Clinical aspects of cleft lip and palate reconstruction 2 rec

Part -2 REVISION & REVIEW

PROBLEMS AND MANAGEMENTThe Neonatal PeriodThe Neonatal Period & InfancyThe Toddler YearsThe School YearsThe Teenage YearsControversies Conclusion

The Neonatal PeriodPROBLEMS

COSMESISSUCKLING SWALLOWING & FEEDING

Breast Feeding may not be Possible Special Bottles- Droppers, Spoons

ASPIRATION Pneumonia During Feeding

Patience is needed In Sleep –Regurgitation

Burping Sleeping in Lateral or Prone position

The Neonatal PeriodPROBLEMS (contd)

MIDDLE EAR Eustachion tube dysfunction (22% to 88%) CSOM HEARING LOSS SPEECH DEFECT Abnormal curvature of the eustachian tube lumen Abnormal insertions of the tensor and levator veli

palatini muscles into the cartilages Reflux of food into the tube REPEATED TYMPANOSTOMY TUBE PLACEMENT

The Neonatal Period & InfancyPROBLEMS (contd)

PROTRUDING PREMAXILLA Presurgical Nasoalveolar Mould

Latham ApplianceGrayson, presurgical nasal alveolar moulding (PSNAM)

Grayson’s Latham’s

Management Schedule

PALATAL OBTURATORLIP REPAIR

SOFT PALATE REPAIRHARD PALATE REPAIR

TYMPANOSTOMY TUBEPHAYNGOPLASTYBONE GRAFTING

ORTHODNTICS

COSMETIC REVISIONS

AGE

MONTHS YEARS

0 3 6 9 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

The Neonatal Period & InfancyREPAIR OF LIP

Unilateral Various methods Most Commonly used

MILLARD’s

Z-PLASTY ON MUCOSAL SURFACE

A

B

C

MUCOSAL FLAPS FOR RECON NASAL FLOOR

MEDIAL FLAP LATERAL FLAP MEDIAL FLAP LATERAL FLAP

The Neonatal Period & InfancyREPAIR OF LIP

Unilateral Residual Deformity

AT STITCH REMOVAL

AT STITCH REMOVAL

SMALL NOSTRIL ALA?

PERFECT WHITE ROLL

ALAR DEFORMITY

VERMILLION BULGE

AT 8 YEARS

GOOD PALATE REPAIR

The Neonatal Period & InfancyREPAIR OF LIP

Unilateral Residual Deformity

SHORT UPPER LIP

TIGHT WHITE ROLL

DEPRESSED ALAR CARTILAGESTEP DEFORMITY

PERFECT WHITE ROLL

VERMILLION BULGE

ALAR BASE ROTATED UP

LIP LONGER ON CLEFT SIDE

AT PALATE REPAIR

The Neonatal Period & InfancyREPAIR OF LIP

Unilateral Residual Deformity

AT PALATE REPAIR

AT STITCH REMOVAL

AT 3YEARS AGE

PER OPERATIVE

NEAR PERFECT RESULTS

The Neonatal Period & InfancyREPAIR OF LIP

Bilateral Problems The premaxilla is extremely protrusive The premaxilla and prolabium can be of variable size The columella is deficient/almost nonexistent Prolabium is devoid of muscles

