A Comparative Study of the Aesthetic Outcome of Two Techniques for Unilateral Complete Cleft Lip Repair.

BACKGROUND: Cleft lip repair aims to create symmetric nasolabial morphology with minimal scarring. Poor aesthetic outcomes may have damaging psychosocial implications. Determining the optimal method of recreating lip symmetry is a major goal of applied cleft clinical research. This study aims to determine whether subjective assessment could differentiate aesthetic outcome between two surgeons who use two different surgical techniques for unilateral cleft lip repair. METHODS: Surgeon A uses a modified rotation-advancement technique incorporating a supra-white roll flap and Noordhoff-style vermilion flap. Surgeon B uses an upper and lower triangle technique. Neither surgeon used presurgical orthopedics. Five-year postoperative frontal photographs (cropped according to the Asher-McDade aesthetic index) were analyzed by a panel of 40 blinded surgical and lay reviewers using a five-point Likert scale. The assessments were repeated after a 2-week interval to assess intrarater reliability. RESULTS: Thirty-nine consecutive complete unilateral cleft lip and palate patients were assessed for each surgeon. The mean Likert score for surgical/lay assessors was 3.07/3.00 for surgeon A and 2.67/2.61 for surgeon B. This difference was statistically significant (p < 0.05). The interrater reliability was excellent and the intrarater reliability was fair. There was good correlation between lay and surgical assessors. CONCLUSION: Subjective assessment of clinical photography provides a reliable method of differentiating aesthetic outcome after unilateral cleft lip repair and presents a rapid and straightforward clinically relevant method of comparing surgical outcomes.

Prospective Patient-Related Outcome Evaluation of Secondary Cleft Rhinoplasty Using a Validated Questionnaire.

OBJECTIVE: To evaluate patient satisfaction and quality of life following secondary cleft rhinoplasty. DESIGN: Prospective consecutive patient, single unit, single surgeon study. SETTING: Spires Cleft Centre, Salisbury, Wilshire, United Kingdom, and private practice. PATIENTS, PARTICIPANTS: 56 (27 secondary cleft rhinoplasty) patients completed evaluation forms preoperatively and 3 to 6 months postoperatively. INTERVENTIONS: Subjective assessment was performed using a validated Rhinoplasty Outcomes Evaluation (ROE) questionnaire. This instrument comprises six questions that capture three quality-of-life domains: physical, mental/emotional, and social. MAIN OUTCOME: Rhinoplasty outcomes evaluation scores were calculated (range = 0 to 100) to indication satisfaction with rhinoplasty outcomes. RESULTS: Average age was 28 years (range = 18 to 59 years). There was a significant subjective improvement in the total ROE evaluation scores from 28 ± 10 to 80 ± 11 (P < .01) in secondary cleft rhinoplasty. Similar results were achieved in noncleft rhinoplasty 34 ± 9 to 84 ± 9 (P < .01). Specific scores for nasal aesthetic appearance improved from 0.3 ± 0.2 to 3.2 ± 0.3 (P < .01) in secondary cleft rhinoplasty. No significant change was seen in breathing capacity in secondary cleft rhinoplasty (from 2.7 ± 0.3 to 3.2 ± 0.2; P = .29). All patients said they would undergo the procedure again. CONCLUSION: Our results demonstrate high patient satisfaction after cleft rhinoplasty with particular regard to cosmetic appearance. These results are similar to those for noncleft rhinoplasty. We would recommend the use of this simple and quick validated outcome tool with all rhinoplasty patients.

The value of microbiological screening in cleft lip and palate surgery.

OBJECTIVE: This study was performed to investigate whether nasal and oropharyngeal microbiological swabs taken prior to cleft lip and palate surgery correlated with the oronasal flora at the time of surgery and whether specific culture results affected surgical outcome. METHODS: Prospective audit set in two designated U.K. cleft centers each with a single surgeon. Nasal and oropharyngeal microbiological swabs were taken within 2 weeks prior to surgery and again on the operating table. Adverse outcome measures included postoperative pyrexia, wound dehiscence, or fistula formation. RESULTS: One hundred forty-four cases were recruited over 12 months. Nasal swabs cultured organisms significantly more often than oropharyngeal swabs (p < .0001). No significant difference was detected in the number of cases with a positive microbiology culture preoperatively compared with perioperative sampling (48% and 50%). The specific organisms cultured from preoperative swabs were the same as those cultured at surgery in only half of cases. Preoperative microbiology swabs were poorly predictive of the oronasal flora at surgery. Antibiotic treatment of patients with positive preoperative microbiology did not significantly reduce the incidence of bacterial colonization or significantly alter clinical outcome. CONCLUSION: Preoperative microbiological investigation is not helpful in predicting the nasal and oropharyngeal flora at the time of surgery. Further, culture results did not correlate with postoperative outcome, regardless of whether pre- or perioperative antibiotic therapy was instigated. This evidence suggests that microbiology screening swabs are an unnecessary investigation.

