Achieving the Optimal Aesthetic Benefit While Correcting Midface Deficiency: Utilizing A High Winged Le Fort I in Cleft and Craniofacial Patients.

ABSTRACT: Craniofacial anomalies are congenital disorders that affect the cranium and facial bones, with cleft lip and palate being the most common. These anomalies are often associated with abnormal development of pharyngeal arches and can result in the development of class III malocclusion and severe maxillary retrusion. Current treatment includes orthodontic decompensation and Le Fort I osteotomy to correct the maxillomandibular relationship. However, the traditional Le Fort I (LFI) advancement does not fully address the lack of skeletal volume in the midface. The high winged Le Fort I osteotomy (HWLFI) is an excellent surgical option for simultaneous correction of the midface deficiency and malocclusion while restoring optimal esthetic convexity. A retrospective chart review was conducted to include all cleft and craniofacial patients who underwent HWLFI advancement from 2002 to 2018. Patients had a minimum of 12 months of follow-up. Patient data and complications were reviewed. Standardized facial photographs were analyzed for esthetic improvement, occlusion, and beneficial salutary effects on the midface. Forty-three patients met the inclusion criteria. The mean age at surgery was 18.9 years. The mean follow-up was 32 months. Early complications included infection (9.3%) and temporary nerve paresthesia (2.3%). Late complications included infection (6.5%), wound dehiscence (4.3%), and painful hardware (2.3%). One patient (2.3 percent) had clinically significant relapse that required surgery. Postoperatively, patients demonstrated excellent midface projection and correction of the skeletal malocclusion. The HWLFI advancement significantly improves both the malocclusion and esthetic concerns of cleft and craniofacial patients by reestablishing maximal midfacial support. Important advantages of the HWLFI are avoidance of alloplastic implant use and extensive and potentially unstable surgical procedures that increase orbital volume.

Surgical Hypercorrection of Trigonocephaly: Evaluation of Surgical Outcomes.

BACKGROUND: A lasting correction of trigonocephaly is difficult to achieve, as a durable correction requires significant expansion to overcome galeal restriction and soft tissue recoil of the scalp. High rates of relapse have been reported throughout the literature. The specific aim of this study was to determine if the senior author's method of "hypercorrection" decreases relapse and the need for subsequent revisional surgery. METHODS: Patients who underwent operative correction of metopic craniosynostosis between 1988 and 2011 were reviewed. All patients underwent the "hypercorrection" technique performed by the senior author. Hypercorrection consisted of a fronto-orbital advancement of 2.5 to 3.5 cm and a concomitant hyperexpansion of bitemporal projection. Split cranial bone grafting ensured adequate coverage of the significantly expanded cranial vault. Only patients who had at least 5 years of follow-up were included for review of outcomes. Relapse was defined as recurrence of bitemporal constriction or lateral orbital retrusion, requiring surgical correction. RESULTS: Fifty-eight patients met criteria. Mean age at the time of surgery was 11 months. Mean follow-up was 9.0 years. During this time, 2 patients exhibited relapse requiring camouflage procedures. Cranial bone defects were found in 4 patients (7%), 3 of whom underwent cranial bone grafting, while 1 underwent methylmethacrylate placement at an outside institution. One patient underwent fat grafting for areas of soft tissue irregularity. No patients exhibited persistent sequelae of hypercorrection significant enough to require repeat fronto-orbital advancement. CONCLUSION: Surgical hypercorrection of trigonocephaly seems to minimize relapse and the need for revision in long-term follow-up and is therefore an important technique to consider.

The Protruding Premaxilla: Is Our Current Approach the Right Answer?

BACKGROUND: In bilateral cleft patients, surgeons usually attempt to move the premaxillary segment posteriorly. These patients almost always develop maxillary hypoplasia, rendering our current algorithms questionable. The authors sought to determine if the lateral segments are in an appropriate position to serve as a target for movement of the premaxilla. METHODS: Bilateral cleft lip and palate patients treated at the University of Michigan from 1997 to 2015 were reviewed. Patients with skull radiographs or computed tomography (CT) imaging performed at age 3 or younger were included. Noncleft patients <3 years old seen in the craniofacial clinic during 2015 with negative imaging were included as comparative norms. Sella-nasion-A (SNA), sella-nasion-piriform (SNP), and sella-nasion-posterior nasal spine (SN-PNS) angles were determined in both the cleft patients and the comparative norms. Paired t tests assuming unequal variance were used to compare angles between normal and cleft patients. RESULTS: Eighty-six bilateral cleft patients were identified, and 16 had imaging. Only 7 patients had a CT or skull radiograph. Thirteen noncleft patients with negative imaging were included. The mean SNA angle was 100.8 in cleft patients and 86.1 in noncleft patients (P = 0.002). The mean SNP angle was 62.9 in cleft patients and 71.3 in noncleft patients (P = 0.02). The mean SN-PNS angle was 23.2 in cleft patients and 33.8 in noncleft patients (P = 0.005). CONCLUSIONS: Our results indicate that the maxilla is deficient early in life with posterior positioning of the lateral segments. Therefore, the lateral segments should not serve as a reference point when treating the premaxilla.

Complications and the Need for Long-Term Follow-Up after Secondary Speech Surgery: A National and Longitudinal Claims Analysis.

BACKGROUND: Although most patients attain normal speech after cleft palate repair, up to 20 percent require secondary speech surgery. Despite the frequency of these procedures, complications and rates of subsequent revisions of secondary speech surgery after all procedure types have never been reviewed using national, longitudinal data. METHODS: The authors examined insurance claims from Clinformatics Data Mart between 2001 and 2017. Cases were categorized as palatalprocedures (i.e., palatoplasty, revision palatoplasty, secondary lengthening, palatal island flap) or pharyngeal procedures (i.e., pharyngeal flap, dynamic sphincter pharyngoplasty) (n = 846). Continuous enrollment from 180 days before to 30 days after surgery was required. Patients were excluded if they underwent palatoplasty, or any surgery at less than 3 years of age, without a speech diagnosis. Outcomes included 30-day complications and rates of subsequent revision secondary speech surgery. Multivariable logistic regression was used to evaluate the relationship between procedure type and complications. RESULTS: In this cohort, 52.5 percent underwent pharyngeal procedures, and 47.5 percent underwent palatal procedures. Complications occurred in 10.9 percent of patients and included respiratory complications (4.0 percent), bleeding (1.2 percent), dehiscence (3.6 percent), and critical care episodes (3.0 percent). There was no difference in complications between procedure types (OR, 0.87; 95 percent CI, 0.56 to 1.37; p = 0.56). The subsequent revision rate was 12.7 percent, but was 21.7 percent in patients with 3 years of postoperative enrollment. CONCLUSIONS: Although complication rates were comparable to those in recent literature, rates of subsequent revisions of secondary speech procedures were high in patients with longer postoperative enrollment. Thus, these patients merit prolonged follow-up, as velopharyngeal dysfunction may recur over time. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.