Functional cleft palate surgery.

Cleft lip and palate (CLP) as a dislocation malformation confronts parents with a malformation of their child that could not be more central and visible: the face. In addition to the stigmatizing appearance, however, in cases of a CLP, food intake, physiological breathing, speech and hearing are also affected. In this paper, the principles of morphofunctional surgical reconstruction of the cleft palate are presented. With the closure of the palate, and restoration of the anatomy, a situation is achieved enabling nasal respiration, normal or near normal speech without nasality, improved ventilation of the middle ear, normal oral functions with coordinated interaction of the tongue with the hard and soft palate important for the oral and pharyngeal phases of feeding. With the establishment of physiological function, in the early phases of the infant and toddler, these activities initiate essential growth stimulation, leading to normalisation of facial and cranial growth. If these functional considerations are disregarded during primary closure, lifelong impairment of one or more of the abovementioned processes often follows. In many cases, despite secondary surgery and revision, it might not be possible to correct and achieve the best possible outcomes, especially if critical stages of development and growth have been missed or there has been significant tissue loss due to resection of existing tissue while primary surgery. This paper describes functional surgical methods and reviews long term, over many decades, results of children with cleft palate.

Tackling the challenges of providing surgical services in low resource LMICs: Shortcomings in surgical healthcare in Nepal.

Province-2 is small but densely populated area in the plains of Nepal with 20% of the population on 3% of the land. It is one of the two poorest provinces, with the lowest human and logistic resources. Therefore, there is an enormous and urgent need for improvement of appropriate health care facilities, accessible for all the people. The rural population remains desperately impoverished and to date the provincial and federal governments have lacked the funds to support these needy people. Our work aimed to create a small working model to address the existing problems by establishing the Janakpur Trauma and Orthopaedic Hospital, and ultimately in collaboration with Future Faces, the Craniofacial Centre Nepal, to provide appropriate care at an affordable price to the people in Province-2. This model has been successful, but one of the main challenge remains payments to the health care providers. It is difficult to balance the income and expenditure of hospital services in order to sustain these works and so regular external financial input is required for maintaining continuity of care. It is expected that government agencies and universities such as Madhesh Institute of Health Sciences (MIHS) should be able to educate and assist in the provision of standard care for common illnesses and create suitable human resources to face these challenges.

Obstacles for accessing customised craniofacial implants in low- and middle-income countries.

INTRODUCTION: Many low resourced low- and middle-income countries (LMICs) do not have access to (high tech) developments in the medical field. The aim of this study is to research how a contemporary high-tech solution, such as customized medical implants, can be transferred to low resource LMICs. MATERIALS AND METHODS: We explored the internet to retrieve data regarding internet coverage, services providing free email accounts, and the availability of connecting devices. Additionally, a computerized search was performed for currently available PSI concepts and other important emerging technologies with potential value in craniomaxillofacial surgery. Lastly, we searched the internet for the availability of CT scan devices and smartphones in the LMICs. RESULTS: Internet penetration and access to computers/smartphones is low in the LMIC's. Moreover, availability of radiology departments and radiologist is very limited (60 radiologist per 190 million Nigerian inhabitants) and a lack of knowledge concerning import regulations and customs clearance, limit the accessibility/availability for patient-specific implants, since this is crucial in developing and delivering these devices. Lastly, appropriate training and instrumentation is vital (yet, currently difficult) to acquire and foresee, in order to achieve the best post-operative results. CONCLUSION: This research confirms great difficulties achieving our aims but with persistence and adoption of well-constructed programs it should be possible.

Nasal symmetry after different techniques of primary lip repair for unilateral complete cleft lip with or without cleft of the alveolus and palate: A systematic review.

The aim of this systematic review was to establish the effect of different surgical repairs for the lip on nasal symmetry. PubMed, Scopus, Embase, Cochrane CENTRAL, and Ovid databases search was performed initially for only English-language articles, in patients with unilateral complete cleft lip with or without cleft alveolus and palate (UCCLAP) who were younger than 1 year of age and undergoing cleft lip repair, and are published from the earliest data available up to December 31, 2020. The primary outcome variable was nasal symmetry, with reported complications being secondary variables. A qualitative synthesis was provided. A total of 19,828 records were obtained, and 17 articles were selected for final review. Assessment of the risk of bias of the included randomized controlled trials (RCTs) (N-1) was done with the Cochrane Risk of Bias 2 (RoB-2) tool, and the ROBINS-I tool was used for non-randomized studies (n = 14). Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to evaluate the quality of the body of evidence. The majority of the included studies compared the triangular repair with the rotation advancement (RA) techniques, and preferred RA or its modifications. In terms of the nasal symmetry, the Fisher repair proved to be superior to the RA technique. Neither RA nor straight line repair was superior to one another. The Delaire technique may be preferred over the modified RA. Also, satisfactory outcomes were observed with simultaneous lip-nose repair. This systematic review examined a plethora of techniques, and the heterogeneity between studies was very high regarding type of surgery, method of nasal symmetry assessment, and length of follow-up, thus producing low-quality evidence; therefore, results should be interpreted with caution. Future research requires RCTs with larger sample sizes and appropriate length of follow-up, and surgeries preferably performed by a single experienced surgeon.

