The Reconstruction of the Central Tubercle in Bilateral Cleft Lips: Bilateral Lateral Mucosal Advancement Flap With Reinforcement of the Orbicularis Oris Muscle.

BACKGROUND: There are various methods to correct the whistle deformity in bilateral cleft lip. In case of the central deficiency with concomitant lateral excess, local tissue rearrangement can be used to reposition the lateral tissue. We designed bilateral lateral advancement flap with reinforcement of the orbicularis oris muscle. METHOD: Thirteen bilateral cleft lip patients with whistling lip deformity from July 2009 to February 2017 underwent our method of tubercle formation. Vertical upper lip measurements of upper lip were recorded. Augmentation percentage was documented using follow-up measurements compared with preoperative measurements. The average follow-up period was 16.2 months (range, 9-26 months). The axis of the flap and central incision were placed on the red line (wet-dry vermilion border). Dissection was performed through the submucosal plane. After entire dissection, inter-orbicularis oris muscle suture on both medial edge of the flap was performed. In case it was necessary, back-cutting incision on both curvature of the central orbicularis oris could facilitate central augmentation. Elevated superior and inferior trap-door flaps were trimmed to make natural central lip line along with the lateral mucosal flaps. Both lateral parts of vermilions were closed in V-Y advancement fashion. RESULT: The vertical height of central tubercle (T) had a mean increase of 136.9%, which was significantly different from preoperative measurement (P < 0.05). There were no surgical complications. CONCLUSIONS: Our surgical method is safe, useful, and effective to correct the whistle deformity of the central deficiency with concomitant lateral excess.

Correlation Between Speech Outcomes and the Amount of Maxillary Advancement After Orthognathic Surgery (Le Fort I Conventional Osteotomy and Distraction Osteogenesis) in Patients With Cleft Lip and Palate.

BACKGROUND: The purpose of this study is to evaluate the factors affecting the speech outcome following Le fort I conventional osteotomy(CO) or Le Fort I distraction osteogenesis(DO) in patients with cleft lip and palate at a single institution. METHOD: Records of cleft lip and palate patients who underwent orthognathic surgery between 2010 and 2015 were reviewed. Data included age at orthognathic surgery, sex, cleft lip and palate type, type of orthognathic surgery, the amount of maxillary advancement, and speech assessment. Speech outcomes were classified into 2 categories. Compared with the pre and post-operative Pittsburgh Weighted speech scale scores, in case that the post-operative total score is increased the authors define it as "Speech deterioration" and if not, the authors define it as "Speech preservation." RESULT: The 44 patients were identified, 33 patients underwent CO and 11 patients underwent DO. The mean age was 19.4 ±â€Š1.4. The mean period time of speech evaluation after orthognathic surgery was 1.0 ±â€Š0.46 year. The mean amount of maxillary advancement was 7.2 ±â€Š3.2 mm and show significant correlation with speech outcomes. (P = 0.012) . In CO group, the patients who had the maxilla 1∼5 mm advancement maintained their speech completely and 44% of patients with 6∼8 mm deteriorated their speech. In DO group, patients with 9∼10 mm maintained their speech completely, 50% of patients with 11∼12 mm deteriorated their speech and 100% of patients with 13∼16 mm deteriorated their speech. According to the relationship between the amount of maxillary advancement and speech outcomes, there was a statistically significant correlation in both CO and DO groups. (P = 0.04, 0.029). CONCLUSION: It was found that speech of the patients with more amount of maxillary advancement tended to get worse. Also, it was observed that there exist some stable ranges of maxillary advancement for speech safety which does not effect on speech. (1∼5 mm in CO group and 9∼10 mm in DO group).

Reduction Malarplasty that Uses Malar Setback Without Resection of Malar Body Strip.