Repair of oronasal fistulae using auricular cartilage grafts in five cats.

OBJECTIVE: To describe repair of chronic palatine defects in cats, with free cartilage graft harvested from either the pinna (scapha) or vertical ear canal (annular cartilage). STUDY DESIGN: Retrospective study. ANIMALS: Cats (n=5) with chronic oronasal fistula. METHODS: Cartilage was harvested from either the scapha or annular cartilage and epithelium removed. After preparation of the edges of the palatal defect by separation of the oral and palatal mucosa circumferentially, the graft was inserted between the epithelial layers and secured without tension. The graft acted as a scaffold for migration of granulation tissue and epithelialization. RESULTS: Oronasal fistulae were successfully repaired in 5 cats (3 pinna grafts; 2 annular cartilage grafts); 1 cat required a second graft after the first graft was dislodged. CONCLUSIONS: Auricular cartilage provides a reliable framework for repair of oronasal fistulae in cats. CLINICAL RELEVANCE: Chronic oronasal fistulae refractory to conventional repair can be treated by use of auricular free graft (pinna or annular cartilage) without disfigurement. Use of annular cartilage to support palatal repairs offers surgeons an additional option when other methods have failed. We recommend using conchal cartilage as the initial treatment approach for repair of small oronasal fistulae in cats.

A late complication following the insertion of hydrogel breast implants.

This case report draws attention to an unusual presentation and subsequent complication following the insertion of a PIP Hydrogel implant for breast augmentation. A cutaneous and capsular foreign body giant cell reaction was identified, and was preceded by the development of a notable increase in breast volume prior to spontaneous discharge. We believe that this was caused by subclinical leakage of the implant contents through a degrading shell. The biodegradability of hydrogel makes it impossible to ascertain the precise nature of the material that leaked out. Given this demonstrable leakage, the adverse clinical effects and the potential for toxicity that is currently unknown, we question whether this product (and other hydrogel breast implants like it) should be formally recalled for the benefit of patient safety.

Implementation of standardized medical photography for cleft lip and palate audit.

Much has been published relating to the treatment and surgical outcome of cleft lip and palate disorders. Clinical audit is one of the most important tools for assessing the quality of care provided, with medical photography an invaluable component of this process. The Clinical Standards Advisory Group Report 1998 recommended that cleft lip and palate patients should be audited when 0 (under 1 year of age), and then at the ages of 5, 10, 15 and 20 years. For both audit and research purposes, medical photographs need to be accurate and of a consistently high standard. This paper describes the development of a standardized photographic protocol for cleft patients of audit age, to the benefit of both the multidisciplinary team and the patients.

Effect of Veau-Wardill-Kilner type of cleft palate repair on long-term midfacial growth.

There is a common concern that the Veau-Wardill-Kilner type of cleft palate repair causes extensive denudation of the palate, resulting in inhibition of maxillary growth. The evidence for this belief is equivocal in the literature. The authors present some long-term results of this technique from a pure sample of nonsyndromic complete unilateral cleft lip and palate patients operated on by a single intermediate-volume cleft surgeon over a period of 25 years. Twenty-five patients, all born between 1977 and 1989, met the above inclusion criteria. Their age at the time of collection of study models and cephalograms was 9 to 17 years (average, 12 years). Midfacial growth was studied using 12-year dental models and lateral cephalograms taken before definitive orthodontic treatment. These were evaluated using the GOSLON Yardstick and digital cephalometric analysis. The final GOSLON results show that 72 percent of the patients had a good or satisfactory outcome, with a GOSLON score of 1, 2, or 3, and only 28 percent ended with a poor score of 4 or 5. The poor sensitivity of cephalometrics in discerning statistically significant differences was highlighted by the huge overlaps observed in the 95 percent confidence interval graph of mean sella-nasion-subspinale angle (S-N-A) values when comparing the results of the Eurocleft centers with those of the authors' center. The results suggest that satisfactory long-term midfacial growth can be obtained with Veau-Wardill-Kilner cleft palate repair.