Effect of collagen matrix on postoperative palatal fistula in cleft palate repair.

Palatal fistula is a challenging complication following cleft palate repair. We investigated the usefulness of collagen matrix in the prevention of postoperative fistula. We performed a retrospective cohort study of patients with cleft palate who underwent primary palatoplasty (Furlow's double opposing z-plasty) in Seoul National University Children's Hospital. Collagen Graft and Collagen Membrane (Genoss, Suwon, Republic of Korea) were selectively used in patients who failed complete two-layer closure. The effect of collagen matrix on fistula formation was evaluated according to palatal ratio (cleft width to total palatal width) and cleft width. A total of 244 patients (male, 92 and female, 152; median age, 18 months) were analyzed. The average cleft width was 7.0 mm, and the average palatal ratio was 0.21. The overall fistula rate was 3.6% (9/244). Palatal ratio (p = 0.014) and cleft width (p = 0.004) were independent factors impacting the incidence of postoperative fistula. Receiver operating characteristic curve analysis showed that the cutoff values in terms of screening for developing postoperative fistula were a palatal ratio of 0.285 and a cleft width of 9.25 mm. Among nonsyndromic patients with values above those cutoffs, the rates of fistula development were 0/5, 1/6 (16.7%), and 4/22 (18.2%) for those who received Collagen Graft, Collagen Membrane, and no collagen, respectively. Collagen matrix may serve as an effective tool for the prevention of palatal fistula when complete two-layer closure fails, especially in wide palatal clefts. The benefit was most evident in Collagen Graft with thick and porous structure.

Reduction Malarplasty that Uses Malar Setback Without Resection of Malar Body Strip.

BACKGROUND: Various surgical methods have been developed and used to reduce prominent malar bones. The most common reduction malarplasty methods are resection of the bone strip of the malar bone with L-osteotomy or I-osteotomy, followed by setback and fixation. However, these methods could be associated with complications due to the bone strip resection. The present article introduces an effective and safe method that reduces the zygoma without resection of a malar bone strip. METHODS: Through preauricular and intraoral incisions, we performed the current L-osteotomy without resection of the malar bone strip using a reciprocating saw. We created back space for zygoma setback by removing the posterior wall of the maxillary sinus, which acted as a bony interference. We were able to set the lateral segment of the zygoma back about 3-5 mm. We fixed the zygomatic arch with wire and the zygomatic body with a prebent plate and screw. Thereafter, we performed rasping of the anterior part of the zygoma to achieve sufficient reduction. After performing our reduction malarplasty for 139 patients, clinical outcomes were evaluated. RESULTS: Most patients responded to the satisfaction survey as excellent and good. There were no major complications 6 months postoperatively. CONCLUSIONS: The key of our method of reduction malarplasty is to create posterior space without resecting the malar body strip, which results in an effective setback. This method enables surgeons to effectively maintain the zygoma body, which leads to high satisfaction rates and fewer complications. Therefore, this study proved the safety and effectiveness of our method of reduction malarplasty. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Limited incision with thorough elevation palatoplasty: technical evolution for superior results in cleft repair of the secondary palate.

BACKGROUND: All kinds of palatoplasty emphasize elongating the soft palate and reconstructing the velar musculature without complication. We present the limited incision with thorough elevation (LITE) palatoplasty that leaves the anterior margin of the hard palate intact, achieving a fully movable bipedicled flap for complete closure and an adequate functioning velar muscular sling. METHODS: Fifty-six patients consecutively underwent the LITE palatoplasty. The patients were diagnosed with varying degrees of cleft of the secondary palate. The length of the soft palate was measured, preoperatively and postoperatively, to quantify the lengthening effect of the surgical procedure. The LITE palatoplasty lengthens the soft palate by full mobilization of the velar musculature and reconstruction of the muscles. The LITE palatoplasty also completely repairs the hard palate and leaves no raw surfaces, which can be disadvantageous to the maxillary growth. RESULTS: The average length of soft palate was 18.5±3.1 mm preoperatively, and the increased length of the soft palate was 5.06±2.41 mm (27.3±17.4%). There were no complications including fistula formation, hematoma, or wound problems. After 2 years of operation, only 2 patients who had multiple congenital problems showed grade 1 hypernasality in speech assessment. CONCLUSIONS: The LITE palatoplasty gives satisfactory results in elongating the soft palate and reconstructing a functional velar sling without leaving any raw surfaces that can be detrimental to healing and facial growth. And there was a better speech outcome without complications.

