Nasal Tip Vascularization and Its Application for Columellar Reconstruction.

OBJECTIVE: Many studies have been published about the vascular anatomy of the nose and its utility for nasal reconstruction. Anatomic variations of the main arteries and their perforators are well described in the literature. A nasal tip perforator, not well described in the published studies, is analyzed in the present study and its utility for columellar reconstruction. This paper presents an anatomic study of the nasal tip artery and its clinical applications for columellar repair. METHODS: This study investigated the nasal tip perforator artery during nasal tip flap surgery for columellar repair in patients with sequels after nasal continuous positive airway pressure use. A descriptive anatomic study was conducted using intraoperative vascular dissection of patients operated on for nasal columellar defects by the author between 2013 and 2018. An observational study of a group of patients operated on for columellar repair using the axial nasal tip flap is presented here. RESULTS: The nasal tip artery was found in all the intraoperative dissections. Location and trajectory are described. Observed columellar length and width in operated patients have been nonstatistical and significantly different than controls in this study. CONCLUSIONS: The presence and trajectory of the nasal tip artery have been consistent in all the studied cases. The nasal tip flap based on this perforator has been a useful method for columellar repair in the studied group of patients. The presence of this vessel may augment blood supply to the nasal tip skin. By confirming the preservation of this artery, the surgeon may elevate the nasal tip flap safely.

Flap Necrosis Associated With Furlow's Palatoplasty.

BACKGROUND: Numerous authors have reported their outcomes after using Furlow's palatoplasty for cleft palate repair. However, little attention has been given to the operative complications associated with this technique. The present study was carried out to present cases and analyze the various factors influencing the development of this complication accompanying Furlow's palatoplasty. MATERIALS AND METHODS: This is a case report study of patients with cleft palate admitted to our center due to sequelae after primary cleft palate repair using Furlow palatoplasty between 2003 and 2021. Patient information was identified from the Smile Train cleft charity organization, parents' reports, and hospital records (intake forms and operating room registries). RESULTS: Five patients were identified as having secondary cleft palate with palatal flap necrosis and associated with Furlow palatoplasty during patient evaluation at our center between 2003 and 2021. The observed prevalence was 1.54%. CONCLUSIONS: Palatal flap necrosis is a rare but serious complication after primary Furlow's palatoplasty. The occurrence of this complication can be reduced by careful preoperative planning, and prevention is possible.

Postoperative Nasal Conformers in Cleft Rhinoplasty: Are They Efficacious?

BACKGROUND: Lip and nose symmetry the goal of repair of unilateral cleft lip and different preoperative and postoperative treatments have been developed with this purpose. The objective of this study was to compare 2 techniques used for primary cleft lip nose repair. MATERIALS AND METHODS: This is an retrospective study between 2 groups of patients with unilateral cleft lip and palate who underwent primary nasolabial repair either with or without postoperative nasal conformers. Data collection was accomplished by evaluation of nasal symmetry through anthropometric measurements under general anesthesia during primary cleft palate repair. RESULTS: Our comparative study did not find a statistically significant difference regarding percentile indexes of nasal asymmetry between the 2 groups. Major revision requirement (>3 mm of asymmetry in any of the nose measurements) was observed in 3.84% of nasal conformer group and 4.65% of the group without nasal conformers. CONCLUSIONS: The results obtained from this study provides showed that placement of postoperative nasal conformers did not improve nasal symmetry in patients with unilateral cleft lip and palate. Based on these findings and available scientific evidence, definitive conclusions about the effectiveness of these devices on nasal symmetry after unilateral cleft lip nose repair cannot be drawn.

Effect of Nonradical Intravelar Veloplasty in Patients With Unilateral Cleft Lip and Palate: A Comparative Study and Systematic Review.

BACKGROUND: The purpose of this study was to compare 2 techniques used for primary muscular repair and perform a systematic review of the literature to evaluate the effects of radical intravelar veloplasty (IVV) on nonsyndromic unilateral cleft lip and palate. METHODS: This is an ambispective study between 2 groups of patients with unilateral cleft lip and palate who were operated using a radical and conservative form of IVV in Lima Peru. Data collection was accomplished by evaluation of speech development and middle ear function of the patients. A systematic review of the literature for studies published until June 2020 to evaluate the effect using the radical IVV in patients with cleft lip and palate. RESULTS: Our comparative study did not find statistically significant differences in speech development between the studied techniques for unilateral cleft palate repair. Increased number of ear tube placements have been observed in the group treated with radical form of IVV. After systematic literature searching, 10 identified studies were qualified for the final analysis, which included 1367 patients. The overall study quality according to Oxford CEBM and GRADE scale was low. CONCLUSIONS: The results arising from this study provides statistical evidence that one technique let us obtain better speech outcomes. A technique with conservative IVV has statistical significant fewer rate of middle ear disorders after primary cleft palate repair. Based on available scientific evidence, definitive conclusions about the effectiveness of radical IVV on velopharyngeal and middle ear function cannot be drawn.

