Wide Cleft Research Articles

Filling the Void: Use of the Interpositional Buccal Fat Pad to Decrease Palatal Contraction and Fistula Formation

Objective: The objective of this study was to evaluate the ability of the buccal fat pad flap (BFPF) to fill the void remaining after muscle transposition and study its effect on durability, fistula rate, palatal shortening/contraction, and relapse of muscle positioning in wide and challenging cleft repairs. Design: A retrospective chart review was performed. Charts were abstracted for standard demographics, reason for BFPF utilization, palatal length, palatal fistula, co-morbidities, and speech outcomes. Patients, Participants: Patients under age 3 who underwent primary palatoplasty between October 2007 and September 2015 which utilized a medially placed BFPF were identified. Results: Fifty-three patients were identified. Mean age at palatoplasty was 1.4 (0.78-2.55) years. Mean follow-up was 2.52 (0.02-7.26) years. Twenty-four (45.3%) patients had concerning intraoperative findings warranting flap utilization. Twenty-nine (54.7%) patients underwent BFPF for large dead-space volume. Four patients (7.55%) experienced a fistula. Thirty-nine patients had comments on their palatal length. Of these, 28 (71.8%) were of average length, and 8 (20.5%) were long. Thirty-three patients have undergone formal speech evaluation. Of these, 20 (60.6%) were of normal resonance, and 12 (36.4%) demonstrated nominal hypernasality. No patients have yet to require a secondary speech operation. Conclusion: Use of the BFPF has become more common in our practice particularly in challenging cleft palate repairs. It is a versatile technique addressing large interpositional dead space and thin outer and inner lamellae in the anterior soft palate after posterior muscle transposition. Early results, in difficult repairs, demonstrate excellent durability and that palatal length appears to be maintained, potentially lessening the need for secondary speech surgery.

Is the early mixed dentition dental arch relationship related to the anteroposterior alignment of the maxillary segments in infants with CUCLP?

Midface retrusion is a concern in patients with complete unilateral cleft lip and palate (CUCLP). Maxillary segment alignment may influence the prognosis after corrective surgery. This study assessed the association between maxillary segment alignment and interarch relationship observed in the early mixed dentition. The null hypothesis was that there is no relation between the initial alignment of cleft segments and the width of the cleft in the infant, and the early mixed dentition interarch relationship. The sample consists of 352 children with CUCLP treated at the Hospital for Rehabilitation of Craniofacial Anomalies/USP. Dental models were obtained before lip repair at three months and at the age of six. Based on the first, the sample was then divided into two groups: anteroposterior aligned and anteroposterior misaligned maxillary segments. They were also divided into 4 groups according to the cleft width (Narrow, Medium, Wide and Very Wide). Interarch relationship was graded using the 5-year-old index. The statistical association was evaluated using the chi-squared test (P<.05). Cleft width was inversely related to interarch relationship in the early mixed dentition phase. Interarch relationship at the age of six was more favourable in children with misaligned maxillary segments than in children with aligned segments (P=.048). Five-year interarch relationship in patients with CUCLP is related to the anteroposterior relationship of infant maxillary segments and initial cleft width before primary surgeries. Wide alveolar clefts and sagittally aligned maxillary segments showed a worse interarch relationship in the early mixed dentition.

Analysis of the Intrinsic Predictors of Oronasal Fistula in Primary Cleft Palate Repair Using Intravelar Veloplasty.

