The correlation between training and skill of the surgeon and reoperation rate for persistent cleft palate speech.

The correlation between the surgeons training and skill and the speech after primary repair was tested using the reoperation rate as a measure for success in 439 cleft palate/cleft lip and palate (CP/CLP) patients operated at the average age of 22 months by 4 specialists and 4 residents. The reoperation rate for residents was 11-60% (av. 36) and for specialists 13-31% (av. 19). The relative reoperation rates in CP/CLP were 20/19% for specialists but 35/38% residents. In groups consisting of the four with the best (A) and the four with the worst results (B) the reoperations rate in group A was 16% for CP and 13% for CLP, but in group B 37/44%. As the residents became specialists, the degree of their improvement varied greatly. Thus both the training and skill are important for the patients speech, but they are not necessarily synonymous terms.

Comparison of quality of speech after Veau-Wardill-Kilner pushback operation and the Cronin modification in the primary treatment of cleft palate.

The quality of speech was compared in 124 young adults with isolated cleft palate. Forty-seven subjects were excluded because of the presence of factors that might have biased the evaluation of the success rate of the two operations studied, leaving 77 subjects who had undergone primary palatoplasty for analysis. One stage closure of the soft and hard palate was done for 43 patients by the mucoperiosteal palatal V to Y pushback technique (Veau-Wardill-Kilner, group V), and 34 underwent the Cronin modification (group C). Their speech was tape recorded, analysed by three qualified listeners, and hypernasality assessed by four published hypernasality indexes. More subjects in group C achieved normal resonance than in group V, who had higher hypernasality index scores than group C. The groups managed pressure consonants similarly. Only a few patients had weak plosives, audible nasal air emission, or compensatory articulation. Similar numbers of secondary operations were done for both groups. However, group V would have actually required secondary surgery more frequently than group C.

Periosteal flaps and grafts in primary cleft repair: a follow-up study.

A long-term follow-up study of maxillary clefts operated on primarily with the maxillary periosteal flap (67 patients) and the free tibial periosteal graft (23 patients) showed a definite bone bridge in 64 versus 85 percent of the patients. Still, secondary bone grafting was indicated in both in over 70 percent. Lateral crossbite was observed in all and anterior crossbite (mostly dental) was seen in over 80 percent of both groups. There were no statistically significant differences in the cephalometric angular measurements between the groups. Inside the maxillary periosteal flap group the maxillary growth was more retarded in unilateral and especially bilateral complete clefts than in alveolar clefts only. The maxillary growth seemed to be on average better than in primarily bone-grafted materials. The primary use of periosteum had been abandoned in our unit already in 1974, because it did not fulfill the expectations of prevention of maxillary collapse, lesser need for secondary bone grafting, and better midfacial growth.

Treatment of severe developmental asymmetry of the female breast.

In a material of 49 female patients with severe developmental breast asymmetry, Poland's syndrome and isolated unilateral hypoplasia were the most frequent etiological factors (69%). Prosthetic augmentation alone, transfer of the de-epithelialized latissimus dorsi musculocutaneous flap to fill up the infraclavicular hollow, combined with an expander prosthesis for the breast, or augmentation with tissue from the contralateral "healthy" hypertrophic breast were found to be the methods of choice in selected cases. In order to achieve optimum symmetry the contralateral ptotic/hypertrophic breast should be corrected in most patients.

Accelerated tissue expansion with the "overfilling" technique.

Temporary overexpansion of the tissues at each filling session increased the actual inflation volume by about 59 percent. This shortened the process of tissue expansion considerably. "Overexpansion" means that the pressure in the expander is increased to a point where the dermal capillary flow is zero or the patient experiences so much discomfort that inflation cannot be carried out any further. The pressure in the expander is thereafter gradually decreased by taking out saline until both the capillary refill and all other clinical criteria are sufficient for safe dermal circulation. Comparison of the expander volume at the final pressure to the initial filling volume at the same pressure before the "overfilling" confirmed an average gain of about 59 percent in 14 patients.

