Primary Pharyngeal Flap With Palate Repair Improves Speech Outcome in Older Children and Adults: A Comparative Study.

BACKGROUND: Repair of cleft palate after 6 years of age is controversial in regard to the surgical procedure and the speech outcome. Primary repair alone may not be considered sufficient to achieve intelligible speech. The authors consider addition of pharyngeal flap at the time of primary repair to be a significant factor in improving speech. METHODS: Prospectively maintained data of all cleft palate patients operated from 2013 to 2017 (5 years) was analyzed to identify patients older than 6 years. Complete cleft palate, incomplete cleft palate, and cleft of the soft palate were further stratified according to different Randall types. They were divided into 2 main types: primary palate repair only and primary palate repair with pharyngeal flap. Speech was assessed preoperatively and 12 months postoperatively by Pittsburgh weighted speech scale. RESULTS: A total of 139 patients were analyzed. There were 78 males and 61 females. Their ages ranged from 6 to 60 years (mean age, 12.5 years). The overall preoperative speech score in palate repair-only group was 12.15, whereas the postoperative score was 7.32. In patients who underwent primary pharyngeal flap along with palate repair, the preoperative speech score was 11.3, and the postoperative score was 3.76. CONCLUSIONS: In select group of patients who report late for palate repair, addition of pharyngeal flap along with the primary palate repair improves the speech outcome in all Randall groups.

Pakistan Comprehensive Fistula Classification: A Novel Scheme and Algorithm for Management of Palatal Fistula/Dehiscence.

BACKGROUND: It is not easy to find a management-based classification of palatal fistula in the literature. A few attempts have been made to classify the wide variety of fistulae that do not describe the fistula details comprehensively and guide toward its management. The authors have come across a wide variety of fistulae that could not be classified according to any of the prevailing classification systems. The presented classification gives a clear and exact understanding of location and size of fistula/dehiscence. Palatal function has been included as one of the important determinants for devising a management plan. Based on this classification, the authors have proposed an algorithm that encompasses clear guidelines for surgical treatment of these fistulae. METHODS: Over the past 15 years, the authors' team operated on 2537 palatal fistula patients. The medical records of these patients were reviewed to determine the location, size, and velopharyngeal competence. A new classification and algorithm were developed. RESULTS: Of 2537 patients, 2258 had midline fistulae, 208 had lateral fistulae, and 53 had subtotal fistulae. There were 18 patients with dehiscence. Recurrence developed in 181 patients. CONCLUSION: The authors believe that this classification and algorithm can help follow a practical approach to manage palatal fistulae and dehiscence.

Continuous Versus Interrupted Sutures for Primary Cleft Palate Repair.

BACKGROUND: Cleft palate is a common congenital problem. It is traditionally surgically repaired with interrupted sutures between the ages of 6 and 18 months, with the aim of achieving closure of both nasal and oral layers. In various fields of surgery, continuous, rather than interrupted, sutures are the norm. There are no reports, however, of continuous suture repair for cleft palate. METHODS: A comparative study was designed at Clapp Hospital Lahore, to compare the effectiveness of 2 techniques. A total of 152 patients were included in the study over a period of 3 years. Per-operatively, the duration of surgery (time for nasal and oral layer closure) and the number of suture materials used were noted and compared between the 2 groups. Postoperatively, we compared the rate of wound dehiscence and fistula formation between the 2 groups. RESULTS: Out of 152 patients, 84 patients were operated on by continuous technique and 68 patients by interrupted technique. The mean duration of nasal layer closure in group A was 7.08 minutes, whereas that in group B was 11.50 minutes. The mean number of sutures required for the continuous suture group was 2.12, whereas that for the interrupted suture group was 4.59 (P < 0.05). There were no differences seen in either of the 2 postoperative outcomes compared in this study. CONCLUSION: A continuous closure technique can be utilized in palate repair, as it us more cost-effective and time-efficient.

Radical Dissection of Greater Palatine Artery and Dynamic Reconstruction of Cleft Palate.

BACKGROUND: Restoration of proper anatomy and physiology is an integral part of cleft palate repair. The senior author has devised a new technique of radical release of greater palatine vessels, which helps in achieving tension-free closure of palatal cleft. In addition, release and transposition of palatal muscles is performed without the use of operative microscope, resulting in improved palatal function. This technique is applicable to all types of clefts of the palate and can be performed on adult patients as well. MATERIALS AND METHODS: This is a retrospective case series of cleft palate repairs performed over a period of 3 years. Single-stage repair with modified Bardach's technique for complete cleft palate and von Langenbeck's technique for incomplete cleft palate with radical release of greater palatine vessels and levator complex retropositioning was performed. The outcome measures were closure of palatal defect and speech production. A follow-up of at least 6 months was completed in each patient. RESULTS: A total of 1568 patients were included in the study. Their age ranged from 9 months to 54 years. The overall fistula rate was 6.1%. Improvement of speech was observed even in adult patients. CONCLUSIONS: Radical release of greater palatine artery and levator complex transposition can dramatically improve results of cleft palate repair. This technique helps in dynamic reconstruction of cleft palate and can be effectively applied in all age groups.

