A systematic review of differences in outcome between one and two stage palate repair in cleft lip and palate.

The aim of this systematic review was to determine whether one-stage palatoplasty for children born with cleft lip and palate shows overall advantages in outcome compared with two-stage palatoplasty. The included studies were controlled studies of syndromic and non-syndromic children born with unilateral cleft lip and palate, bilateral cleft lip and palate, or isolated cleft palate. The interventions studied were one-stage palatoplasty and two-stage palatoplasty starting with the soft palate. The outcomes were facial growth, speech, hearing, presence of fistulae, other complications related to surgery, health-related quality of life, and health economics. In total, 14 original studies were included. Results were dichotomized into showing advantage for one- or two-stage palatoplasty for the respective outcome and compared with the results from six included systematic reviews. No overall advantage for either surgical strategy was found for any of the outcome measures. The certainty of evidence was highest for the presence of fistulae, followed by facial growth and speech. For several outcomes, the quality of the existing evidence was too low to allow for any conclusions to be drawn. Neither one- nor two-stage palatoplasty showed significant advantages in clinical outcomes compared with the other. Other aspects such as ethics, economics, or surgeon's preference might hence be of more importance. Homogenous choices of outcome measures and defined minimal clinically important differences would facilitate further research.

Long-term speech outcome after anterior distraction osteogenesis of the maxilla in patients with cleft lip and palate.

Advancement of the maxilla may increase the distance between the soft palate and the posterior pharyngeal wall in patients with cleft lip and palate, implying a risk of velopharyngeal dysfunction. The aim was to evaluate long-term speech outcome in a consecutive series of patients treated with distraction osteogenesis (DO). Fourteen out of the 16 patients agreed to participate. A long-term speech follow-up was performed 1.5 to 13.5 years after DO. For two participants, audio recordings before DO were missing, and for another one, it was incomplete. The percentage of consonants correct (PCC) based on phonetic transcription and perceived velopharyngeal competence rated on a three-point scale were assessed before and after DO by three independent judges, based on audio recordings of reading of standardised sentences. Also, the participants were asked how they perceived their speech after DO. Changes in PCC were insignificant. Four participants perceived deteriorated speech related to DO. In two cases, the subjective deterioration did not correlate to results from perceptual assessment. In two others, the subjective deterioration correlated with the perceptual assessment, and the velopharyngeal function was judged as being incompetent after DO. After secondary velopharyngeal surgery, velopharyngeal function improved to competent in one case and marginally incompetent in the other. The results need to be interpreted with caution due to methodological limitations but indicate that some patients develop deteriorated velopharyngeal function after DO. The impact on articulation needs to be further explored. It is important that patients are informed before treatment of the risk of velopharyngeal dysfunction after DO.

Long-term patient-reported outcomes after anterior distraction osteogenesis of the maxilla in patients with cleft.

Maxillary growth inhibition in patients with cleft lip and palate (CLP) is an undesired effect that may occur in the teens despite proper primary care. Dental malocclusion and distortion of facial appearance can be treated with external distraction osteogenesis (DO) of the maxilla. This entails a Le Fort I osteotomy, fastening a semi-circular distractor to the skull, distraction for three weeks, and fixation for three months before removal of the device.The aim of this descriptive long-term follow-up study was to evaluate DO of the maxilla from the patient-reported long-term perspective.Fourteen patients underwent a long-term follow-up including a questionnaire regarding their experience of DO. Sex, CLP diagnosis, age at DO and follow-up, and time required for active distraction and fixation were noted. Furthermore, documentation on rhinoplasty, lip plasty and velopharyngeal plasty after DO was registered. Objective results were assessed by a positive dental overjet in the front.Ten patients considered the distractor an everyday constraint, but all thought the procedure was worthwhile and would recommend it to others. Thirteen patients experienced improved bite and chewing, whereas one considered function unchanged. All were satisfied with their dental alignment. Three patients underwent a velopharyngeal plasty after DO. Moreover, six rhinoplasties and two lip plasties were performed.Despite a long and challenging treatment, teenagers and young adults with CLP and maxillary hypoplasia tolerate DO of the maxilla very well. Secondary measures to improve speech and appearance are often indicated.