The purpose of the present study was to investigate various factors of cleft palate and to analyze their effect on fistula occurrence following palatal muscle repair using intravelar veloplasty. A retrospective review of patients who underwent palatoplasty was performed. Primary palatoplasty was performed by a single surgeon in a single center. A total of 165 patients who underwent palatoplasty were enrolled. Primary palatoplasty with levator veli palatini muscle repair using intravelar veloplasty was performed. Three extrinsic factors (age, gender, and body weight) and 6 intrinsic factors (cleft width, ratio of cleft width to intermaxillary tuberosity distance, cleft anterior margin shape, uvula position, cleft lip, and radical intravelar veloplasty) were analyzed. Palatal fistula occurred in 11 (6.67%) patients. The occurrence of fistula was significantly correlated with a specific Veau classification, that is, type II (P = .041). Fistula tended to occur more frequently with a wide cleft palate (P = .063), and the high-risk cutoff value of the width was 7.75 mm. A larger cleft width tended to increase the occurrence of fistula. Close observation and information about the higher risk of fistula formation should be given to patients with a large cleft width who underwent intravelar veloplasty.

Abstract QS11: The Burden Of Nasoalveolar Molding: Is It The Most Cost-effective Approach To Facilitate Wide Cleft Lip And Nasal Repair?

Purpose: Over the last three years a shift at our institution has taken place in which patients originally designated for nasoalveolar molding (NAM) as an adjunct to cleft lip repair (repair after 3 months) have instead undergone early cleft lip repair (ECLR) (2-5 weeks of life) without NAM. After implementing the ECLR program at CHLA, only a small subset of patients still undergo NAM with the standard surgical timing of repair. The financial and social impact of this potential paradigm shift has not been studied. We sought to examine the financial and cost-effectiveness of the ECLR protocol. Methods: We reviewed records for all patients who underwent NAM as an adjunct to cleft lip repair from November 2011 to June 2018. From November 2011 to February 2014, NAM with standard timing of lip repair was the only intervention offered to patients with wide cleft lip defects. From February 2014 to June 2018, ECLR without adjunctive NAM was offered as an alternative. Retrospective chart review of the two groups was conducted with emphasis on the following variables: NAM and ECLR cleft classifications, NAM dental visits, ECLR length of hospital stay, ECLR patients’ cleft width ratio (CWR), and operative dates. ECLR patients who had a Cleft Width Ratio (CWR), defined as the cleft width/commissure width, of > 0.5 and unilateral complete cleft lip (UCL) were identified as patients who would have originally been offered NAM as an adjunct to their cleft lip repair. Results: NAM patients required an average of 11 preoperative dental visits, accounting for $2,132 in lost income per family. The average direct costs of NAM totaled $12,290 for the hospital, physician, and device costs. The cumulative direct cost of NAM over the entire study period was $970,910. ECLR patients underwent lip repair significantly earlier than NAM patients (33 ± 14 days vs. 112.9 ± 28 days, p< 0.001). Following the introduction of ECLR, NAM usage decreased by 48% (52 to 27 patients) and unilateral cleft lip patients undergoing NAM decreased by 86% (35 to 5 patients). 26 patients were diverted from NAM to ECLR resulting in a healthcare cost burden of $319,540 less ($96,830 per year). Conclusion: ECLR without NAM is more cost-effective and results in excellent surgical and aesthetic outcomes. NAM as an adjunct to wide cleft lip and nasal repair is no longer the most cost-effective option at our institution. We believe that ECLR has the potential to decrease the burden of health care costs in the United States.

Interdental Distraction Osteogenesis in Unilateral Cleft Lip and Palate Patient with Wide Alveolar Cleft

Alveolar bone grafting is routinely performed in repair of alveolar clefts. When the alveolar cleft is wider than 11 mm, however, the survival rate of the bone graft and prognosis are poor. Here, we describe successful orthodontic treatment using interdental distraction osteogenesis (IDO) with a tooth-tooth type distractor to reduce the width of the alveolar cleft in a patient with unilateral cleft lip and palate. The patient was a 12-year-old girl with unilateral cleft lip and palate, maxillary dentition midline deviation, congenitally missing maxillary lateral incisors, a palatally-displaced right upper first premolar, a wide alveolar cleft (20 mm), and mandibular prognathism due to maxillary hypoplasia. Treatment comprised a combination of orthodontic treatment and IDO. After treatment, appropriate occlusion, space closure in the maxillary arch, coincidence of the maxillary and facial midlines, and incorporation of the right maxillary first premolar into the arch were obtained. These results suggest that IDO is effective in treating cleft lip and palate patients with a wide alveolar cleft.