BACKGROUND: Various surgical methods have been developed and used to reduce prominent malar bones. The most common reduction malarplasty methods are resection of the bone strip of the malar bone with L-osteotomy or I-osteotomy, followed by setback and fixation. However, these methods could be associated with complications due to the bone strip resection. The present article introduces an effective and safe method that reduces the zygoma without resection of a malar bone strip. METHODS: Through preauricular and intraoral incisions, we performed the current L-osteotomy without resection of the malar bone strip using a reciprocating saw. We created back space for zygoma setback by removing the posterior wall of the maxillary sinus, which acted as a bony interference. We were able to set the lateral segment of the zygoma back about 3-5 mm. We fixed the zygomatic arch with wire and the zygomatic body with a prebent plate and screw. Thereafter, we performed rasping of the anterior part of the zygoma to achieve sufficient reduction. After performing our reduction malarplasty for 139 patients, clinical outcomes were evaluated. RESULTS: Most patients responded to the satisfaction survey as excellent and good. There were no major complications 6 months postoperatively. CONCLUSIONS: The key of our method of reduction malarplasty is to create posterior space without resecting the malar body strip, which results in an effective setback. This method enables surgeons to effectively maintain the zygoma body, which leads to high satisfaction rates and fewer complications. Therefore, this study proved the safety and effectiveness of our method of reduction malarplasty. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Limited incision with thorough elevation palatoplasty: technical evolution for superior results in cleft repair of the secondary palate.

BACKGROUND: All kinds of palatoplasty emphasize elongating the soft palate and reconstructing the velar musculature without complication. We present the limited incision with thorough elevation (LITE) palatoplasty that leaves the anterior margin of the hard palate intact, achieving a fully movable bipedicled flap for complete closure and an adequate functioning velar muscular sling. METHODS: Fifty-six patients consecutively underwent the LITE palatoplasty. The patients were diagnosed with varying degrees of cleft of the secondary palate. The length of the soft palate was measured, preoperatively and postoperatively, to quantify the lengthening effect of the surgical procedure. The LITE palatoplasty lengthens the soft palate by full mobilization of the velar musculature and reconstruction of the muscles. The LITE palatoplasty also completely repairs the hard palate and leaves no raw surfaces, which can be disadvantageous to the maxillary growth. RESULTS: The average length of soft palate was 18.5±3.1 mm preoperatively, and the increased length of the soft palate was 5.06±2.41 mm (27.3±17.4%). There were no complications including fistula formation, hematoma, or wound problems. After 2 years of operation, only 2 patients who had multiple congenital problems showed grade 1 hypernasality in speech assessment. CONCLUSIONS: The LITE palatoplasty gives satisfactory results in elongating the soft palate and reconstructing a functional velar sling without leaving any raw surfaces that can be detrimental to healing and facial growth. And there was a better speech outcome without complications.

Internal carotid artery variations in velocardiofacial syndrome patients and its implications for surgery.

BACKGROUND: Medially displaced internal carotid arteries in velocardiofacial syndrome carry a risk during pharyngeal flap surgery. This study was designed to evaluate the frequency of medially deviated internal carotid arteries in both velocardiofacial syndrome patients and the general pediatric population and to assess the minimum distance to the pharyngeal walls to define the potential risk of internal carotid artery injury during pharyngeal surgery. METHODS: Twenty-three consecutive patients with velocardiofacial syndrome who underwent posterior pharyngeal flap surgery and 21 control subjects who did not have velocardiofacial syndrome but who underwent oropharynx magnetic resonance imaging were reviewed. RESULTS: Medial deviation of at least one internal carotid artery was documented in 10 velocardiofacial syndrome patients (43.5 percent), compared with three patients (14.3 percent) in the control group (p=0.034). The mean±SD minimum distance to the posterior pharyngeal wall was 3.78±1.86 mm in velocardiofacial syndrome patients and 9.17±2.94 mm in the control group (p=0.014). Only one patient had significant medial dislocation of the internal carotid artery, and the closest distance from the pharyngeal wall was 0.86 mm. CONCLUSIONS: In velocardiofacial syndrome patients, medial dislocation of the internal carotid artery was common, and the minimum distance to the pharyngeal wall was short compared with the control group. However, in most of the authors' patients, the course of the cervical portion of the internal carotid artery is irrelevant to pharyngeal flap surgery. The authors conclude that preoperative vascular imaging study is not cost-effective in velocardiofacial syndrome patients but that intraoperative use of ultrasound imaging is still valuable for the purpose of planning pharyngeal flap surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.