Primary Cleft Rhinoplasty: Surgical Outcomes and Complications Using Three Techniques for Unilateral Cleft Lip Nose Repair.

BACKGROUND: This study represents a single surgeon's 10 years of experience addressing unilateral cleft lip and palate nose deformity. The purpose was to compare surgical outcomes and related complications using 3 different techniques to improve nasal shape in primary unilateral cleft rhinoplasty. METHODS: This retrospective study with Institutional Ethical Committee approval compares 3 groups of patients with unilateral cleft lip nose and palate who were operated on using different techniques from 2007 to 2017. Surgical outcomes were analyzed by physical examination at least 1 year after primary rhinoplasty. Anthropometric measurements were obtained for the cleft and noncleft sides of the nose. RESULTS: Approach with general analysis indicated differences among the 3 techniques. The author's comparative study revealed differences in nose symmetry and related complications, including increased recurrence of nose deformity using the modified McComb technique. Better short-term nose symmetry was observed using Potter technique and the V-Y-Z rhinoplasty. CONCLUSIONS: Potter approach and the V-Y-Z techniques achieve better short-term nose symmetry than the McComb method. Complications were less common in the group of patients operated on using the modified McComb technique. Additional studies are required to evaluate functional and long-term outcomes after primary rhinoplasty using the proposed methods.

The Lima Surgical Protocol for Cleft Palate Repair.

BACKGROUND: A cleft team experience addressing non-syndromic cleft palate and cleft lip and palate is presented. The purpose of the present study is to compare surgical outcomes using 2 different protocols for cleft palate repair provided by a cleft team in Lima, Perú. METHODS: This is a comparative study between 2 groups of patients with non-syndromic cleft palate who were operated using different surgical protocols from 1999 to 2014. One hundred twenty-four children with non-syndromic isolated cleft palate and cleft lip and palate treated from 2007 to 2014 using a surgical protocol developed by our cleft team in Lima, Perú were compared with 145 children with cleft palate and cleft lip and palate treated by the same team using different protocol from 1999 to 2007. Data collection was accomplished by evaluation of symptomatic oronasal fistulas, presence of velopharyngeal insufficiency (VPI) and postoperative complications. RESULTS: Statistical significant differences were observed between the 2 groups regarding the development of flap necrosis in favor of the Lima protocol. No significant difference in palatal fistula and VPI rate between the 2 protocols was found. CONCLUSIONS: The Lima Surgical Protocol for cleft palate repair is an alternative strategy which uses the strengths of different surgical techniques based on the severity of the cleft. We observed better surgical outcomes using the Lima protocol with regards to postoperative complications in patients with non-syndromic cleft palate.

About a "New" Technique for Uvular Repair.

This letter is about a recent publication in the Cleft Palate Craniofacial Journal titled: "The significance of uvula after palatoplasty: A new technique to improve the aesthetic outcome" published by Elsherbiny et al (Cleft Palate Craniofacial J 2018;55(3):451-455). The authors present the use of one hemi-uvula for uvular repair during primary palatoplasty as their "new technique." The method of primary uvuloplasty using one-hemiuvula was extensively used by different surgeons in south America and presented and published in different scientific meetings and indexed scientific journals since the 90s. The original concept was described by Carlos Navarro in Perú and published by me in different scientific indexed journals and a textbook.

Simulation-Based Comprehensive Cleft Care Workshops: A Reproducible Model for Sustainable Education.

