A multi-centric, single-blinded, randomized, parallel-group study to evaluate the effectiveness of nasoalveolar moulding treatment in non-syndromic patients with complete unilateral cleft lip, alveolus and palate (NAMUC study): a study protocol for a randomized controlled trial.

BACKGROUND: Cleft lip and palate (CLP) are among the most common congenital anomaly that affects up to 33,000 newborns in India every year. Nasoalveolar moulding (NAM) is a non-surgical treatment performed between 0 and 6 months of age to reduce the cleft and improve nasal aesthetics prior to lip surgery. The NAM treatment has been a controversial treatment option with 51% of the cleft teams in Europe, 37% of teams in the USA and 25 of cleft teams in India adopting this methodology. This treatment adds to the already existing high burden of care for these patients. Furthermore, the supporting evidence for this technique is limited with no high-quality long-term clinical trials available on the effectiveness of this treatment. METHOD: The NAMUC study is an investigator-initiated, multi-centre, single-blinded randomized controlled trial with a parallel group design. The study will compare the effectiveness of NAM treatment provided prior to lip surgery against the no-treatment control group in 274 patients with non-syndromic unilateral complete cleft lip and palate. The primary endpoint of the trial is the nasolabial aesthetics measured using the Asher McDade index at 5 years of age. The secondary outcomes include dentofacial development, speech, hearing, cost-effectiveness, quality of life, patient perception, feeding and intangible benefits. Randomization will be carried out via central online system and stratified based on cleft width, birth weight and clinical trial site. DISCUSSION: We expect the results from this study on the effectiveness of treatment with NAM appliance in the long term along with the cost-effectiveness evaluation can eliminate the dilemma and differences in clinical care across the globe. TRIAL REGISTRATION: ClinicalTrials.gov CTRI/2022/11/047426 (Clinical Trials Registry India). Registered on 18 November 2022. The first patient was recruited on 11 December 2022. CTR India does not pick up on Google search with just the trial number. The following steps have to be carried out to pick up. How to search: ( https://ctri.nic.in/Clinicaltrials/advsearch.php -use the search boxes by entering the following details: Interventional trial > November 2022 > NAMUC).

Alveolar bone grafting and gingivoperiosteoplasty in bilateral cleft lip and palate.

PURPOSE OF REVIEW: Gingivoperiosteoplasty (GPP) and alveolar bone grafting (ABG) procedures have a vast history. There have been many publications regarding ABG and secondary ABG, with and without presurgical infant orthopedics (PSIO), in bilateral cleft lip and palate patients. There is little long-term data available describing results of both techniques. RECENT FINDINGS: The interdisciplinary approach to primary and secondary surgical procedures has proven to be beneficial for patients with bilateral cleft lip and palate. In the neonates, naso-alveolar molding (NAM) has been found to optimize the aesthetic outcome as well as re-approximating the arches to facilitate GPP. During the mixed dentition stage, arch preparation/expansion before the secondary ABG procedure improves arch morphology, restores the functional interarch relationship, and facilitates surgery. SUMMARY: This review aims to highlight the key points of both the procedures and why combining both procedures along with PSIO procedures such as NAM might be helpful for the patients in the long term.

Retrospective Analysis of Subtarsal Incision in Maxillofacial Trauma.

INTRODUCTION: Subciliary, subtarsal and infraorbital incisions are the conventional cutaneous approaches to infraorbital rim and floor. MATERIALS AND METHODS: A retrospective study was developed with 30 patients reviewed over a period of 12 months. RESULT: No cases showed ectropion in minimum 12-month follow-up. Mild scleral show was present in 3 cases. At the end of 12 months, scar was invisible in 25 patients, mild in 4 patients and moderate in 1 patient who developed wound infection. CONCLUSION: Subtarsal incision shows good result with very minimal post-operative complications.

A retrospective analysis of latissimus dorsi-serratus anterior chimeric flap reconstruction in 47 patients with extensive lower extremity trauma.