Curettage and electrodessication combined with photodynamic therapy in the treatment of large squamous cell carcinomas in unfit and frail patients.

A Caucasian female patient in her 90s was referred to the department of plastic and reconstructive surgery for surgical removal of a large invasive squamous cell carcinoma on the anterior chest wall. A skin biopsy prior to the referral indicated that the tumour was moderately differentiated. The patient suffered from severe congestive heart failure with a mechanical valve prosthesis and atrial fibrillation, and was therefore treated with anticoagulants. Hence, a surgical procedure would be hazardous. Therefore, other treatment options were considered. The principal aim was to reduce the amount of tumour tissue to an appropriate size suitable for later excision with primary wound closure. After interdisciplinary discussions, curettage and electrodessication combined with photodynamic therapy was judged the best alternative treatment in this case. At the 1.5 years follow-up after the intervention there was no indication for further surgery. The patient was at that stage content with the treatment and its outcome.

On the role of the frontal projection in videoradiography of velopharynx in decision-making for a velopharyngeal flap plasty in patients with cleft palate.

Despite uneventful primary surgery, patients with cleft palate may experience velopharyngeal insufficiency (VPI) and hypernasal speech. Videoradiography of velopharynx is a commonly used method to visualize velopharyngeal function and a velopharyngeal flap is often used to counteract VPI. The aim of this study was to investigate whether the frontal projection on videoradiography plays a role in the decision-making about velopharyngeal flap surgery, or possibly the width and orientation of the flap. A secondary aim was to evaluate the effect of the flap in improving velopharyngeal function. Between 2007 and 2016, 75 patients had received a flap at our department. During the same period of time, 41 patients who had undergone videoradiography did not receive a flap. Medical records, particularly regarding speech assessments, videoradiography statements and operating records, were scrutinised to seek information about the factors leading up to the decision about whether or not to perform a flap. In only one instance, reduced lateral pharyngeal wall movement found on the frontal projection was clearly taken into account when deciding to refrain from performing a velopharyngeal flap. Only a slight agreement was found between pre-operative speech assessment and findings in videoradiography. Hypernasality was reduced by flap surgery in 97% of the patients. We conclude the frontal projection of the videoradiographic examination seems to have no crucial role in the decision-making on performing a velopharyngeal flap or not in patients with cleft palate. Even with reduced lateral pharyngeal wall movement, a velopharyngeal flap effectively reduces hypernasality and VPI.

Patient-reported outcome after oncoplastic breast surgery compared with conventional breast-conserving surgery in breast cancer.

INTRODUCTION: Oncoplastic breast surgery (OBS) has developed as an extension of breast-conserving surgery (BCS) in an effort to improve esthetic and functional outcome following surgery for breast cancer. The aim of the present study was to evaluate the possible benefits of OBS, as compared with BCS, with regard to health-related quality of life (HRQoL), using patient-reported outcome measures (PROMs). PATIENTS AND METHODS: Patients treated with OBS (n = 200) and BCS (n = 1304) in the period 1 January 2008 to 31 December 2013 were identified in a research database and in the Danish Breast Cancer Cooperative Group (DBCG) registry. Data on patient, tumor, and treatment characteristics were retrieved from the DBCG registry. Patients were sent a survey including the Breast-Q™ BCT postoperative module and a study-specific questionnaire (SSQ) in 2016. A good outcome in the Breast-Q module was defined as above the median. OBS was compared to BCS using a logistic regression analysis, and then adjusted for potential confounders, yielding odds ratios (OR) with 95% confidence intervals. RESULTS: There was a statistically significant better outcome considering the HRQoL domain "Psychosocial Well-being " for patients treated with OBS as compared with BCS (OR 2.15: 1.25-3.69). No statistically significant differences were found for the domains "Physical Well-being" (0.83: 0.50-1.39), "Satisfaction with Breast" (0.95: 0.57-1.59), or "Sexual Well-being" (1.42: 0.78-2.58). CONCLUSION: The present study indicates better outcomes of HRQoL for breast cancer patients treated with OBS as compared to patients treated with BCS. There was no increase in physical discomfort among OBS patients despite more extensive surgery.