OBJECTIVE: Evaluate simulation-based comprehensive cleft care workshops as a reproducible model for education with sustained impact. DESIGN: Cross-sectional survey-based evaluation. SETTING: Simulation-based comprehensive cleft care workshop. PARTICIPANTS: Total of 180 participants. INTERVENTIONS: Three-day simulation-based comprehensive cleft care workshop. MAIN OUTCOME MEASURES: Number of workshop participants stratified by specialty, satisfaction with the workshop, satisfaction with simulation-based workshops as educational tools, impact on cleft surgery procedural confidence, short-term impact on clinical practice, medium-term impact on clinical practice. RESULTS: The workshop included 180 participants from 5 continents. The response rate was 54.5%, with participants reporting high satisfaction with all aspects of the workshop and with simulation-based workshops as educational tools. Participants reported a significant improvement in cleft lip (33.3 ± 5.7 vs 25.7 ± 7.6; P < .001) and palate (32.4 ± 7.1 vs 23.7 ± 6.6; P < .001) surgery procedural confidence following the simulation sessions. Participants also reported a positive short-term and medium-term impact on their clinical practices. CONCLUSION: Simulation-based comprehensive cleft care workshops are well received by participants, lead to improved cleft surgery procedural confidence, and have a sustained positive impact on participants' clinical practices. Future efforts should focus on evaluating and quantifying this perceived positive impact, as well reproducing these efforts in other areas of need.

Two Methods of Cleft Palate Repair in Patients With Complete Unilateral Cleft Lip and Palate.

OBJECTIVE: The objective of this study was to compare the surgical outcome between 2 patient groups with complete unilateral cleft lip and palate who underwent different types of palatoplasty. METHODS: This is a cohort study between 2 groups of patients with complete unilateral cleft lip and palate who were operated using different surgical techniques from 2008 to 2011. About 28 patients were operated using a primary lip nose repair with vomer flap for hard palate single-layer closure and delayed soft palate repair (modified Oslo protocol) and 32 patients were operated using our protocol in Lima. Data collection was accomplished by evaluation of symptomatic oronasal fistulas, presence of velopharyngeal insufficiency and evaluation of dental arch relationships (scored using the 5-year-olds' index). RESULTS: Our comparative study observed statistically significant differences between the 2 groups regarding the presence of oronasal fistulas and velopharyngeal insufficiency in favor of our palatoplasty technique. A statistically significant difference was not found in functional vestibular oronasal fistula development between the studied techniques for unilateral cleft palate repair. This comparative study did not observe significant differences in dental arch relationships between the studied techniques. CONCLUSION: In this study, better surgical outcome than modified Oslo protocol regarding oronasal fistulas and velopharyngeal insufficiency on patients with complete unilateral cleft lip and palate was observed. The results arising from this study do not provide evidence that one technique is enough to obtain better functional closure of the alveolar cleft and dental arch relationship at 5 years.

Primary unilateral cleft lip nasal deformity repair using V-Y-Z plasty: An anthropometric study.

BACKGROUND: Secondary nose deformity after unilateral cleft lip repair is a common problem. Loss of tip projection on the cleft side of unilateral cleft lip nasal deformity can be difficult to correct due to lack of adequate support. The purpose of this study is to evaluate the surgical outcome after using V-Y-Z plasty to address unilateral cleft lip nasal deformities. METHODS: A cross-sectional study of one surgeon's outcome of 58 performed primary complete unilateral cleft lip nasal deformity repairs. All these patients met the study criterion of having anthropometric measurements at the cleft and non-cleft side of the nose performed at least 1 year postoperatively. RESULTS: Since 2012, 32 consecutive patients have undergone primary anatomical repair of the cleft nasal deformity in patients with a complete unilateral cleft. We have not found statistically significant differences between the cleft and non-cleft nostril dome height and columella length measured at least 1 year postoperatively. CONCLUSIONS: The findings suggest that the V-Y-Z plasty is a good alternative to create a more symmetric nasal tip in patients with primary unilateral cleft lip nasal deformity. Additional studies are required to evaluate functional and long-term outcomes after primary rhinoplasty in patients with unilateral cleft lip.

Surgical Technique for Whistler Deformity Repair in Bilateral Cleft Lip Patients: An Anthropometric Study.