Primary hereditary systemic amyloidosis (Meretoja's syndrome): clinical features and treatment by plastic surgery.

The characteristic, bloodhound-like appearance, which degenerates gradually, of patients with primary hereditary systemic amyloidosis, also called Meretoja's syndrome (MS), is attributable to amyloid degeneration of the craniofacial skin and peripheral facial nerves, but apparently also to amyloid deposits in the muscles; a finding not previously described. A material of five patients treated with plastic surgery is presented, and the peculiarities and differences of this rare disease in comparison with other peripheral neuropathies is discussed from a reconstructive viewpoint.

Tissue expander injection dome leakage.

Injection dome leakage was found to be the cause for partial disappearance of the saline solution injected into some tissue expanders. When the injection domes of 22 consecutively removed tissue expanders were checked, we found that the average leakage pressure of these was 32 mmHg, with a range of 8 to 110 mmHg. When the patients were lying on their expanders, the weight of the corresponding body part caused intraluminal pressures of up to 90 mmHg in their expanders. Following removal of the expanders, the total leakage was calculated quantitatively and found to be maximally over 50 percent of the injected volume in some instances. The leakage flow through the injection dome in seven consecutively removed expanders was checked at pressures of 25, 50, and 75 mmHg over 30 minutes and was found to be slow. The possibility of injection dome leakage should be kept in mind, however, as a potential complication under unfavorable conditions. At the same time, we want to emphasize that in most instances tissue expanders function quite well and in predictable ways.

Validity of laser Doppler flowmetry for measuring the effect of the tissue expander pressure on skin circulation. Simultaneous measurement of tissue pressure and laser Doppler flowmetry.

Intermittent Laser Doppler Flowmetry (LDF) was used in five patients to measure changes in the dermal blood flow when changing intraluminal pressures in tissue expanders (TE). In another patient, continuous monitoring of the intraluminal pressure in the TE and simultaneous LDF was used. Our finding is that LDF is a suitable method for the registration of reactions in dermal circulation, caused by TE pressure changes. A statistically significant association between the changes of the LDF values and the intraluminal pressure in the TE was observed.

Solitary metastatic melanoma of the soft palate.

Melanoma of the oral mucosa is frequently situated in the area of the hard palate but extremely rarely in the soft palate. Even metastatic tumors are very rare in this location, and surgery at this stage is seldom indicated. Two patients with solitary metastatic melanoma of the soft palate are described. In both, a subtotal excision of the soft palate was performed, completed by reconstruction with pharyngeal flaps and island flaps from the hard palate. Both patients are alive and free from recurrence 12 years and 4 years after the primary diagnosis of melanoma and 2 years and 18 months after the palatal reconstruction. One patient has normal speech with no nasality; the other patient has very slight hypernasality but no other problems.

Spontaneous narrowing of the palatal cleft during the first year of life: a quantitative study.

In 44 clefts of the hard palate the relative size of the cleft, as a percentage of the total palatal area, decreased by an average of 7% between the ages of 3 and 17 months. The relative size of the cleft at the second examination was only 52% of that at the first evaluation. The length of the cleft (per cent of the palatoalveolar length) shortened by 7%. The palatal height increased by 2.2 mm in this group and by 2.4 mm in a control group (23) with only minor posterior clefts. The spontaneous narrowing, most evident in wide anterior clefts, seems to be primarily due to actual growth, and not to bending or collapse. This phenomenon should be taken into consideration in the choice of the optimum age for surgery, which, in selected cases, should not take place before the age of one year.

Epidemiology of orofacial clefts in Finland: a review.

