[Nasendoscopic comparison for cleft palate repair after velopharyngeal muscle reconstruction].

OBJECTIVE: To find out the nasendoscopic changes of velopharyngeal configuration and movement after palatoplasty with or without velopharyngeal muscle reconstruction. METHODS: The nasendoscopy was taken in forty-one patients with palatoplasty, 22 repaired by velopharyngeal muscle reconstruction and 19 with modified von Langenbeck's procedure (non-reconstructive group). RESULTS: In patients with velopharyngeal muscle reconstruction, the velopharyngeal ports are smooth and full with a definite reduction in size than patients without velopharyngeal muscle reconstruction. During phonation, the complete and marginal velopharyngeal competence rate in reconstructive group (90.91%) is higher than the group of non-reconstruction (37.31%) The major velopharyngeal closure is circular movement in reconstructive group, otherwise coronal closure in nonconstructive group. CONCLUSIONS: Based the observation of nasendoscopy, the velopharyngeal muscle reconstruction in palatoplasty has more definite improvement to velopharyngeal closure than non-reconstructive procedure. Palatoplasty with velopharyngeal muscle reconstruction could reduce the size of velopharyngeal port and make the complete velopharyngeal closure easier.

A modified procedure for velopharyngeal sphincteroplasty in primary cleft palate repair and secondary velopharyngeal incompetence treatment and its preliminary results.

During cleft repair, velopharyngeal sphincter reconstruction is still a challenge to plastic surgeons. To improve the surgical treatment for cleft palate and secondary velopharyngeal incompetence (VPI), a carefully designed modified procedure for primary palatoplasty and secondary VPI was presented. Fifty-six patients (48 for primary cleft palate repair and eight for secondary VPI of previously repaired clefts) underwent this procedure from 1988 to 2001. The modified procedure is a combination of the tunnelled palatopharyngeus myomucosal flap for dynamic circular reconstruction of the pharyngeal element of the velopharyngeal sphincter and the double-reversing Z-plasty with levator velo palatini muscles reposition in the velar element of the sphincter. The satisfactory velopharyngeal competence (complete velopharyngeal closure and marginal velopharyngeal closure) was achieved in 23 of 25 patients with primary cleft palate repair examined by nasendoscopy and the nasality, speech articulation and intelligibility are also assessed in 25 primary cleft palate repaired patients with 92% satisfactory result (normal speech and speech with mild VPI) in single word test and 88% in continuous speech evaluation. Based on our experience, we believe that this modified procedure is a reasonable choice for primary cleft repair and secondary VPI treatment because it is in accord with normal physiology and anatomy of the velopharyngeal sphincter, can lengthen the soft palate, decrease the enlarged velopharynx, augment the posterior pharyngeal wall, and enhance the relationship between the muscles of velopharyngeal sphincter which results in a dynamic neo-sphincter in palatopharyngoplasty. Further study of the procedure is needed. The theoretical basis, operative highlights, velopharyngeal function, advantages and disadvantages of the modified procedure were discussed.

Sutural distraction osteogenesis (SDO) versus osteotomy distraction osteogenesis (ODO) for midfacial advancement: a new technique and primary clinical report.

A new technique of osteotomy distraction osteogenesis (ODO) and sutural distraction osteogenesis (SDO) by the use of bone-borne traction hooks is presented. The technique of osteotomy plus distraction osteogenesis is suitable for adult patients. The technique of sutural distraction osteogenesis is suitable for young patients, ages 6 through 12 years. The distraction system consists of a face-bow, orthodontic elastics, and bone-borne traction hooks. The bone-borne traction hooks are made of titanium, with two traction hooks running laterally or downwardly. When a Le Fort III osteotomy is needed, bone-borne traction hooks are inserted through the nostrils into a bone hole drilled at the lateral-inferior pyriform aperture. When no osteotomy is needed, only the bone-borne traction hooks are placed. Heavy elastics were used in the technique of osteotomy distraction osteogenesis for Le Fort III osteotomy adult patients, whereas light forces and thus light elastics were used for younger patients. Three adult patients and four children were treated by osteotomy distraction and sutural distraction, respectively. All seven patients with midfacial hypoplasia established a harmonious facial profile and normal occlusal relationships. Radiographic examination showed balanced advancement of the midfacial skeleton. It is suggested that the treatment of midfacial hypoplasia in children by the technique of sutural distraction osteogenesis is to be preferred because of its simplicity and relative noninvasiveness. Thus, the authors suggest that midfacial hypoplasia should be treated at a younger age by this technique, potentially eliminating the need for a Le Fort III osteotomy at an older age.

[A comparison of the velopharyngeal closure after palatoplasty between with or without velopharyngeal muscular reconstruction].