Oncoplastic Breast Surgery Compared to Conventional Breast-Conserving Surgery With Regard to Oncologic Outcome.

INTRODUCTION: Oncoplastic breast surgery (OBS) has been implemented with increasing frequency in the treatment of breast cancer. The aim of this study was to compare the oncologic outcome after OBS to the outcome after conventional breast-conserving surgery (BCS) in patients with invasive breast cancer. PATIENTS AND METHODS: In all, 197 patients treated with OBS were compared to 1399 patients treated with conventional BCS from 2008 to 2013. We evaluated nonradical primary tumor excision, time to initiation of adjuvant therapy, disease-free survival (risk of recurrent disease), and survival (cause specific and overall). Identification of patients and follow-up were made using the Danish Breast Cancer Cooperative Group registry and the Danish Cause of Death registry. Multivariate logistic regression and the Cox proportional hazard analysis were used to obtain odds ratios and hazard ratios with 95% confidence intervals (CI). RESULTS: There was a lower risk for nonradical primary tumor excision for patients undergoing OBS versus conventional BCS (adjusted odds ratio:95% CI, 0.50:0.29-0.84). No significant differences were found with regard to a delay in initiation of adjuvant chemotherapy (adjusted hazard ratio:95% CI, 1.14:0.89-1.45) or radiotherapy (0.91:0.71-1.16), disease-free survival (1.23:0.61-2.47), breast cancer as cause of death (1.46:0.52-4.09), breast cancer as underlying or multiple cause of death (0.90:0.34-2.37), or overall survival (0.90:0.51-1.60). CONCLUSION: We found no significant differences in oncologic outcome comparing OBS to conventional BCS. However, a lower risk of nonradical primary tumor excision was found for patients treated with OBS. These results indicate that OBS is a safe procedure.

Female and Male Differences in Academic Achievement in Individuals With Cleft: A Population-Based Register Study.

OBJECTIVE: The focus of this study was to determine if there is any significant difference in academic achievement for girls and boys with a cleft compared to the general population of Swedish students at graduation from compulsory school. DESIGN: A retrospective population-based study using data obtained from the Swedish Medical Birth Register that was linked to the Swedish School-Grade Register. PARTICIPANTS: Two hundred seventy girls and 241 boys with cleft palate (CP), 222 girls and 429 boys with cleft lip (CL), and 299 girls and 531 boys with cleft lip and palate (CLP) were compared with the compulsory school population comprising 609,397 girls and 640,007 boys. MAIN OUTCOME MEASURES: (1) Odds of receiving the lowest grade and reduced odds in receiving high grades in Mathematics, English, and Swedish. (2) grade point average (GPA). RESULTS: In all 3 subject grades, for boys with cleft there was no difference when compared to the male population. Girls with cleft were similar to their peers with a few exceptions. Girls with CLP had lower Math grades, and girls with CP had lower Math, English, and Swedish grades. Girls with CP and CLP achieved a significantly lower GPA in comparison to the female population and boys with CP and CL achieved lower GPAs in comparison to the male population. CONCLUSIONS: This study indicates that educational outcomes for girls with cleft are more negatively affected than for boys with cleft.

Patient-reported long-term outcome after primary hypospadias repair.

PURPOSE: Long-term evaluation of the surgical outcome after puberty, particularly patient reported outcome is rare in the literature. The aims of this study were to investigation the patients' satisfaction with the long-term results and their views and memories of their childhood surgery and follow-up. METHODS: A modified version of previously used questionnaire was sent to 134 patients ages 18 years or older previously primarily repaired due to hypospadias by one of the authors (HS) between 1989 -2009. RESULTS: Thirty-nine patients responded. Eighty-two per cent were satisfied with the appearance of their penis, 87% were satisfied with their ability to urinate and their sexual function and 92% were satisfied with the overall surgical results. Ninety per cent of patients were positive to the current duration of our post-pubertal follow-up program or would have preferred an even longer follow-up. CONCLUSIONS: The majority of patients were satisfied with the long-term surgical results and the duration of follow-up. Despite having problems patients does not always contact the health care system spontaneously, which warrants long-term follow-up.