Does Primary Vomer Flap Significantly Affect Maxillary Growth?

BACKGROUNDCleft lip and palate (CLP) is a common congenital anomaly. Efficient surgical management of CLP is challenging in severe cases with wide clefts. Use of primary vomer flap simultaneous with cleft lip repair is effective in some cases, but remains a challenging topic. METHODSThis study evaluated 81 non-syndromic CLP patients with extensive palatal cleft and no other underlying condition. Thirty-nine patients (group A) who were infants over 6 months of age underwent primary vomer flap during lip repair to decrease the size of their extensive palatal cleft. The results in this group were compared with group B (n=42) who did not receive primary vomer flap.RESULTSComparison of the two groups showed that although maxillary growth impairment and maxillary constriction had a higher frequency in group A, the palatal cleft was smaller among them, which enabled easier and more efficient cleft repair in the next step. The difference in maxillary growth impairment was not significant between the two groups. However, the prevalence of some complications such as velopharyngeal incompetence and maxillary growth impairment was slightly higher in group A compared with group B. CONCLUSIONUse of primary vomer flap at the time of lip repair can decrease the size of palatal cleft and enhance its later closure. However, since impairment of the maxillary growth was slightly (but insignificantly) higher in the vomer flap group, it should be performed at ages over 6 months of age, as well as in certain cases.

Early outcomes of cleft and palatal width following anterior palate repair (vomerine flap) in infants with wide cleft lip and palate.

BackgroundAnterior palatal repair performed during cleft lip repair using a vomerine flap may assist in recruiting additional soft tissue for subsequent completion of palatoplasty, especially in patients with a wide cleft. We present our early results in the hope of triggering a re-evaluation of this technique regarding its advantages for maxillary growth through further studies of patients with a wide cleft.MethodsA retrospective analysis of patients with complete unilateral and bilateral cleft lip and palate was performed, including cleft and palatal measurements taken during initial surgery (lip repair together with anterior palate repair) and upon completion of palatoplasty.ResultsIn total, 14 patients were included in this study, of whom nine (63.3%) had unilateral cleft lip and palate and five (37.5%) had bilateral cleft. All patients had a wide cleft palate. Lip and anterior palate repair was done at a median age of 3 months, while completion of palatoplasty was done at a median age of 10.5 months. Measurements taken upon completion of palatoplasty showed significant cleft width reduction in the mid-palate and intertubercle regions; however, the palatal arch distances at nearby landmarks showed non-significant marginal changes.ConclusionsAnterior palate repair using a vomerine flap significantly reduced the remaining cleft width, while the palatal width remained. Further research is warranted to explore the long-term effects of this technique in wide cleft patients in terms of facial growth.

Does the Children's Hospital of Philadelphia Modification Improve the Fistula Rate in Furlow Double-Opposing Z-Plasty?