Does Sphenopalatine Ganglion Block Improve Pain Control and Intraoperative Hemodynamics in Children Undergoing Palatoplasty? A Randomized Controlled Trial.

PURPOSE: Children undergoing cleft palate repair have pain, dysphagia, and wound irritation in the immediate postoperative phase that may compromise surgical outcomes. This trial evaluates the efficacy of the sphenopalatine ganglion block (SPGB) in optimizing intraoperative hemodynamics and postoperative analgesia in children undergoing primary palatoplasty. MATERIALS AND METHODS: The study was designed as a prospective, double-blind, randomized controlled trial comparing the use of SPGB with general anesthesia (GA) (study group) versus the use of only GA (control group). Routine preoperative documentation included type of cleft, patient weight, hemoglobin (Hb%), packed cell volume (PCV), blood pressure, and echocardiogram. Intraoperative monitoring included heart rate, blood pressure, and surgical field assessment. Postoperatively, the pain score, pain-free duration, and need for rescue analgesics were recorded. Postsurgical changes in Hb% and PCV values were assessed. Data analysis of collected variables was performed using SPSS software (version 16; IBM, Armonk, NY). Quantitative data were assessed for normality using the Shapiro-Wilk test and analyzed using the independent-sample t test, and the Fisher exact test was used for comparison of the binary variable (gender). The outcome variables were compared between the study and control groups after adjustment for confounding variables. P < .05 was considered statistically significant. RESULTS: We randomized 100 patients undergoing primary palatoplasty under GA into the control group (n = 49) and study group (SPGB) (n = 51). Three patients were excluded from the control group because of changes in intraoperative anesthetic protocol. The results showed statistically significant differences in the postsurgical pain-free duration (19.46 minutes vs 87.59 minutes) and mean blood loss (105.5 mL vs 62 mL) in favor of the study group. Surgical field and postoperative reduction of Hb% and PCV were also significantly favorable for the study group. CONCLUSIONS: SPGB is a potent pre-emptive technique offering excellent perioperative analgesia, hemodynamic stability, and a clear surgical field.

A comparative study of two different techniques for complete bilateral cleft lip repair using two-dimensional photographic analysis.

BACKGROUND: The aim of this study was to compare the clinical outcomes of two techniques to repair complete bilateral cleft lip by using indirect two-dimensional photographic analysis. METHODS: One hundred eight bilateral cleft patients were included in this study, 54 patients operated on with the Millard technique and 54 patients operated on with the Afroze technique. Each group of patients was further separated into two subgroups containing symmetrical and asymmetrical cleft lips. All patients were photographed preoperatively and 4 years postoperatively in frontal and submentovertical views in a reproducible way. Eight measurements were performed on the photographs. From these measurements, seven ratios were calculated to compare the two techniques. RESULTS: The outcomes of the interobserver and intraobserver measurements were analyzed using the Pearson correlation test. There was a statistically significant reliability in the intraobserver and interobserver ratios. Analysis of the ratios was performed using the independent samples t test (5 percent level of significance). The authors found that the Afroze technique was better than the Millard technique in six of the seven parameters for symmetrical clefts and in four of the seven parameters for asymmetrical clefts; however, there was no statistically significant difference seen between the two techniques. CONCLUSIONS: The Afroze technique seems to have good clinical outcomes on bilateral cleft lip patients, but more research and long-term follow-up are needed to determine the full outcome of the technique in various parameters.

Colonization of the cleft nasal floor by anaerobic oral flora in patients with oronasal fistulae.

OBJECTIVES: Aerobic oral bacteria only rarely colonize the cleft nasal floor in patients with patent oronasal fistula. There are no studies that have investigated whether anaerobic oral flora colonize this site and whether attempting to culture them is useful for assessing the patency of oronasal fistulae in the clinic. DESIGN: A prospective study of 13 patients with cleft with patent unilateral oronasal fistulae. Microbiological culture swabs were taken from the oral cavity and both nasal floors, with the unaffected side being used as a control. Following aerobic and anaerobic culture, bacterial isolates were identified and compared. MAIN OUTCOME MEASURE: A significant growth of anaerobic oral bacteria from the cleft nasal floor when compared with the unaffected side. RESULTS: Aerobic oral flora was cultured from the oral cavity in all 13 patients. A light growth of aerobic oral flora was found in the cleft nasal floor in two patients, and anaerobic oral flora was cultured from the cleft nasal floor in the same two patients. No statistical correlation was found between growth of anaerobic flora and the cleft nasal floor (p =.48). CONCLUSIONS: Like aerobic oral flora, anaerobic oral bacteria would appear to only rarely colonize the cleft nasal floor in patients with oronasal fistulae. This additional investigation does not appear to be helpful in the assessment of oronasal fistulae in the clinic.

Modification of the Hunsuck sagittal split osteotomy using a nerve hook. Technical note.

A modification of the Hunsuck mandibular sagittal split osteotomy is described by which a nerve hook is used to facilitate the optimum placement of the medial bone cut. The simple technique assists with the location of the lingula, protects the inferior alveolar nerve as it enters the mandibular foramen, and enables a bone cut to be placed into the mandibular foramen itself.