Smoking increases donor site complications in breast reconstruction with DIEP flap.

OBJECTIVE: Reconstruction with deep inferior epigastric perforator flap (DIEP) is considered to be the first choice for autologous breast reconstruction. The primary aims of this retrospective study were to find out if differences in smoking habits and BMI are useful predictors for postoperative complications in DIEP surgery. METHODS: Three hundred and one patients were included. Data regarding smoking habits, BMI, age at surgery, total and final flap weight, abdominal scars, parity, number of perforators, chemotherapy, post mastectomy radiation therapy, and preoperative mapping of perforators with either Computer Tomography Angiography or hand-held ultra sound Doppler were collected. Complications that occurred in the first 30 postoperative days were taken into account. RESULTS AND CONCLUSIONS: It was found that former smokers had a risk for donor site complication more than double that of never smokers (OR =2.12, CI =1.10-4.10, p = 0.025). Differences in BMI within the range from 18-33.7 did not have any significant impact on complication rates, neither at the donor site nor at the breast.

An analysis of complications in secondary bone grafting in patients with unilateral complete cleft lip and palate.

AIM: The aim of this investigation was to assess the outcome of secondary alveolar bone grafts 6 months after the procedure and examine the possible influence of patient sex, age at surgery, cleft width, and dehiscence of mucosa and sequestered bone at 2 weeks. METHODS: Thirty-nine consecutive patients with unilateral complete cleft lip and palate were reconstructed with secondary alveolar bone grafting. Age at surgery ranged from 7.3-12.5 years (mean = 8.6). Cleft width varied between 2.2-14 mm (mean = 7.3). Bone was harvested either from the iliac crest or from the chin. Two-dimensional dental radiographs of the cleft area were taken before and 6 months after surgery. RESULTS: Two weeks after surgery, 10 patients had minor dehiscence of the sutured gingival tissues and five had bone sequesters. However, only one of the treatments turned out to be unsuccessful with a Bergland index of IV. Twenty-nine patients had an initial uneventful course; but, at a follow-up 6 months later, two patients had a Bergland index of III and four a Bergland index of IV. In three of these cases, there were circumstances that could have contributed to the lack of success; but, in the remaining three, no such circumstances could be identified. CONCLUSION: The success rate of secondary bone grafting is high, and initial wound healing problems do not necessarily lead to a failed reconstruction. Failure may be related to factors such as exposed tooth enamel during an operation, postoperative infection, and poor compliance. Still, failed operations occur without any obvious causes.

Failed hypospadias repair: An algorithm for secondary reconstruction using remaining local tissue.

Salvage hypospadias surgery is performed after failed primary reconstruction. Several treatment strategies have been suggested, all with pros and cons. The aim of this study was to evaluate our treatment algorithm for primary hypospadias repair applied to secondary cases in which a salvage procedure is indicated and, most importantly, local tissue is present. The algorithm was applied to 36 consecutive patients who had undergone a total of 109 surgical procedures before referral. In accordance with the algorithm, 12 patients without ventral curvature achieved a satisfactory result with one procedure by the use of local skin flaps. Six patients with moderate ventral curvature underwent orthoplasty, fistula closure, and/or urethral reconstruction using local skin flaps in one session. Eighteen patients with a severe ventral curvature or a proximal meatus were reconstructed in two stages using Byars' technique. After a median of two salvage procedures (range: 1-4), all patients but one, who awaits splitting of a skin bridge in the meatus, were successfully reconstructed. Two patients in active follow-up have potential problems requiring further surgery. Our findings indicate that failed hypospadias repairs are often due to an underestimation of the ventral curvature at the initial repair. Therefore, reevaluation of the degree of curvature is important. One-stage salvage repairs can be used, provided that none or minimal curvature remains. In cases of marked curvature, however, a meticulous resection of the chordee and ventral scarring is crucial. The subsequent repair of the large ventral defect and the long urethral reconstruction can, in most cases, be safely managed in a two-stage procedure.