Oronasal fistulas (ONFs) have been the most common complication of primary cleft palatoplasty. The present study evaluated the incidence of ONFs after primary standard Furlow and modified Furlow palatoplasty and a buccal fat pad flap (BFPF) as a viable tissue layer to facilitate wound healing. A retrospective cohort study was conducted. The data from all the patients who had met the criteria for primary palatoplasty from 2003 to 2016 and had undergone surgery by a single surgeon were retrospectively reviewed from an established cleft databank. An initial group of patients (2003 to 2007; standard Furlow palatoplasty) and a subsequent group (2008 to 2016; modified Furlow palatoplasty), all of whom had received the BFPF, were evaluated. The primary outcome variable was the development of palatal fistula. An additional outcome predictor included single versus staged palatoplasty. A χ2 analysis using a 1-tailed Fisher exact test was used, with statistical significance established at P≤.05 to determine the difference in ONF development using different operative techniques. A total of 49 patients had undergone standard Furlow palatoplasty, with an ONF rate of 22.4%. Of the 49 patients, 28 had had isolated cleft palate (ICP; 6 ONFs), 12 had had unilateral cleft lip/palate (UCLP; 2 ONFs), 9 had had bilateral cleft lip/palate (BCLP; 3 ONFs). A total of 65 patients had undergone modified Furlow palatoplasty with a BFPF, with a total ONF rate of 3%. Of the 65 patients, 40 had had ICP (1 ONF), 18 had had UCLP, and 7 had had BCLP (1 ONF). This difference in the ONF rate was statistically significant (P=.0015). The staged repairs resulted in an ONF rate (22.6%) that was significantly greater (P=.029) than the rate with nonstaged repairs (7.1%). The occurrence of ONFs tended to be greater in the patients with BCLP, syndromic patients, after staged repairs, and patients with wide cleft defects. A reduced ONF rate appeared to be associated with the modified Furlow palatoplasty and single-stage palatoplasty. Among the cleft types, BCLP showed a tendency to an increased postoperative ONF rate.

Quantitative Effects of Cleft Lip and Nose Adhesion on Nostril and Alveolar Discrepancy

BACKGROUND: Although there are considerable data quantifying the effects of nasoalveolar molding on definitive lip repair, less is known about the effect of cleft lip and nose adhesion (CLNA) on the alveolar segments and nostril shape in patients who are unable to undergo craniofacial orthodontics. CLNA approximates the lip segments, resulting in the conversion of a complete cleft lip to an incomplete cleft lip while sparing the tissues and landmarks for eventual definitive lip repair. In resource-constrained environments or situations where patients cannot undergo craniofacial orthodontics, CLNA has been shown to qualitatively improve nostril shape before definitive reconstruction in wide cleft. However, less is known about the effects of CLNA alone on the nostril and alveolar cleft segments dimensions. MATERIALS AND METHODS: After obtaining Institutional Review Board approval, a single-center retrospective review of unilateral cleft lip patients undergoing CLNA was performed. Measurements were taken at the time of CLNA and at formal repair. The following data points were extracted for the cleft and noncleft side: nostril height (NH), nostril width (NW), alveolar height (AH), and alveolar width (AW). Dimensional changes from the time of CLNA and time of formal repair were statistically analyzed using a paired Student’s t test. RESULTS: A total of 1,053 surgical cases were reviewed. Eight patients met criteria for inclusion. Average NH before CLNA was 2.3 mm on the cleft side and 5.6 mm on the noncleft side (P = 0.020). After CLNA, the NH on the cleft versus noncleft side was 4.5 and 5.0 mm, respectively (P = 0.553). Average NW before CLNA was 14.8 mm on the cleft side, compared to 7.3 mm on the noncleft side (P = 0.003). After CLNA, the average NW on the cleft side was 11.2 mm, compared to 7.1 mm on the noncleft side (P = 0.007). CLNA resulted in a significant reduction in NW on the cleft side (P = 0.002). The average AW discrepancy, measured as the gap between alveolar segments, was 9.9 mm before CLNA and significantly decreased to 1.5 mm before definitive repair (P = 0.002). AH discrepancy decreased from 11.4 to 6.5 mm (P = 0.060). CONCLUSION: This study reports quantitative changes with CLNA, a powerful tool for reshaping the nostril and approximating the alveolar segments in cases where nasoalveolar molding is not an option. This study demonstrates that CLNA alone achieves a cleft NH which approaches the noncleft side, improved AH and width discrepancy by closure of the gap between alveolar segments, and significant reduction in NW.