OBJECTIVE: The purpose of this study was to evaluate the surgical outcome of secondary bilateral cleft lips after using a surgical technique for whistler deformity repair. DESIGN: A prospective cohort study of one surgeon's outcome of 38 consecutive performed bilateral whistler deformity repairs was conducted. SETTING: Data from the Outreach Surgical Center Program, Lima, Peru, were used. PATIENTS: Thirty-eight patients with lip deformity related to unsatisfactory bilateral cleft lip repair were operated on using the proposed surgical technique since 2008. All these patients met the study criterion of having anthropometric measurements performed at least 1 year postoperatively. MAIN OUTCOME MEASURES: Measurement of lip height, lip width, vermilion height, cupid bow, and nasal base width was performed at the right and left side of the lip, preoperatively and at least 1 year postoperatively. ANALYSIS: The matched pair t test analyses were performed when the assumptions required were met. When the normality assumption was not met, the Wilcoxon signed rank test, a nonparametric test was used to assess the statistical significance of differences between the studied sample and control group. RESULTS: The study found statistically significant differences between the preoperatory and control groups in most of the lip measurements. In addition, we have found statistically significant differences between the preoperatory and postoperatory groups in most of the anthropometric lip measurements, in favor of the second group, after lip repair using the proposed technique and measured at least 1 year postoperatively. CONCLUSIONS: The findings suggest that the proposed technique is a good alternative to address the whistler deformity related to the bilateral cleft lip primary repair.

A 20-year experience in unilateral cleft lip repair: From Millard to the triple unilimb Z-plasty technique.

BACKGROUND: This study describes a 20-year experience of treating patients with unilateral cleft lip. During this time, various techniques were used including Millard's technique and its modification and two types of geometrically designed procedures. The study objective was to compare surgical outcomes of different surgical techniques for unilateral cleft lip repair. MATERIALS AND METHODS: This is a retrospective audit of outcomes after unilateral cleft lip repair performed by a single surgeon since 1995. Of the 827 patients who underwent surgery, 277 met the criterion of having anthropometric measurements performed ≥1 year postoperatively. The patients were stratified into three groups according to cleft severity: incomplete, complete with less deficiency (3-6 mm difference between cleft and non-cleft lip height) and complete with more deficiency (>6 mm difference between cleft and non-cleft lip height). Anthropometric measurements, scar assessment and complications were recorded. RESULTS: There were no differences in outcomes between Millard and Reichert-Millard techniques for incomplete unilateral cleft lip. For complete unilateral cleft lip and less tissue deficiency, lip symmetry was better using upper rotation advancement plus double unilimb Z-plasty than the Reichert-Millard technique. For complete unilateral cleft lip and more tissue deficiency, lip symmetry was better after triple unilimb Z-plasty than after upper rotation advancement plus double unilimb Z-plasty. CONCLUSIONS: We presented a 20-year experience performing unilateral cleft lip repair. An individualised classification system with corresponding surgical techniques was successfully used during this period. The individualised surgical protocol used in this study allowed us to achieve improved surgical outcomes.

Comparison of two models of surgical care for patients with cleft lip and palate in resource-challenged settings.

BACKGROUND: The Peruvian health system is limited in providing specialized care for patients with clefts because there are an insufficient number of hospitals and few specially trained doctors in rural areas of the country. The most common model of care in these areas is the surgical mission wherein experienced cleft surgeons perform surgeries and teach local doctors. The purpose of this research was to identify the differences in outcome between the surgical mission trip and the referral center model of care provided by the same team. METHODS: A retrospective analysis (2002-2012) was performed on data from surgical outcomes provided by the Outreach Surgical Center Lima that utilized both models of care (surgical mission and referral center). A total of 935 procedures were performed in 680 patients with clefts who were treated by the Outreach Surgical Center Program Lima since 2002. Patients in both groups were identified from our records (medical records and screening-day registries). All patients underwent a physical examination, had photographs taken, and any unfavorable results and complications were documented. Comparison of categorical variables (including outcomes) between care models was performed using Pearson's χ (2) test or Fisher's exact test when appropriate. In all cases a two-tailed test was performed and the p value for rejecting the null hypothesis (no difference or no association) was set at 0.05. RESULTS: We found significant differences between the two models of care with respect to unilateral cleft lip and cleft palate dehiscence (p = 0.02 and p = 0.04, respectively), palate postoperative hemorrhage (p < 0.01), and palatal fistula (p < 0.01) outcomes. DISCUSSION: Differences in observed surgical outcomes between the two models might be attributed to the surgeon's performance and/or the patient's age, and these factors are also considered with respect to the model of care. Limitations in long-term medical evaluation at each site should be identified and strategies to improve surgical outcomes must be developed to ensure that patients served by surgical missions obtain the same results achieved at a referral center.

The double unilimb z-plasty technique for whistler deformity repair in unilateral cleft lip patients: an anthropometric study.

