'Suspension Palatoplasty' - A method of surgical correction of VPI post Cleft Palate repair.

OBJECTIVE: To design the technique of 'Suspension Palatoplasty' for Velopharyngeal Insufficiency (VPI) post Cleft Palate (CP) based on optimal spatial positioning of palate at the time of VPI correction, by using a non-obstructive, high, midline pharyngeal flap for predictable velopharyngeal closure and normal speech. To evaluate the results of CP patients with VPI operated using the technique of 'Suspension palatoplasty'. DESIGN: An ambi-spective longitudinal clinical study. SETTING: Comprehensive cleft care clinic in a private trust hospital. PATIENTS, PARTICIPANTS: Patients operated using the 'Suspension Palatoplasty' technique for VPI post CP repair between 2014 and 2018 with a minimum follow-up period of 5 years. INTERVENTIONS: 'Suspension Palatoplasty' - Double Opposing Z (DOZ) plasty with palatal myoplasty is used to revise soft palate and a narrow superiorly based pharyngeal flap is used to suspend it for a dynamic velopharyngeal closure. MAIN OUTCOME MEASURE: Speech outcome and surgical complications. RESULTS: 70 out of 119 studied were found to have normal speech (59%), and another 25 patients (21%) had acceptable speech. Thus 95 out of 119 patients (80%) had normal or near-normal speech and did not require any further speech therapy or surgeries. 12 patients had snoring without difficulty in breathing. One patient had symptoms suggestive of obstructive sleep apnea. Younger patients had a higher percentage of normal speech outcomes. Many of our adult patients also attained normal speech. CONCLUSION: 'Suspension Palatoplasty' aims to achieve normal speech with little effort. It has minimal side effects. The author has performed 403 cases to date.

Microvascular reconstruction in salvaging the gastric conduit post-esophagectomy after iatrogenic right gastroepiploic vessel injury.

The preservation of the right gastroepiploic vessels is essential to ensure proper perfusion of the gastric conduit following esophagectomy. The loss of these vessels can lead to conduit ischemia or necrosis, resulting in significant postoperative complications. Traditional approaches such as colonic or jejunal interposition require extensive surgery and multiple anastomoses. In this report, we present our successful experience of salvaging the gastric tube through microvascular reconstruction following iatrogenic injury to the right gastroepiploic vessels in two cases. The first case involved re-anastomosis of the right gastroepiploic vein, while the second case required reconstruction of both the artery and vein during esophagectomy in a single setting. The procedures were performed by an experienced surgical team using microvascular techniques. Both patients had uneventful postoperative courses without any anastomotic leakage or major complications. Adequate perfusion of the salvaged gastric tube was confirmed intraoperatively using indocyanine green fluorescence perfusion imaging. In conclusion, immediate microvascular reconstruction offers a viable solution by restoring perfusion of the gastric tube in cases of right gastroepiploic vessel injury during esophagectomy.

Primary Free Flaps for Coverage and Reconstruction in Acute Facial Trauma.

Background Acute facial trauma in motor vehicle accident defects may be associated with skeletal, neuromuscular, or mucosal losses. Simultaneous repair of the critical structures in these defects mandates the use of flap cover; paucity of local tissues necessitates the use of free skin flaps. Materials and Methods Six free flap reconstructions for acute facial trauma defects over a 10-year period were reviewed. The defect location, associated injuries, flap choice, additional reconstructive procedures, and flap outcomes were analyzed. Results There were four males and two females with ages between 18 and 63 years. Four defects were located in the lateral face and scalp, and two in the lower central face. Defect size ranged between 96 and 346 cm 2 . There were fractures in three, facial nerve injuries in two, and loss of facial muscles in one. Five free flaps were anterolateral thigh flap; simple and composite, one was a radial artery forearm flap. Recipient pedicles were the superficial temporal vessels in two and facial vessels in four cases. There were no re-explorations but one flap necrosed on 7th postoperative day on account of invasive aspergillosis. Discussion Use of free flaps for ballistic wounds is common. In uncommon nonballistic traumatic facial defects, the location, nature of the defect, and type of associated injuries and need for simultaneous reconstructions may dictate the use of free flaps and permit a one stage debridement, flap coverage, and a simultaneous reconstruction of lost functional units. Conclusion Free flap coverage in high velocity acute facial trauma defects offers a better possibility for primary reconstruction of associated facial injuries and helps in achieving better functional outcomes.

