What critical structure should be repaired during a cleft reconstruction?
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Obicularis oris
What would be the possible advantage of splitting up the primary repair of the palate
into two stages (one for soft palate repair and another for hard palate repair)?
,Give this one a try later!
Another approach used to balance speech issues with growth-related
concerns is to stage the closure of the secondary palate with two
operations. Generally this involves the repair of the soft palate early in life
as an initial step, followed by closure of the hard palate later in infancy. The
idea is that timely repair of the soft palate, which is critical for speech, is
accomplished while hard palate repair with mucoperiosteal stripping is
delayed until growth is further along.117,118 Although this technique is not
advocated by the majority of surgeons, some surgeons may feel that
repairing the hard palate portion later may offer the advantages of less
growth restriction, easier repair of larger clefts, and less chance for
fistula formation. No convincing data exist to favor this approach over a
single-stage repair, but the practice is continued by some centers where
anecdotal evidence suggests that there may be some benefit. In contrast
most North American speech and language pathologists prefer closure of
the palate as a single operation.1
What determines when a LeFort III vs Monoblock vs a Facial Bipartition should be
used?
Give this one a try later!
, The type of osteotomies selected to manage the “total midface” deficiency
or deformity and residual cranial vault dysplasia should depend on the
extent and location of the presenting dysmorphology rather than on a
fixed approach to the midface malformation.47,53–56,65,66,72,78–82 The
selection of a monobloc (with or without additional orbital segmentation),
facial bipartition (with or without additional orbital segmental osteotomies),
or Le Fort III osteotomy to manage the basic horizontal, transverse, vertical
orbital, and upper midface deficiencies or deformities in a patient with
Crouzon’s syndrome depends on the patient’s presenting midface and
anterior cranial vault morphology. The observed dysmorphology is
dependent on the original malformation, the previous procedures carried
out, and the effects of ongoing growth (Figures 46-4 and 46-5).
When evaluating the upper and midface in a child born with Crouzon’s
syndrome, if the supraorbital ridge is in good position when viewed from
the sagittal plane (the depth of the upper orbits is adequate), the
midface and forehead have a normal arc of rotation in the transverse
plane (not concave), and the root of the nose is of normal width (minimal
orbital hypertelorism), there is little need to reconstruct this region (the
forehead and upper orbits) any further. In such patients, the basic residual
midface deformity is in the lower half of the orbits, zygomatic buttress,
and maxilla. If so, the deformity may be effectively managed using an
extracranial Le Fort III osteotomy.
If the supraorbital ridges, anterior cranial base, zygomas, nose, lower
orbits, and maxilla all remain deficient in the sagittal plane (horizontal
retrusion), a monobloc osteotomy is indicated (see Figures 46-4 and 46-5).
In these patients, the forehead is generally flat and retruded and will also
require reshaping and advancement. If upper midface hypertelorism
(increased transverse width) and midface flattening (horizontal retrusion)
with loss of the normal facial curvature (concave arc) are also present, the
monobloc unit is split vertically in the midline (facial bipartition), a wedge
of interorbital (nasal and ethmoidal) bone is removed, and the orbits and
zygomas are repositioned medially while the maxilla at the palatal level is
widened.
What happens when an alveolar bone graft is attempted in an older patient (after
eruption of the canines)?
, Give this one a try later!
Patients older than 12 years of age who undergo grafting have been
reported to have decreased success when evaluated using the Bergland
scale,6,18,28,30,34,35 loss of osseous support of teeth adjacent to the
cleft,21 and increased morbidity.30 There is less opportunity to salvage the
lateral incisor, and there is a delay in correction of the orthodontic
condition. This delayed grafting does allow for increased options with
regard to donor site for graft material because harvest of the mandibular
symphysis becomes possible.
What can be done to aid in closures of extremely wide palatal clefts?
Give this one a try later!
In very wide clefts some surgeons will advocate the consideration of a
pharyngeal flap at the primary palatoplasty procedure to assist in closure
since revision palatoplasty is sometimes unsuccessful in eradicating fistulas.
Those who use this technique usually perform it in extremely wide clefts
and do so very selectively. This allows the central portion of the closure to
be filled with posterior pharyngeal wall tissue making the closure of the
nasal and palatal mucosa easier. Patients with Pierre Robin syndrome or
Treacher Collins syndrome may have exceptionally wide clefts that are
difficult to close with no tension, and this technique may be considered.
The drawbacks of using a pharyngeal flap during the repair of the palate
include a significantly increased risk for complications such as bleeding,
snoring, obstructive sleep apnea, or hyponasality.
What is the OMENS classification criteria for hemifacial microsomia?