The Neonatal Period & Infancy Protruding Pre Maxilla

Presurgical Naso Aleolar MouldingSurgical Set-BackAggressive Advancement

NOSE

PROLABIUM

PREMAXILLA

VOMER

PREMAXILLARY-VOMERINE SUTURERESECTION OF VOMER

BEFORE RESECTION AFTER RESECTION OF VOMER

UPPER LIP

The Neonatal Period & InfancyREPAIR OF LIP

Bilateral Methods

ManyMillard’s Procedure : St line repair

FOR INCOM PLETE CLEFT

FOR COMPLETE CLEFT

The Neonatal Period & InfancyMyoplastic Repair

INCISION LINES

PROLABIUM LIFTED OFF PREMAXILLA

REPAIR OF MUSCLES WHITE ROLL EXCISED

INCISION LINES DE-EPITHELIZED

PROLABIUM LIFTED OFF PREMAXILLA

REPAIR OF MUSCLES

INCISION IN GINGIVO-BUCCAL SULCUS WITH A CUT-BACK

PRE-OP STITCH REMOVAL PALATE REPAIR

The Neonatal Period & InfancyREPAIR OF PALATE

Timing : 9-18 months SPEECH/ MAXILLARY HYPOPLASIA

Soft palate: FIRST?Hard palate : TOGETHER

The Neonatal Period & InfancyREPAIR OF PALATE

1. Schweckendick’s Primary Veloplasty2. V-Y Pushback3. Von Langenbeck Palatal Repair4. Furlow Palatoplasty

SCHWECKENDICK’S

WARDILL’S PUSH-BACKWARDILL’S

The Neonatal Period & InfancyREPAIR OF PALATE

1. Schweckendick’s Primary Veloplasty2. V-Y Pushback3. Von Langenbeck Palatal Repair4. Furlow Palatoplasty

FURLOW’S PALATOPLASTY

INCISIONS PALATAL MUCOSA INCISIONS NASAL MUCOSA

LEVATOR PALATII LEVATOR PALATII VON LANGENBECK’S

The Toddler YearsPRIORITY: SPEECHVELOPHARYNGEAL DYSFUNCTION

A. VELOPHARYNGEAL MISLEARNING SPEECH THERAPY i.e. Phoneme Specific Nasal Air Emission”

B. VELOPHARYNGEAL INCOMPETENCY SURGERY i.e.“Apraxia neurological deficit

C. VELOPHARYNGEAL INSUFFICIENCY SURGERY

i.e. Anatomical deficit

The Toddler YearsPriority: Speech

“CLEFT ERRORS OF SPEECH” in 30% PRIMARY ERROR - due to VPD (hypernasality)

consonants are most difficult sounds (plosives) SECONDARY ERROR - due to attempted

correction Glottic Stops, Nasal Grimace

VELOPHARYNGEAL DYSFUNCTION Diagnosed By Fiberoptic Laryngoscopy Or Ba-

swallow Surgical Repair After Failed Speech Therapy -

Usually Around Age 4

SIGNS AND SYMPTOMSHistory of NASAL REGURGITATION post

cleft palate repairHistory of need for multiple placement of PE

tubesNasal GRIMACEHOARSE Vocal Quality Decreased INTELLIGIBILITY

VELOPHARYNGEAL DYSFUNCTION

Surgical TechniquesVELOPHARYNGEAL

INCOMPETENCESuperior Based

Pharyngeal FlapSphincter

Pharyngoplasty Palatopharyngeus

Complications CONTINUED VPI STENOTIC SIDE

PORTS

The Toddler YearsGrowth hormone deficiency

40 Times More Common In CLAPSUSPECT: when below 5% on growth chart

The School YearsThree primary issues

ORTHODONTICS Poor Occlusion Congenitally Absent Teeth

ALVEOLAR BONE GRAFTING Fills Alveolar Defect - Around Age 12

PSYCHOLOGICAL GROWTH Considered Standard Of Care

The Teenage YearsMIDFACE RETRUSION

ETIOLOGY - ?Early Palatal Repair CORRECTIVE OSTEOTOMY: Around Age 18

PSYCHOLOGICAL DEVELOPMENT Counseling Standard Of Care

RHINOPLASTY Usually Last Procedure Performed, Around Age

20

Surgical TechniquesAlveolar Bone

GraftingIliac Crest Bone

GraftComplications

Infected Donor Site Hematoma

Failed Graft Dehiscence Palatal Prosthesis

Surgical TechniquesMidfacial Advancement

LeForte(I,II,III) Osteotomies Leave Vascular Pedicle

Attached In Back Of Maxilla - Prevents Necrosis

Complications Malocclusion Infection Necrosis

Surgical TechniquesRhinoplasty

Standard Techniques Tip: Projection Alar:

Rotation/Buckling/ Base/ Alar Facial angle

Columellar : Length/ Rotation of crura

Complications Alar Stenosis

Controversies: Otologic Disease>90% have COME (chr. otitis media + effusion)

Robinson, et al prospective, 150 patients - 92%

Muntz, et al. retrospective, 96%

Pathology: Eust.Tube Dysfunction (controversial)

abnormal muscular attachment/abnormal canal Huang, et al. - Cadaveric study

palatal repair restores ET function. ?Midface growth?

Controversies:Timing of RepairEARLY REPAIR

ADVANTAGE: improved speech Rohrich, et. al; retrospective study. The earlier the

repair, the better speech. DISADVANTAGE: worsening midface retrusion

Rohrich, et. al; people with unrepaired palates have less midface retrusion

Controversies: VPISurgical Repair

Reserved for failure of speech therapyPHARYNGEAL FLAP - superiorly based

Advantage: time tested, severe cases Disadvantage: passive obturator

SPHINCTER PHARYNGOPLASTY (palatopharyngeus rotation flap) Advantage: active sphincter Disadvantage: new technique

ControversiesPresurgical Nasal

Alveolar Moldingmolds palate,

alveolus and nose Advantage: excellent

early results Disadvantage: no

long term resultsGrayson, et al.

(2009)

Conclusion and Future DirectionsMultidisciplinary approachNot merely a “surgical problem”Evaluation of controversies for Consensus

Alveolar bone grafting: PRE-OR POST- ORTHODONTICS

PSNAM? (Pre Surgical Nasoalveolar Moulding)Pharyngoplasty vs. pharyngeal flap