Management of Epirubicin Extravasation Injuries of the Hand with Debridement and Flap Cover-A Case Series.

Chemotherapy extravasation injury is an iatrogenic injury due to extravasation of the drug from the vessel during infusion therapy. Among various chemotherapeutic drugs, DNA binding vesicants like epirubicin and doxorubicin can lead to extensive tissue necrosis following extravasation. They are commonly used in many chemotherapy regimens including those for carcinoma breast. We present our case series in the management of these wounds with aggressive debridement and regional (pedicled groin)/free flaps (superficial circumflex iliac artery perforator, lateral arm) for cover in five patients. All flaps healed well with patient returning to further treatment in 3 to 4 weeks post-surgery with preservation of hand function. Thus, early recognition of the type of drug that has extravasated is crucial. Regional and free flaps are superior to local flaps because there are no extra incisions and grafts on the limb that has already been injured.

'Suspension Palatoplasty' - A new Method of Primary Palate Repair for Speaking Un-Repaired Clefts.

OBJECTIVE: To design a technique of palate repair with predictable Velo Pharyngeal (VP) closure and normal speech - 'Suspension Palatoplasty' in speaking unrepaired Cleft Palate (CP) patients. To evaluate the results of patients with CP operated using the technique of 'Suspension palatoplasty' from 2014 -2018 in terms of surgical complications and speech outcomes. DESIGN: An ambi-spective longitudinal clinical study. SETTING: Comprehensive cleft care clinic in a private trust hospital. PATIENTS/ PARTICIPANTS: Patients above 6 years of age with isolated CP, cleft lip and palate (CLP), operated using 'Suspension Palatoplasty' technique between 2014 and 2018 were included with minimum follow up period of 5 years. Subjective speech evaluation was done by two speech therapists and analysed. INTERVENTION: Author designed the technique of 'Suspension Palatoplasty' which aims to suspend the soft palate repaired by 'Hybrid Palatoplasty' technique, close to the nasopharynx using narrow pharyngeal flap with the pedicle based superiorly at adenoids, for an acceptable VP closure. MAIN OUTCOME MEASURES: Speech outcome and surgical complications were assessed. RESULTS: Out of 94 cases operated with age ranging from 6 to 45 years, 59 (62.8%) had normal speech, 12 (12.8%) had articulation errors but with no Velo-Pharyngeal Insufficiency (VPI) and 23 patients (24.4%) had hypernasality/ nasal emission (Suspected VPI). None of them had difficulty in breathing but one patient had snoring. CONCLUSION: 'Suspension Palatoplasty' is a simple primary operation with excellent speech outcomes with no obstructive sequelae in patients with speaking unrepaired cleft palate.

Hybrid Palatoplasty: A Simplified DOZ (Double Opposing Z Plasty) with Palatal Myoplasty for Primary Palate Repair.