OBJECTIVE: The purpose of this study was to evaluate the symmetry in lip and vermillion height after using the double unilimb Z-plasty method for whistler deformity repair. DESIGN: This is a retrospective audit of 1 surgeon's outcome of 52 consecutive performed whistler deformity repairs. SETTING: Data from the Outreach Surgical Center Program, Lima, Peru, were used. PATIENTS: Since 2009, 52 adult patients with lip deformity related to unsatisfactory unilateral cleft lip repair were operated on using the double unilimb Z-plasty. All these patients met the study criterion of having anthropometric measurements performed at least 1 year postoperatively. MAIN OUTCOME MEASURES: Data collection of lip and vermilion height was performed at the right and left side of the lip, immediately before the surgery (preoperatory) and at least 1 year postoperatively. The lip measurements were obtained using calipers. ANALYSIS: The matched pair t test analyses were performed when the assumptions required were met. When the normality assumption was not met, the Wilcoxon signed rank test, a nonparametric test, was used to assess the statistical significance of differences between the cleft side and the noncleft side. RESULTS: The study found no statistically significant differences between the right and left side in lip height (P = 0.51) and vermilion height (P = 0.57) after lip repair using the double unilimb Z-plasty technique measured at least 1 year postoperatively. CONCLUSIONS: The findings suggest that the double unilimb Z-plasty technique is a good alternative to address the whistler deformity related to the unilateral cleft lip primary repair. This is a simple method, easy to perform by surgeons, for whistler deformity management in unilateral cleft lip patients.

Anatomic study of the retaining ligaments of the face and applications for facial rejuvenation.

BACKGROUND: The retaining ligaments of the face support the facial soft tissue in a normal anatomic position, thereby resisting gravitational change. In this study, a technique utilizing surgical plication of the superficial musculoaponeurotic system (SMAS) to the retaining ligaments of the face and finger-assisted malar elevation (FAME) dissection of the midface is presented. METHODS: The anatomy of the facial retaining ligaments was studied in 20 half-faces of ten fresh cadavers, and the localization of the ligaments was examined macroscopically. Surgical correction of facial aging with plication of the SMAS to the retaining ligaments and FAME dissection of the midface has been performed in 74 face-lift patients since 2006. Outcomes were determined by case notes, clinical review, and a patient questionnaire. RESULTS: The studied ligaments (zygomatic and masseteric) were present in all cadaver dissections. The zygomatic ligament was located 4.3-5.5 cm from the tragus and originates near the inferior border of the anterior zygomatic arch. The masseteric ligament was located 3.7-5.2 cm from the tragus below the junction of the zygomatic arch and masseter muscle. All the patients answered a satisfaction questionnaire and reported high levels of satisfaction at least 1 year after treatment. CONCLUSIONS: We have identified the facial retaining ligaments in all cadaver dissections and their relationship with other structures of the face are described here. This study demonstrates that our face-lift technique is safe and produces highly predictable and natural results. 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 .

Mixed Dentition Period Follow-up of Primary Unilateral Cleft Nose Deformity Repair.

Background: Recently, there has been an increased acceptance of the primary cleft rhinoplasty providing acceptable outcomes. Nose reconstruction, and specifically cleft nose deformity, should be addressed based on this philosophy. The purpose of this study was to evaluate surgical outcomes during the mixed dentition period after primary surgery to address unilateral cleft lip nose deformity based on the proposed technique. Methods: This is a retrospective cohort study. Thirty-two primary complete unilateral cleft lip patients were operated on by a single surgeon using the V-Y-Z cleft rhinoplasty. This method combines a composite V-Y advancement flap with lateral Z-plasty. Data collection was accomplished by evaluation of nasal symmetry through anthropometric measurements performed under general anesthesia during primary cleft palatoplasty and alveolar bone graft. The outcomes were evaluated through anthropometric measurements of the repaired nose during the mixed dentition period of follow-up, and no type of presurgical management was performed for any of the patients. Results: Total nasal symmetry has been observed in 34.37% of patients at 7 years or more and 40.62% at 1-year follow-up. Nonstatistically significant differences were observed during follow-up, and major revision requirement (>3 mm of asymmetry in any of the nose measurements) was observed in 9.37% of patients. Conclusions: The proposed primary cleft rhinoplasty is a good approach to improve nasal appearance in patients with complete unilateral cleft lip and palate.