Early Cleft Repair Versus Nasoalveolar Molding: Comparing Preoperative Severity and Postoperative Results Utilizing a Computer Engineered AI System

BACKGROUND: Early cleft lip repair (ECLR) can be performed safely and effectively. One persistent question is whether ECLR may be offered to wide unilateral complete clefts who historically would have received nasoalveolar molding (NAM). This study aims to compare the preoperative cleft severity of ECLR patients to those who underwent NAM pretreatment and compare postoperative outcomes. METHODS: Unilateral CL patients (January 1, 2005, to September 11, 2018) were retrospectively reviewed and divided into 2 groups: ECLR (age <3 months) and presurgical NAM with CL repair (age 3–6 months). Pretreatment CL severity was assessed using an AI computer engineered system that calculated cleft width ratios (CWRs, pretreatment cleft width divided by commissure width). For further analysis, a second subset of wide complete cleft lip patients undergoing ECLR (excluding incomplete clefts) was created to compare to the NAM group. RESULTS: Seventy-four ECLR patients and 25 NAM patients (average age at repair 32.24 and 117.56 days, respectively) met inclusion criteria. Mean CWR was 0.456 for ECLR patients and 0.501 for NAM patients (P = 0.165). The ECLR subgroup considering only patients with complete cleft lips had a mean CWR of 0.520, suggesting that this group had more severe clefts. The ECLR subgroup’s average lip length, frontal nasal breadth, commissure length, nostril breadth, nostril width, and nasal angle symmetry ratios were compared to the NAM group’s postoperatively. The average lip length, frontal nasal breadth, and commissure length symmetry ratios for the ECLR subgroup of 27 complete clefts were 0.88, 1.05, and 0.92, respectively, compared to 0.93, 1.08, and 0.89 for the NAM group (P = 0.181, P = 0.526, P = 0.378). The average nostril breadth, nostril width, and nasal angle ratios among the ECLR subgroup were 1.09, 1.17, and 1.12, respectively, compared to 1.12, 1.19, and 1.14 in the NAM group (P = 0.480, P = 0.613, P = 0.640). CONCLUSION: ECLR provides patients with severe cleft lips an alternative option to NAM with at least equivalent results. With increased experience, long-term data, and increased awareness, we feel that ECLR has the potential to be a paradigm shift in the treatment of the cleft lip/nasal deformity.

Treatment of Bilateral Complete Cleft Lip and Palate with Latham Appliance: A Case Report

Cleft lip and palate is one of the most common craniofacial deformities that have physical and psychological influences on patients’ lives. In 1950, the concept of presurgical infant orthopedics (PSIO) was introduced because surgery alone can be aggressive and less controlled treatment in patients with wide cleft or severely protruded premaxilla. Latham appliance is a kind of PSIO which can make an active forces for alignment and approximation of alveolar segments. The newborn with bilateral complete cleft lip and palate was referred from the department of Neonatology to the department of Oral & Maxillofacial Surgery (OMFS) for evaluation and further treatment. The Latham appliance was applied 10 weeks after birth and activated for 1 month. After the resting period, the operation of primary lip and nose repair was performed with removal of the Latham appliance at 6 months after birth. Through the activation of the Latham appliance, minimizing the scar tissue and reducing tension was possible, and a successful result in esthetics and function can be made.

Surgical outcomes of 14 consecutive bilateral cleft lip patients treated with a modified version of the Millard and Manchester methods.

BackgroundBilateral cleft lip deformity is much more difficult to correct than unilateral cleft lip deformity. The complexity of the deformity and the sensitive relationships between the arrangement of the muscles and the characteristics of the external lip necessitate a comprehensive preoperative plan for management. The purpose of this study was to evaluate the repair of bilateral cleft lip using the Byrd modification of the traditional Millard and Manchester methods. A key component of this repair technique is focused on reconstruction of the central tubercle.MethodsFourteen patients with mean age of 5.7 months presented with bilateral cleft lip deformity and were operated on using a modification of the Millard and Manchester techniques. Patients with a very wide cleft lip and protruded or rotated premaxilla were excluded from this study. We analyzed 30 normal children for a comparison with our patients in terms of anthropometric measurements.ResultsBy the end of the follow-up period (between 9 and 19 months), all our patients had obtained a full central segment with adequate white roll in the central segment and a deep gingivolabial sulcus, and we obtained nearly normal anthropometric measurements in comparison with age-matched normal children.ConclusionsWe recommend this modified technique for the treatment of bilateral cleft lip deformity.