Epidemiological studies on clefts in Finland seem to give support to the following theories: 1. Both genetic and environmental factors seem to play a role in the pathogenesis of cleft lip and/or cleft palate, which in the majority of cases are probably two different anomalies. 2. The incidence of cleft lip and/or cleft palate in Finland has increased, probably because of a change in the environmental factors. 3. The incidence of cleft palate in Finland is higher than anywhere, which seems to be the result of differing genetic factors. 4. The exogenous factors remain unidentified, but in cleft lip and/or cleft palate parallel fluctuations and an increasing trend have been noticed, arguing for similar and simultaneous factors. 5. More patients with cleft palate than cleft lip/palate have "cleft syndromes."

Relationship between side of the cleft and handedness of the patient.

The relationship between the type and side of the cleft and the left-right-handedness of the patient was evaluated in 706 patients with cleft, of whom 348 had unilateral cleft of the primary palate. The prevalence of left-handed persons in the group with left-sided cleft (14.5%) was more than three times as high as in the group with right-sided cleft (4.7%), a statistically significant difference. Among the 75 (10.6%) left-handed patients there were 38 unilateral clefts, of which 32 (84.2%) were on the left side; only 6 (15.8%) were on the right. Among the 631 right-handed patients there were 310 unilateral clefts, of which 122 (39.4%) were on the right and 188 (60.6%) were on the left side. Thus, the side of the cleft seemed to be associated with ipsilateral handedness. A large majority of left-handed patients have left-sided clefts, while right-handed patients are more heterogeneous in this respect.

Cervical spondylitis as a complication of secondary cleft palate surgery--a rare variety of the "maladie de Grisel". Case report.

Spontaneous atlanto-axial dislocation, due to metastatic lymphogenous infection and rupture of the transverse ligament is a well-known but rare complication of nasopharyngeal infections and/or operations. Previously one such case has been reported following a velopharyngeal flap (distally based) in a child with cleft palate. This is a report of two adult cleft patients with spondylitis of C III resulting in spontaneous fusion of C II-III, following a combined (cranially based) velopharyngeal flap and a dynamic muscle sphincter operation in one stage. Prolonged postoperative pain and stiffness of the neck should make one suspect this rare complication.

Correlations between microforms of the Van der Woude syndrome and cleft palate.

The lower lip was examined in 397 children with isolated cleft palate (CP), in 518 cleft lip children with or without cleft palate (CL(P)) and in 1000 noncleft children. Familial occurrence of clefts, other concomitant anomalies and the type and extension of the cleft were determined from the child's medical history. A total of 323 orthopantomograms, taken at the ages of 6-12 years, were available in the detection of hypodontia of the permanent teeth excluding the third molars in the CP group. The incidence of lower lip sinus and microforms (conical elevations, CE) was noted. The incidence of sinuses was 2.3% in the CP group, 2.5% in the CL(P) group and 0% in the noncleft group. The corresponding figures for CE were 39.3%, 0.8% and 0.7%, respectively. In the CP group with CE, the familial occurrence of clefts was statistically higher (30.0%) than in the group without CE (20.7%). The corresponding figures for hypodontia were 40.7% and 24.7%, respectively. Conical elevations are cleft palate related disturbances in the development of the lower lip. At least in certain cases the CE do represent microforms of the sinus syndrome. Thus the question arises: do the CE always represent microforms of the Van der Woude syndrome, or are they only pathogenic similarities of a variable etiology?

Correlations of hypodontia in children with isolated cleft palate.

A total of 251 children with isolated cleft palate were examined. Orthopantomograms, taken at the age of 6-12 years, were used in the detection of hypodontia of the permanent teeth, excluding the third molars. The findings were: 1. Familial history of clefting has no pronounced effect on the prevalence of hypodontia; 2. The prevalence of hypodontia was significantly higher in children with conical elevation of the lower lip than in those without it (40% to 25%), and increased with increasing extension of the cleft; 3. Cleft palate was associated with conical elevation and/or hypodontia in 56% of the subjects. The same etiological factor or factors seems to be responsible for the formation of the cleft, for conical elevation, and for hypodontia.