Introduction Surgical techniques for soft palate repair aiming for zero velopharyngeal insufficiency (VPI) are still not achieved. Straight line closure of the soft palate by various techniques of intravelar veloplasty (IVVP) leads to higher incidence of VPI due to scar contracture. Furlow's Z plasty has long, narrow, thin mucosal flaps and mucomuscular flaps with malaligned muscle closure. We present a technique of "hybrid palatoplasty" which borrows from and adds to the existing methods, is robust, is easy to replicate, and results in normal speech consistently. Aim (1) To design a technique of "hybrid palatoplasty"-combining double opposing Z (DOZ) plasty and IVVP, which is applicable to all types of cleft palate. (2) To evaluate the results of cleft palate children operated using the technique of "hybrid palatoplasty" from 2014 to 2015 in terms of surgical complications (fistulae and dehiscence) and incidence of VPI. Methods Our procedure combines aspects of both DOZ and IVVP. It is simplified with design of smaller Z plasties. On one side, from the oral Z plasty muscle is dissected off and sutured to the nasal mucomuscular flap of the opposite side to complete the palatal sling. Oral Z plasty is purely mucosal and reverse of the nasal side. A total of 123 cases, operated below 5 years of age were followed up. Speech was assessed by direct evaluation and tele-evaluation. Results A total of 123 cases, below 5 years of age, were operated between 2014 and 2016 with at least 5 years of follow-up. Note that 120 had normal speech, and 3 had VPI of which 2 were subsequently corrected and went on to develop normal speech. Conclusion This novel "hybrid palatoplasty" is a simple technique with good speech outcome as it combines the principles of Z plasty and direct muscle repair with palatal sling formation.

Neurotization of the human cornea - A comprehensive review and an interim report.

We present a comprehensive review of existing literature on surgical corneal neurotization (SCN) as a treatment modality for neurotrophic keratopathy (NK) with an interim report of seven cases where SCN was performed using the indirect approach and followed up till 18 months postoperatively to look for improvement in ocular surface, corneal sensations, and nerve regeneration by using in vivo confocal microscopy (IVCM). A literature search was performed for publications with keywords "corneal nerves," "neurotization," "esthesiometry," "corneal anesthesia," and "neurotrophic keratopathy." All literature available till December 31, 2020 was reviewed and included to describe NK and its management options, particularly SCN. NK is associated with absent or reduced corneal sensations and is managed using a step-ladder algorithm ranging from medical management for symptomatic relief to surgical corneal neurotization. Both direct and indirect approaches of SCN have a favorable outcome with reduced surgical morbidity in the indirect approach using sural nerve graft. Post neurotization, corneal sensation recovery may take up to 3-6 months, while nerve regeneration on confocal microscopy can take as long as 6 months-1 year.

Efficacy of palatal block for analgesia following palatoplasty in children with cleft palate.

BACKGROUND: This prospective randomized controlled study was undertaken to evaluate the efficacy of palatal block i.e. blocking of naso palatine, greater and also lesser palatine nerves in children with cleft palate undergoing palatoplasty by evaluating its effects on intraoperative anesthetic requirement, postoperative analgesia and parental satisfaction. METHODS: Forty-five pediatric patients aged below five undergoing cleft palate repair were randomly allocated to three groups of 15 each. After tracheal intubation, Group NB received no block for control, group S received 0.5 ml of normal saline and group B received 0.5 ml of 0.25% bupivacaine for palatal block. Postoperative pain score, the time to first demand of analgesia and number of rescue analgesic demands were noted. Finally, the parental satisfaction was graded. RESULTS: The block had no anesthetic sparing effect. The mean pain scores were significantly lower in patients who received block than in the group NB. The mean area under curve for FLACC score in group NB was 29 with 95% CI of 25-32, group S was 15 with 95% CI of 8.9-22.3 and in group B, it was 10 with 95% CI of 6-14. The time to first demand of analgesia was 6 [4.5-6] h in group NB, 18 [6-18] h in group S and 18 [18-18] h in group B (P-0.000). The number of demands of rescue analgesia was significantly less in group B 0 [0-0.25], 0 [0-2] in S group compared to group NB 3 [3-3] (P-0.000). The parental satisfaction was good in patients who received block and poor in group NB. CONCLUSION: Palatal block is technically simple, safe and effectively provides postoperative analgesia with good parental satisfaction. Injection of saline also produced palatal nerve block; however, the effect was not consistent.