Dynamic Docking of a Medium-Sized Molecule to Its Receptor by Multicanonical MD Simulations.

A medium-sized and highly flexible inhibitor to the enzyme β-secretase 1 (BACE), which produces the amyloid β-peptide by cleavage of its precursor protein, was dynamically docked into the large and wide catalytic cleft of BACE that binds to the amyloid-precursor by employing multicanonical molecular dynamics (McMD) simulations. We applied our method to predict the native binding configuration and sample the intermediary structures connecting this natively bound state to the unbound one. Representative structures located at free energy minima obtained from McMD were taken and subjected to canonical simulations to refine and validate them, reproducing the native complex structure in agreement with the experimental data in the most stable structure, i.e., the one at the global minimum. In addition, the binding free energy was estimated by umbrella sampling (US) simulations along representative pathways obtained from the McMD ensemble, followed by weighted histogram analysis to estimate the affinity, which also reproduced the experimental inhibitory affinity. Interestingly, the loss of interactions between the two molecules along the pathway was clearly shown in the free energy landscape, reiterating the fundamental importance of atomistic interactions to the binding affinity between receptor and drug compound. The sampled ensemble by the US simulations smoothly connected the bound and unbound states, refining the binding pathway while staying true to the McMD ensemble.

What We Do: Greater Palatine Medializing Foraminal Osteotomy for Repair of the Wide Cleft Palate.

Wide cleft palates (>15-mm gap) present a number of challenges to the surgeon tasked with their repair ( Bardach, 1999 ). Eliminating the need for secondary surgery due to fistula formation can reduce additional anesthetic and scarring risks and optimize early speech development. Greater palatine foraminal osteotomy is a useful surgical adjunct that allows additional medial movement of oral mucoperiosteal flaps to aid in tension-free closure of the oral layer. We use a technique similar to that described by Seibert in 1995 with a few modifications. Closure of the nasal layer in these wide clefts can be achieved using a sphenoid flap, a technique recently published by our unit ( Khan et al, 2018 ).

Otitis media with effusion in Nigerian children with cleft palate: incidence and risk factors

Otitis media with effusion is common in children with cleft palate, and the aim of this study was to find out its incidence and risk factors in Nigerians. We prospectively studied 84 patients (42 with cleft palate and 42 control subjects); 27 were male and 15 female, who were age and sex matched with control subjects. The extent and size of the clefts were measured using a dental cast and Vernier calipers, and the otitis media was diagnosed with otoscopy and tympanometry. The mean (SD) age of the groups was 11 (7) months (range 1–33). Twelve children in the cleft group had otitis media compared with three in the control group. Infants and boys were more likely to be affected. There was a significant association between age (p=0.02), sex (p=0.01), and size of cleft (p=0.00). However, only the size of the cleft was confirmed to be an independent predictor, with children who had extremely wide clefts being more likely to develop otitis media than those with narrow clefts (OR=8.71, 95%CI=1.07 to 70.5).We conclude that the incidence of otitis media with effusion was higher among children with cleft palate than among those who did not have a cleft. Infants had a higher incidence than older children, and boys had a higher incidence than girls. Age, sex, and the size of the palatal cleft were significantly associated with otitis media, but not the extent of clefting.