A model humanitarian cleft mission: 312 cleft surgeries in 7 days.

BACKGROUND: There are many countries in the world where patients with cleft lip and palate cannot get access to specialized cleft care units. Cleft missions play an important role in providing surgical care to the areas of the world with limited resources. This article presents a model of cleft missions that can be adopted in many countries where expertise is available but resources are limited. Through proper utilization of local human resource, this type of mission can be a cost-effective and robust way of treating patients with cleft in countries with approximately 52% of the world's population. METHODS: We present a case series of patients of one of our cleft missions carried out in Khairpur, Pakistan, in March 2014 over a period of 7 days. Specific details concerning the organization of mission, gathering of patients, preparation for surgery, and carrying out surgical procedures in a safe and swift manner are presented. RESULTS: A total of 312 patients were operated on in 7 days. There were 145 patients with cleft lip and 167 patients with cleft palate. There were 187 male and 125 female patients with mean age of 7 years. Contemporary operative techniques were utilized to repair different types of cleft lip and palate. Of 167 patients, only 16 developed fistula. CONCLUSION: A locoregional cleft team can be more effective to care for the patients with cleft in countries where surgical and other expertise can be utilized by proper organization of cleft missions on a national level.

Management of hypospadias cripples with two-staged Bracka's technique.

Patients labelled as 'hypospadias cripples' pose a challenge to reconstructive surgeons because of the complexity of the problem and limited options for reconstruction. The two-staged Bracka method is a versatile technique that is relatively easy to learn and applicable in difficult cases of salvage hypospadias. Over a period of 8 years, we applied this technique to 100 patients with hypospadias cripples who had previously undergone multiple (3-16) procedures. In the first stage, a full-thickness graft of skin or buccal mucosa was used for urethral plate reconstruction after release of chordee. Stage II was carried out at least 6 months after the first procedure. Meatal opening at the tip of the glans was achieved in 94 patients, straightening of the penis in 96 and proper urinary stream in 92 patients. Fistula formation occurred in nine patients. In our opinion, the two-staged Bracka technique is a useful strategy to deal with the myriad abnormalities encountered in crippled hypospadias. This technique not only creates a neourethra successfully, but also gives the penis a near-normal shape and appearance.

"Homemade" negative pressure wound therapy: treatment of complex wounds under challenging conditions.

UNLABELLED:   Background. Complex wounds pose a challenge to the surgeons regarding coverage and reconstruction. Negative pressure wound therapy (NPWT) has become a widely accepted technology for managing such wounds. Despite the case reports suggesting excellent outcomes of commercially available NPWT systems, there is paucity of randomized, controlled trials. Homemade alternatives can be of great use in hospitals with limited resources if they are found to be effective for managing complex wounds. OBJECTIVE: To determine the effectiveness of "homemade" NPWT for coverage of challenging and difficult wounds of different regions of the body with limited options for reconstruction. METHODS: Forty-four patients with 51 complex wounds involving different parts of body were included in the study. After initial debridement, the patients were treated with NPWT to obtain a healthy granulating wound bed that could be covered with simple reconstruction (ie, skin graft). RESULTS: The average number of dressing changes was 2.9 and the average duration from start of therapy until the wound was ready for coverage was 13 days. Forty-seven wounds were skin grafted and 3 wounds were covered with local turnover flaps. One post sternotomy wound healed by secondary intention. CONCLUSION: This simple "homemade" NPWT system is an effective technique for treating challenging wounds on various parts of the body. .

Use of a pedicled flap for reconstruction of extensive soft tissue defects around elbow.

OBJECTIVE: To determine the reliability of pedicled latissimus dorsi flap for reconstruction of extensive defects around the elbow in terms of flap survival and coverage of exposed bones, vessels or nerves. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Plastic and Reconstructive Surgery at Shaikh Zayed Hospital, from February 2003 to January 2008. METHODOLOGY: Patients with extensive traumatic wounds around the elbow and wounds secondary to release of postburn elbow contracture were included. Patients above 60 years of age with previous history of myocardial infarct, heart failure, chronic obstructive pulmonary disease or insulin dependent diabetes were excluded. Pedicled latissimus dorsi flap was used for defect reconstruction. Overall flap survival and postoperative complications were the outcome measures. RESULTS: There were 28 patients, including 20 males and 8 females, age ranging from 17 to 60 years. Evaluation of the defect considering extent of tissue loss, depth of the defect and exposed vital structure was done. Myocutaneous flap was used in 4 (14%) patients. Muscle only flap was used in 24 patients (86%). Twenty five (90%) flaps survived completely and 3 (10%) had partial loss. Other minor complications were partial graft loss seen in 3 (10%) patients and wound infection seen in 2 (7%) patient. There was no considerable morbidity at donor site and all patients had satisfactory healing. CONCLUSION: Pedicled latissimus dorsi flap is a reliable and safe option for resurfacing extensive soft tissue defects of arm, elbow and forearm.