Analysis of multiple risk factors affecting the result of free flap transfer for necrotising soft tissue defects of the lower extremities in patients with type 2 diabetes mellitus.

BACKGROUND: The limb-threatening large soft tissue defects that occur on the feet of type 2 diabetic patients have complex causes and are less likely to be corrected by free flap reconstruction compared to those in non-diabetic patients. We retrospectively analysed factors affecting the success of free flap transfer for necrotising soft tissue defects of the lower extremities in patients with type 2 diabetes. METHODS: This study included 33 diabetic patients whose feet were treated with free flap transfers. All patients had limb-threatening large soft tissue defects with tendon or bone exposure. The operative results were divided into three groups at 1 month post-operatively: the complete healing group, and the complication group, with either partial necrosis requiring additional simple procedures or flap failure with total necrosis. Nine preoperative factors were analysed: (1) ankle brachial index, (2) HbA1c, (3) BMI, (4) the smoking factor, (5) atherosclerotic calcifications (6) serum creatinine levels (>1.28 mg dL(-1) vs. <1.28 mg dL(-1)), (7) GFR, (8) wound infection and (9) wound defect size. RESULTS: Of the 33 patients, 15 showed complete healing and 18 showed complications of the free flap (eight partial necrosis and 10 flap failure). No atherosclerotic calcifications were found in the patients in the complete healing group, although they were found in 12 patients in the complication group, and this difference was significant (p = 0.002). Patients with serum creatinine levels >1.28 mg dL(-1) had significantly higher free flap transfer complication rates than those with serum creatinine levels <1.28 mg dL(-1) (p = 0.038). CONCLUSIONS: This study analysed the risk factors of free flap reconstruction for limb-threatening large soft tissue defects on the feet of type 2 diabetic patients. Serum creatinine levels >1.28 mg dL(-1) and atherosclerotic calcifications were confirmed as risk factors for flap survival.

Internal carotid artery variations in velocardiofacial syndrome patients and its implications for surgery.

BACKGROUND: Medially displaced internal carotid arteries in velocardiofacial syndrome carry a risk during pharyngeal flap surgery. This study was designed to evaluate the frequency of medially deviated internal carotid arteries in both velocardiofacial syndrome patients and the general pediatric population and to assess the minimum distance to the pharyngeal walls to define the potential risk of internal carotid artery injury during pharyngeal surgery. METHODS: Twenty-three consecutive patients with velocardiofacial syndrome who underwent posterior pharyngeal flap surgery and 21 control subjects who did not have velocardiofacial syndrome but who underwent oropharynx magnetic resonance imaging were reviewed. RESULTS: Medial deviation of at least one internal carotid artery was documented in 10 velocardiofacial syndrome patients (43.5 percent), compared with three patients (14.3 percent) in the control group (p=0.034). The mean±SD minimum distance to the posterior pharyngeal wall was 3.78±1.86 mm in velocardiofacial syndrome patients and 9.17±2.94 mm in the control group (p=0.014). Only one patient had significant medial dislocation of the internal carotid artery, and the closest distance from the pharyngeal wall was 0.86 mm. CONCLUSIONS: In velocardiofacial syndrome patients, medial dislocation of the internal carotid artery was common, and the minimum distance to the pharyngeal wall was short compared with the control group. However, in most of the authors' patients, the course of the cervical portion of the internal carotid artery is irrelevant to pharyngeal flap surgery. The authors conclude that preoperative vascular imaging study is not cost-effective in velocardiofacial syndrome patients but that intraoperative use of ultrasound imaging is still valuable for the purpose of planning pharyngeal flap surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.