Blood flow dynamics and sensitivity in breasts after reconstruction with DIEP-flap.

A method of breast reconstruction is based on the Deep Inferior Epigastric Perforator (DIEP) technique. Skin and fat are transplanted from the abdomen to the chest; blood vessels are reconnected through microsurgery. Nerves are, however, left unconnected. This study aims to evaluate the blood flow and reinnervation of blood vessels and skin in breasts reconstructed by DIEP flaps without neural repair. In all, DIEP flaps of 10 patients were tested at an average of 16.3 months postoperatively. Blood flow was assessed by PeriScan PIM II System, both before and after indirect heating. Tactile perception threshold was assessed by Semmes-Weinstein monofilament and thermal sensibility by SENSELab MSA Thermotest. The patients' contralateral breasts were used as controls. The blood flow of the flaps was statistically significantly lower than in the control breasts, both before and after indirect heating. The change in blood flow after indirect heating did, however, not significantly differ when comparing the breasts. All flaps regained deep pressure sensibility in all four quadrants. Five patients regained even better sensibility in one of their quadrants. Seven patients regained perception of cold stimuli, five perceived warmth. This study has shown that skin blood flow regulation is present in DIEP flaps 1 year after reconstruction. Blood flow dynamics are very similar to those in the normal breast. There is also a recovery of tactile and thermal sensibility, but this study has not shown any clear parallels between recovery blood flow, tactile sensibility and thermal sensibility.

Surgical strategy, methods of reconstruction, surgical margins and postoperative complications in oncoplastic breast surgery.

BACKGROUND: Oncoplastic breast surgery is an evolving discipline in the surgical treatment of breast cancer aimed to improve the outcome. METHODS: Oncoplastic breast surgery was performed between January 2008 and December 2010 on 72 women with 74 breast cancers selected from a population of 1,018 primary breast cancer patients. Careful preoperative planning revealed the possibility of partial breast reconstruction with volume reduction, volume displacement or volume replacement depending on breast size as well as tumour size and location. Data were registered consecutively. RESULTS: The surgical plan was successful in all but one case, where a mastectomy had to be performed during the primary surgery. In 53 cases, a contralateral mammoplasty was performed during the operation to achieve symmetry. During the follow-up period until November 2011, only one patient needed corrective surgery. Final histopathological examination indicated that seven cases required extended resection and three cases required a mastectomy. Five patients experienced delayed wound healing, although complications requiring further surgery occurred for the reconstructed breast in four cases, the contralateral breast in three cases and the axilla after exaeresis in two cases because of haematoma. Such complications led to slight delay in adjuvant therapy for four patients. CONCLUSIONS: This study demonstrates that it is feasible to implement oncoplastic breast surgery into daily clinical practice as a supplement to conventional breast cancer surgery. As such, oncoplastic breast surgery may provide a markedly better outcome than breast-conserving surgery in terms of shape and symmetry without compromising the surgical margins. Level of Evidence: Level IV, prognostic/risk study.

Neonatal scalp haematoma and necrosis.

Birth trauma after prolonged deliveries and instrument-assisted extractions can result in skin lesions and reduced viability of the scalp. In these instances, scalp swellings and haematomas are often also seen. The classification and inter-relationship between these conditions might not, however, always be clear. This report describes three cases of neonates with scalp swellings and necrosis. Nomenclature, underlying causes, work up, treatment options, and outcomes are presented and discussed. The first case consisted of a newborn with a subgaleal haematoma and occipital pressure necrosis that healed by secondary intention. In the second case, an infected scalp haematoma led to scarring and alopecia that required secondary reconstruction with tissue expansion. The third neonate suffered from a subgaleal haematoma and a scalp lesion that required split skin grafting and secondary reconstruction with tissue expansion.

Speech and phonology in Swedish-speaking 3-year-olds with unilateral complete cleft lip and palate following different methods for primary palatal surgery.