Segmental Maxillary Osteotomy to Close Wide Alveolar Clefts

Wide alveolar clefts are challenging to treat and are often associated with a higher chance of failure requiring repeated bone grafts. Even if successful, an excessively large cleft leads to a wide edentulous space, and patients are faced with prolonged orthodontic treatment. We present a series of large alveolar clefts closed with the aid of segmental maxillary osteotomies. Cases of alveolar clefts treated by segmental maxillary osteotomy from 2014 to 2016 were reviewed. Preoperative and postoperative computed tomography scans were analyzed to assess the alveolar gap and bone filling. Demographic characteristics, diagnoses, and operative techniques were reviewed and described. A total of 10 alveolar fistulae were addressed, using 6 segmental osteotomies in 6 patients. Of the cases, 66% were bilateral. There were 4 female and 2 male patients with an average age of 12.6years. The average preoperative cleft width was 14.2mm on computed tomography scans. Postoperatively, all clefts were successfully closed and no adverse effects were observed. Segmental maxillary osteotomy with concurrent bone grafting and fistula closure is an effective approach to treat excessively wide alveolar clefts. This enables a prudent dental substitution or prosthodontic planwhile minimizing prolonged orthodontia, in addition to achieving the traditional goals of alveolar bone grafting (stabilizing the maxillary arch, closing fistulae, and permitting canine eruption).

Abstract: Square Root Palatoplasty: A New Modification of Double Opposing (Furlow) Palatoplasty

INTRODUCTION: Double opposing palatoplasty has gained a wide popularity for primary palatoplasty in the US since its first description by Dr.Furlow in 1976. The advantages of Furlow palatoplasty are better repositioning of levator muscle (and formation of functional levator sling), palatal lengthening, tighter nasopharyngeal sphincter and decreased risk of longitudinal scar contracture. However, the desired gain in length is created at the expense of shortening in the transverse axis and therefore, it is difficult to achieve tension-free closure with double opposing palatoplasty in wide clefts. Our aim in this study is to introduce a new modification of Furlow repair to overcome the disadvantages and compare its surgical outcomes with straight line repair. METHODS: In this technique, an incision similar to square root shape is planned in the soft palate. Anteriorly based oral mucosal flap, which forms the transverse axis of the square root sign” is almost 90 degrees to the central limb along the cleft edges. This design allows better mobilization and vascularity of this flap, and prevents accidental tearing of the oral mucosal flap towards its base. Posteriorly based oral myomucosal flap, which forms the smaller “V” of the square root sign, can be easily transposed with this design. The levator veli palatini sling is reconstructed under the operating microscope and a spacer (acellular dermal matrix) is placed between mucosal layer and oral layer. All patients undergoing primary palatoplasty by a single surgeon over 6 years were retrospectively reviewed. A total of 57 consecutive patients included in the study were divided into two groups: 30 in the modified furlow palatoplasy (MVP) group and 27 in the straight line repair group. Clinical characteristics (age at the time of surgery, sex, cleft type) and surgical outcomes (rate of fistula formation and speech outcomes) were compared between two groups. Speech outcomes are classified into 3 categories: normal speech, hypernasal and hyponasal speech. RESULTS: Median age of repair at both groups was 8 months. Distribution of sex, cleft type and presence of associated syndromes were similar between the groups. Most common cleft type was Veau 3 (37% in straight line repair group, 40% in MVP group). Speech evaluation was available in 49 patients (85%). Hypernasality was more common in the straight line group than the MVP group (10/23 vs. 6/26, respectively; p=0.02) Fistula rates did not change significantly between two groups (18% in the MVP group vs 23% in the straight line repair group; p=0.67) CONCLUSION: Modified Furlow double opposing z-plasty along with levator veli palatini retropositioning followed by a spacer of alloderm placed between the posterior nasal spine and the muscle reconstruction of the levator for primary palatal repairs demonstrated superior perceptual speech outcomes and same fistula rate with primary palatal repair.

