Validating the Modified Small Double Opposing Z-Plasty for Palatal Lengthening in Primary Palatoplasty.

OBJECTIVE: To appraise the degree of intraoperative palatal lengthening with the modified Furlow small double-opposing Z-plasty (sDOZ). DESIGN: Retrospective single-surgeon (R.D.) study. PATIENTS: Nonsyndromic children (n = 167) with Veau types I to IV cleft palates who underwent primary sDOZ palatoplasty. INTERVENTIONS: Intraoperative measurements of palatal lengths and widths were collected using calipers, paper rulers, and metal rulers before the administration of local anesthetic solution and before the removal of the mouth gag (initial and final palatal dimensions, respectively). MAIN OUTCOME MEASURES: Assessment of the intraoperative percentage change (difference between final and initial values) in surface palatal length, straight palatal length, and soft palatal length. Bivariate and multivariate analyses were performed to identify independent predictors (sex, age at surgery, Veau, Kernahan/ Stark, and Randall classifications, widest cleft width, presence of lateral relaxing incision, type of coverage with buccal fat flap, and postoperative complications) of soft palatal lengthening. RESULTS: Surface palatal, straight palatal, and soft palatal lengths had an intraoperative increase of 8%, 14.7%, and 27.7%, respectively. The degree of intraoperative soft palatal lengthening significantly varied among Veau cleft types (I = II < III = IV). Veau type III and cleft lip/palate were independent positive predictors (P < .001) of soft palatal lengthening, while other tested variables were not correlated (P > .05) with this outcome. CONCLUSIONS: Overall intraoperative palatal lengthening occurs with the modified sDOZ palatoplasty, with differences within the spectrum of cleft palate deformity.

Avoiding Inferior Alveolar Nerve Injury During Sagittal Split Ramus Osteotomy.

Orthognathic surgery is highly effective in improving overall facial esthetics, in addition to achieving an ideal occlusion. Sagittal split ramus osteotomy (SSRO) of the mandible is the mainstay of modern orthognathic surgery, but intraoperative injury to the inferior alveolar nerve (IAN) remains one of the common complications. The authors report a case of 19-year-old male patient with left cleft lip and palate who received orthognathic surgery involving SSRO. The patient's right IAN ran close to the outer cortex of the mandible, but SSRO was successfully performed without injuring the nerve. Detailed preoperative evaluation using computed tomography images is essential. Blind splitting maneuvers during SSRO may cause IAN injury, and direct visualization inside the ramus helps to prevent injury to the nerve. Sagittal split ramus osteotomy could be considered as a viable option even when the IAN runs close to the outer cortex. This article describes SSRO procedures, highlighting the methods to avoid nerve injury.

Long-Term Outcome of Primary Rhinoplasty with Overcorrection in Patients with Unilateral Cleft Lip: Avoiding Intermediate Rhinoplasty.

BACKGROUND: No consensus exists regarding the timing or technique of rhinoplasty for correction of the unilateral cleft lip nose deformity, with few studies examining the long-term effects of a single technique. This study appraised the long-term outcomes of primary rhinoplasty using the Tajima technique for overcorrection in a cohort of patients with unilateral cleft lip nose deformity after attaining skeletal maturity. METHODS: Consecutive nonsyndromic patients with unilateral cleft lip nose deformity ( n = 103) who underwent primary rhinoplasty with overcorrection by a single surgeon between 2000 and 2005 were reviewed. Patients with unilateral cleft lip and nasal deformity who underwent primary rhinoplasty (but with no overcorrection) ( n = 30) and noncleft individuals ( n = 27) were recruited for comparison. Outcomes were assessed through FACE-Q scales evaluating satisfaction with appearance of nose and nostrils (two scales) and computer-based objective photogrammetric analysis of nasal symmetry (nostril height, nostril width, nostril area, alar height, and alar width parameters). RESULTS: Significant differences (all P < 0.001) were observed between the Tajima and non-Tajima groups for all but one photogrammetric nasal parameter (nostril area), with the Tajima group demonstrating closer mean values to the noncleft group. The Tajima and noncleft groups demonstrated no significant difference (all P > 0.05) for scores of FACE-Q nose and nostrils scales. CONCLUSION: This study indicated that the patients who underwent primary rhinoplasty with overcorrection had improved results with no necessity for intermediate rhinoplasty, emphasizing that the procedure is an effective approach to correct the unilateral cleft nose deformity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Modified Medial Incision Small Double-Opposing Z-Plasty for Treating Veau Type I Cleft Palate: Is the Early Result Reproducible?

OBJECTIVE: An inspiring early result with no oronasal fistula formation was recently described for a modified medial incision small double-opposing Z-plasty (MIsDOZ) for treating Veau type I cleft palate. This study describes an early single-surgeon experience in applying this newly proposed surgical approach. DESIGN: Retrospective single-surgeon study. PATIENTS: Consecutive nonsyndromic patients (n = 27) with Veau I cleft palate. INTERVENTIONS: Topographic anatomical-guided MIsDOZ palatoplasty with pyramidal space dissection (releasing of the ligamentous fibers in the greater palatine neurovascular bundle and pyramidal process region, in-fracture of the pterygoid hamulus, and widening of space of Ernst) performed by a novice surgeon (RD). MEAN OUTCOME MEASURES: Age at surgery, the presence of cleft lip, palatal cleft width, use of lateral relaxing incision, and 6-month complication rate (bleeding, dehiscence, fistula, and flap necrosis). A published senior surgeon-based outcome dataset (n = 24) was retrieved for comparison purposes. RESULTS: Twenty-two (81.5%) and 5 (18.5%) patients received the medial incision only technique and lateral incision technique, respectively (P = .002). Age, presence of cleft lip, and cleft width were not associated (all P > .05) with the use of lateral incision. Comparative analysis between the novice surgeon- and senior surgeon-based datasets revealed no significant differences for sex (females: 74.1% vs 62.5%; P = .546), age (10.2 ± 1.7 vs 9.6 ± 1.2 months; P = .143), rate of lateral incision (18.5% vs 4.2%; P = .195), and postoperative complication rate (0% vs 0%). CONCLUSION: This modified DOZ palatoplasty proved to be a reproducible procedure for Veau I cleft palate closure, with reduced need for lateral incision and with no early complication.

Secondary Alveolar Bone Grafting in Patients with Cleft Lip and Palate: A Step-by-Step Video Series.

SUMMARY: Secondary alveolar bone grafting is one of the key surgical procedures performed to restore dental arch continuity and facilitate tooth eruption in patients with cleft lip and palate. Harvest of cancellous bone graft from the iliac crest has become the gold standard; however. there is no consensus regarding the ideal technique. An optimal bone harvest technique must be aimed at producing minimal donor-site morbidity and patient discomfort. The success of the bone grafting procedure depends largely on the surgical technique. To restore cleft alveolar defects, one must be able to conceptualize the different underlying aspects of the problem to perform an effective surgical repair. It is important for surgeons-in-service to adopt newer techniques that significantly enhance the overall outcome. This article describes two techniques of iliac bone harvest and the principles involved in execution of the alveolar bone grafting procedure. The accompanying four-part video series depicts the bone harvest, flap design, dissection of the recipient cleft alveolus, and bone grafting in a step-by-step manner.