Give this one a try later!
Give this one a try later!
Obicularis oris
What would be the possible advantage of splitting up the primary repair of the palate
into two stages (one for soft palate repair and another for hard palate repair)?
,Give this one a try later!
Another approach used to balance speech issues with growth-related
concerns is to stage the closure of the secondary palate with two
operations. Generally this involves the repair of the soft palate early in life
as an initial step, followed by closure of the hard palate later in infancy. The
idea is that timely repair of the soft palate, which is critical for speech, is
accomplished while hard palate repair with mucoperiosteal stripping is
delayed until growth is further along.117,118 Although this technique is not
advocated by the majority of surgeons, some surgeons may feel that
repairing the hard palate portion later may offer the advantages of less
growth restriction, easier repair of larger clefts, and less chance for
fistula formation. No convincing data exist to favor this approach over a
single-stage repair, but the practice is continued by some centers where
anecdotal evidence suggests that there may be some benefit. In contrast
most North American speech and language pathologists prefer closure of
the palate as a single operation.1
What determines when a LeFort III vs Monoblock vs a Facial Bipartition should be
used?
Give this one a try later!
, The type of osteotomies selected to manage the “total midface” deficiency
or deformity and residual cranial vault dysplasia should depend on the
extent and location of the presenting dysmorphology rather than on a
fixed approach to the midface malformation.47,53–56,65,66,72,78–82 The
selection of a monobloc (with or without additional orbital segmentation),
facial bipartition (with or without additional orbital segmental osteotomies),
or Le Fort III osteotomy to manage the basic horizontal, transverse, vertical
orbital, and upper midface deficiencies or deformities in a patient with
Crouzon’s syndrome depends on the patient’s presenting midface and
anterior cranial vault morphology. The observed dysmorphology is
dependent on the original malformation, the previous procedures carried
out, and the effects of ongoing growth (Figures 46-4 and 46-5).
When evaluating the upper and midface in a child born with Crouzon’s
syndrome, if the supraorbital ridge is in good position when viewed from
the sagittal plane (the depth of the upper orbits is adequate), the
midface and forehead have a normal arc of rotation in the transverse
plane (not concave), and the root of the nose is of normal width (minimal
orbital hypertelorism), there is little need to reconstruct this region (the
forehead and upper orbits) any further. In such patients, the basic residual
midface deformity is in the lower half of the orbits, zygomatic buttress,
and maxilla. If so, the deformity may be effectively managed using an
extracranial Le Fort III osteotomy.
If the supraorbital ridges, anterior cranial base, zygomas, nose, lower
orbits, and maxilla all remain deficient in the sagittal plane (horizontal
retrusion), a monobloc osteotomy is indicated (see Figures 46-4 and 46-5).
In these patients, the forehead is generally flat and retruded and will also
require reshaping and advancement. If upper midface hypertelorism
(increased transverse width) and midface flattening (horizontal retrusion)
with loss of the normal facial curvature (concave arc) are also present, the
monobloc unit is split vertically in the midline (facial bipartition), a wedge
of interorbital (nasal and ethmoidal) bone is removed, and the orbits and
zygomas are repositioned medially while the maxilla at the palatal level is
widened.
What happens when an alveolar bone graft is attempted in an older patient (after
eruption of the canines)?
, Give this one a try later!
Patients older than 12 years of age who undergo grafting have been
reported to have decreased success when evaluated using the Bergland
scale,6,18,28,30,34,35 loss of osseous support of teeth adjacent to the
cleft,21 and increased morbidity.30 There is less opportunity to salvage the
lateral incisor, and there is a delay in correction of the orthodontic
condition. This delayed grafting does allow for increased options with
regard to donor site for graft material because harvest of the mandibular
symphysis becomes possible.
What can be done to aid in closures of extremely wide palatal clefts?
Give this one a try later!
In very wide clefts some surgeons will advocate the consideration of a
pharyngeal flap at the primary palatoplasty procedure to assist in closure
since revision palatoplasty is sometimes unsuccessful in eradicating fistulas.
Those who use this technique usually perform it in extremely wide clefts
and do so very selectively. This allows the central portion of the closure to
be filled with posterior pharyngeal wall tissue making the closure of the
nasal and palatal mucosa easier. Patients with Pierre Robin syndrome or
Treacher Collins syndrome may have exceptionally wide clefts that are
difficult to close with no tension, and this technique may be considered.
The drawbacks of using a pharyngeal flap during the repair of the palate
include a significantly increased risk for complications such as bleeding,
snoring, obstructive sleep apnea, or hyponasality.
What is the OMENS classification criteria for hemifacial microsomia?
Give this one a try later!