Segmental Maxillary Distraction Osteogenesis With a Hybrid-Type Distractor in the Management of Wide Alveolar Cleft.

To investigate segmental maxillary distraction osteogenesis (DO) with hybrid-type distractor in the management of wide alveolar cleft. Six patients underwent segmental DO with a hybrid-type distractor. After the success of DO and 3-month consolidation period, removal of the distractor was accompanied by alveolar bone graft with iliac bone. Panoramic radiograph and computed tomography scanning were taken preoperatively (T0) and the day after distractor removal (T1). The crest distance between the long axis of cleft nearby teeth was measured. All patients completed the DO period, and the succeeding alveolar bone graft healing was uneventful. The mean cleft distance decrease was 12.05 mm (range: 10.1-13.5 mm). As for the mobility degree record of abutment tooth in the transport segment recorded, 6 patients were grading I° at T0, while 5 patients were grading I° and 1 patient was grading II° at T1. Segmental maxillary DO with the hybrid-type distractor is successful to reduce the cleft width in these cases, and it is promising in the treatment of wide dental alveolar cleft, especially for the adult patient.

Buccal Fat Pad: A Useful Adjunct Flap in Cleft Palate Repair.

The aim of the study is to describe the technique and also the outcome of using buccal fat pad (BFP) as an adjunct flap in cleft palate repair and to report the surgical outcome. All the surgical repairs with BFP were done under general anaesthesia. The use of BFP was indicated in patients who needed a secondary palatal cleft repair, those with wide palatal clefts or patients whose primary palatal cleft repair was complicated intraoperatively by inadvertent tearing of the nasal mucosa. The raw wound surfaces were dressed with Vaseline gauze instilled with Framycetin. All subjects 4years of age and below had oral toileting with warm saline-soaked gauze after each meal. The other patients had oral toileting with warm saline mouth bath in addition to conventional toothbrushing. Eight patients were included in this study with an age range of 1-26years (mean ± SD = 6.1 ± 8.6years). Three patients presented with wide palatal clefts, another three presented with dehiscence after a primary repair which necessitated a secondary repair, while the remaining two patients had inadvertent iatrogenic tear of the nasal mucosa during the primary surgical repair. For the latter set of patients, repair was completed by the use of BFP as an adjunct at the same surgery. Post-operative evaluation was satisfactory in all cases, with healing of the flaps and complete epithelialization of the BFP in 1month. All the patients experienced post-operative cheek swelling, signifying the post-operative oedema due to BFP harvest. However, this was usually resolved within 48h. Healing was satisfactory with full epithelialization, and no complications were observed. Successful application of BFP as an adjunct flap in palatal cleft closure is demonstrated in these series. It is recommended that cleft surgeons add this technique to their armamentarium in difficult cases, especially in wide palatal cleft repair, secondary palatal cleft repair and in cases of inadvertent tearing of nasal mucosa during primary cleft palate repair.

Schizencephaly and Porencephaly Due to Fetal Intracranial Hemorrhage: A Report of Two Cases.

Schizencephaly and porencephaly are extremely rare types of cortical dysplasia. Case 1: Prenatal magnetic resonance imaging (MRI) showed wide clefts in the frontal and parietal lobes bilaterally. On postnatal day 3, MRI T2-weighted images showed multiple hypointensities in the clefts and ventricular walls, suggestive of hemosiderosis secondary to intracranial hemorrhage. Case 2: Prenatal MRI showed bilateral cleft and cyst formation in the fetal cerebrum, as well as calcification and hemosiderosis indicative of past hemorrhage. T2-weighted images showed hypointensities in the same regions as the calcification, corresponding with hemosiderosis due to intracranial hemorrhage on postnatal day 10. Thus, prenatal MRI was useful for diagnosing schizencephaly and porencephaly. Schizencephaly and porencephaly were thought to be due to fetal intracranial hemorrhage, which, in the porencephaly case, may have been related to a mutation of COL4A1.