OBJECTIVE: To evaluate the effect of palatoplasty with or without velopharyngeal muscular reconstruction on the velopharyngeal closure under the lateral radiography. METHODS: The lateral radiographs and cephalometric analysis were taken in sixty-two patients with cleft palate and velopharyngeal insufficiency, 32 repaired with velopharyngeal muscular reconstruction and 30 with modified von Langenbeck's procedure (non-reconstructive group). RESULTS: In patients with velopharyngeal muscular reconstruction, the velopharyngeal competence, the reductive rate of nasopharynx, the distance reduction in lower part of the mobile nasopharynx during phonation and the distance in middle part of mobile nasopharyngo in rest were superior to that without velopharyngeal muscular reconstruction, and there were variform PPW eminence-soft palate contact in velopharyngeal closure. The patients with complete or good velopharyngeal closure had a definite reduction in nasopharynx, compared to the patients with velopharyngeal insufficiency in the non-reconstructive group. CONCLUSIONS: The functional area for velopharyngeal closure after palatoplasty might be located in the middle part of mobile nasopharynx. The velopharyngeal muscular reconstruction in palatoplasty could reduce the size of nasopharynx and improve the coordination movement of velopharyngeal closure.

[Mid-premaxillary sutural distraction osteogenesis for repair of alveolus cleft: an experimental study in dogs].

OBJECTIVE: To explore a new technique for repair of alveolar cleft by sutural distraction osteogenesis. METHODS: Nine 8-weeks mongrel dogs were used in this study, three being in the control group, six in the experimental group. Alveolar cleft model was created surgically in all animals. Two weeks later, a U-shaped distractor made of Ni-Ti memory alloy wire was insterted into the premaxilla to distract the mid-premaxillary suture. When the premaxilla of the cleft side approached the ipsilateral maxilla, periosteoplasty of the alveolar cleft was performed. The distractor was removed at two weeks after periosteoplasty. The results were evaluated clinically, radiographically, morphologically and histologically. RESULTS: The cleft model in dogs was stable and similar to the human alveolar cleft. In experimental dogs, the premaxilla was moved gradually toward the maxilla so that the cleft was closed. The distracted mid-premaxillary suture showed a gradually widened traingle, with its tip being posterior. The density of the distracted traingle suture was increased gradually. Bony repair was achieved completely at the cleft three months post-periosteoplasy. The morphology of the mid-premaxillary suture was restored. CONCLUSION: The alveolar cleft could be repaired by the technique of mid-premaxilla suture distraction.

[Sutural distraction osteogenesis for primary cleft palate repair: a preliminary clinical report].

OBJECTIVE: To probe the possibility of a new technique of primary cleft palate repair by sutural distraction osteogenesis. METHODS: The distractor was made of TiNi-shape memory alloy with 2 secure and 2 active arms. Under general anesthesia, 1 hole was drilled on each maxillary process and horizontal plate of palatine. The four arms of the distractor were inserted into holes. The palatine bones would then be distracted and moved medially and posteriorly. After 4 to 5 months' distraction, the two cleft edges approached gradually. The residual cleft, according to its width, was repaired by direct stitch of muco-periosteum incised at cleft edges, or with an additional relaxing incision on one side of the palate. Direct measurement of width of maxillary arch and the cleft, and the length of the hard palate was performed before and after distraction to evaluate the effects of distraction. RESULTS: Eight cleft children at their 2 to 4 years of age were treated by the new technique. Two of them terminated the procedure due to premature dislocation of the distractor. Six children underwent 37 to 126 days' distraction. Dramatic narrowing of the cleft and lengthening of hard palate were seen in these children, with the average narrowing of the cleft being 6.5 mm and average lengthening of the hard palate being 4.8 mm. CONCLUSION: It is clinically demonstrated that palatal tissue regeneration and cleft closure or narrowing and hard palate lengthening could be achieved by the technique of sutural distraction osteogenesis.

The "levator septi nasi muscle" and its clinical significance.

It is strange that all textbooks of anatomy describe the depressor septi nasi muscle singly, without an antagonist. Incidentally, in 1986, a small rod of soft tissue was found between the medial crura of the two alar cartilages during a rhinoplastic operation with the external approach technique of Anderson and Ries. From 1990 through 1995, anatomic dissections of the nasolabial region under 3.5x loupe magnification were performed on 14 Chinese formalin-preserved cadavers, one fresh Chinese cadaver, and one fresh American white female cadaver. The small soft-tissue rod was found in every one of the dissected cadavers, and it was seen to be a pair of muscles. Each one of these paired small muscles arose from the aponeurosis on the dorsum of the nose and inserted into the muscular substance of the upper lip at the base of the columella and to the anterior spine of the maxilla. Histologic examinations of these muscles stained with hematoxylin and eosin and Masson trichrome showed that they were striated muscles. According to its origin and insertion, this newly found muscle was called the "levator septi nasi." Its clinical significance in cleft lip deformity and its relations to the orbicularis oris muscle, the dermocartilaginous ligament of Pitanguy, and the nasal superficial musculoaponeurotic system of Letourneau and Daniel are all discussed.