velum, furnish a better functioning palate with improved articulation as an immediate result. In this connection, the procedure that retains the tissue intact covering the repaired bony cleft, offers a secure method for preventing an anterior perforation, especially as the bone is often cleft much farther anteriorly than indicated by the soft tissue defect.