Objective : To describe and compare speech and phonology at age 3 years in children born with unilateral complete cleft lip and palate treated with three different methods for primary palatal surgery. Design : Prospective study. Setting : Primary care university hospitals. Participants : Twenty-eight Swedish-speaking children born with nonsyndromic unilateral complete cleft lip and palate. Interventions : Three methods for primary palatal surgery: two-stage closure with soft palate closure between 3.4 and 6.4 months and hard palate closure at mean age 12.3 months (n = 9) or 36.2 months (n = 9) or one-stage closure at mean age 13.6 months (n = 10). Main Outcome Measures : Based on independent judgments performed by two speech-language pathologists from standardized video recordings: percent correct consonants adjusted for age, percent active cleft speech characteristics, total number of phonological processes, number of different phonological processes, hypernasality, and audible nasal air leakage. The hard palate was unrepaired in nine of the children treated with two-stage closure. Results : The group treated with one-stage closure showed significantly better results than the group with an unoperated hard palate regarding percent active cleft speech characteristics and total number of phonological processes. Conclusions : Early primary palatal surgery in one or two stages did not result in any significant differences in speech production at age 3 years. However, children with an unoperated hard palate had significantly poorer speech and phonology than peers who had been treated with one-stage palatal closure at about 13 months of age.

Phonology in Swedish-speaking 3-year-olds born with cleft lip and palate and the relationship with consonant production at 18 months.

BACKGROUND: Approximately 50% of children born with cleft palate present speech difficulties around 3 years of age, and several studies report on persisting phonological problems after palatal closure. However, studies on early phonology related to cleft palate are few and have so far mainly been carried out on English-speaking children. Studies on phonology related to cleft palate in languages other than English are also warranted. AIMS: To assess phonology in Swedish-speaking children born with and without unilateral cleft lip and palate (UCLP) at 3 years of age, and to identify variables at 18 months that are associated with restricted phonology at age 3 years. METHODS & PROCEDURES: Eighteen consecutive children born with UCLP and 20 children without cleft lip and palate were included. Transcriptions of audio recordings at 18 months and 3 years were used. Per cent correct consonants adjusted for age (PCC-A), the number of established phonemes, and phonological simplification processes at 3 years were assessed and compared with different aspects of consonant inventory at 18 months. OUTCOMES & RESULTS: PCC-A, the number of established phonemes, and the total number of phonological processes differed significantly at 3 years between the two groups. Total number of oral consonants, oral stops, dental/alveolar oral stops and number of different oral stops at 18 months correlated significantly with PCC-A at 3 years in the UCLP group. CONCLUSIONS & IMPLICATIONS: As a group, children born with UCLP displayed deviant phonology at 3 years compared with peers without cleft lip and palate. Measures of oral consonant and stop production at 18 months might be possible predictors for phonology at 3 years in children born with cleft palate.

The Abbé flap in cleft lip and palate repair.

The Abbé flap is a procedure where the volume of the upper lip is increased at the expense of the lower lip. This study reviewed the Abbé flaps done at Skåne University Hospital during the years 1991-2006 and identified 14 patients. Data was collected from medical records. Eleven patients were deemed fit for interviews and were called to the hospital by standard mail. Six patients responded and were interviewed, examined, and photographed. One patient was interviewed over the telephone. Median age at surgery was 14 years (range = 6-22). The operation time was 152 minutes (range = 90-215). The Abbé flap was divided after 12 days (range = 11-16). All 14 flaps survived and no complications were noted. Secondary corrections were done in nine patients. Three patients experienced having their lips sutured together as difficult, and four patients described this period as easy. All patients described their lips as having better appearance after the operation and, in three of four cases, where a simultaneous columella lengthening was done, the patients described their noses as having better appearance. The scar on the lower lip was negative but also a prerequisite for the operation. All seven patients said the operation was worth all the effort and would recommend it to patients in similar situations. This data supports that the Abbé flap is a safe technique that effectively improves the appearance of the upper lip and satisfies the cleft lip and palate patients.