BACKGROUND: Many flaps have been described for reconstruction of lower extremity defects, including, Latissimus Dorsi, Rectus abdominis, Anterolateral thigh perforator flaps, each having advantages and disadvantages. The defect location, size and specific geometric pattern of defect influences the type of flap that can be used. In this case series, we describe the specific situations where the use of chimeric latissimus dorsi-serratus anterior (LD + SA) free flaps are of advantage in providing complete wound cover. MATERIALS AND METHODS: Case records of all patients who underwent LD + SA free flap transfer for lower extremity trauma at Amandeep Hospital, from Feb 2006 to Feb 2017 were reviewed. Patients were categorised based on the anatomical location and size of defect. The method of usage of the chimeric segments, recipient vessels and type of anastomosis were noted. Flap complications, if any were reviewed. RESULT: 47 patients with lower limb defects were included in the study. All cases were post traumatic in nature. Defect size ranged from 180 sq cm to 1050 sq cm. Average defect size was 487.70 sq cm. All patients underwent soft tissue reconstruction with LD + SA flap. Complete wound cover was obtained. CONCLUSION: Latissimus dorsi + Serratus anterior free tissue transfer is an effective, reliable method of providing cover to extensive lower limb traumatic defects with minimal donor site morbidity, with added freedom of inset and flap positioning. Specific use is seen in patients with broad proximal defect, long defect in the leg, defects involving adjacent anatomical areas and in large defect with dead space.

Nasopharyngeal Dermoids and Cleft Palate.

Nasopharyngeal dermoids associated with cleft palate present as intraoral protruding masses. Only 5 cases of nasopharyngeal dermoids associated with cleft palate have been reported in the literature. We are reporting 4 such cases encountered by us in the last 10 years in our series of 900 cleft palate surgeries. Imaging studies were done to know the extension of dermoid and to look for any associated congenital intracranial anomalies. We observed that nasopharyngeal dermoids are usually nonmalignant and can be easily managed by complete local excision followed by palatal closure after 6 months.

A retrospective analysis of incidence and management of palatal fistula.

BACKGROUND: Cleft palate repair may be compromised by a number of complications, most commonly the development of a fistula. Fistulas may cause hypernasal speech, articulation problems and food or liquid regurgitation from the nose. OBJECTIVE: The study determines the incidence and management of cleft palatal fistulas in a series of primary cleft palate repair surgeries. It is a retrospective analysis of total 185 palatal fistula cases operated at our hospital from the year 2004 to 2016. SUBJECTS AND METHODS: Of 185 palatal fistulas, 132 cases had been operated at our institute for primary palatoplasty, and the rest 53 were the outside-operated cases. The patients with bilateral as well as unilateral cleft lip and palate were included. Isolated cleft palate patients were also included in the study. Palatal fistulas were subdivided into three types depending on their size. Anterior palatal fistulas were mostly treated by using tongue flap (65.57%), followed by local flaps (34.43%). Middle and posterior palatal fistulas were mostly treated by von Langenbeck Palatoplasty. One patient (>5 mm fistula) was treated using free radial forearm flap. RESULTS: Anterior palatal fistulas (65.57%) were most commonly reported, followed by middle (24.86%) and posterior (9.18%). Most commonly, the size of the fistulas ranged from 2 mm to 5 mm. The complication rate was reported to be 3.75% in case of tongue flap and 11.9% complications were reported in case of local flaps. CONCLUSION: Tongue flap remains the flap of choice for managing very difficult and challenging anterior palatal fistulas compared to local flaps.

Role of tongue flap in palatal fistula repair: A series of 41 cases.

INTRODUCTION: Despite the improved techniques of repair of cleft palate, fistula occurrence is still a possibility either due to an error in the surgical technique or due to the poor tissue quality of the patient. Though commonly the fistula closure is established by use of local flaps but at times the site and the size of the fistula make use of local flaps for its repair a remote possibility. The use of tongue flaps because of the central position in the floor of the mouth, mobility and the diversity of positioning the flaps make it a method of choice for closure of anterior palatal fistulae than any other tissues. The aim of this study was to analyse the utility of tongue flap in anterior palatal fistula repair. MATERIALS AND METHODS: We had 41 patients admitted to our hospital during the period 2006-2012 for repair of palatal fistula and were enrolled into the study. In the entire 41 cases, fistula was placed anteriorly. The size of the fistulae varied from 2 cm × 1.5 cm to 5.5 cm × 3 cm. The flaps were divided after 3-week and final inset of the flap was done. OBSERVATION AND RESULT: None of the patients developed flap necrosis, in one case there was the dehiscence of the flap, which was reinset and in one patient there was bleeding. None of our patients developed functional deformity of the tongue. Speech was improved in 75% cases. CONCLUSION: Leaving apart its only drawback of two-staged procedure and transient patient discomfort, tongue flap remains the flap of choice for managing very difficult and challenging anterior palatal fistulae.

Functional outcome of patients undergoing replantation of hand at wrist level-7 year experience.

BACKGROUND: Replantation is defined as reattachment of amputated limb using neurovascular and musculoskeletal structures in order to obtain recovery of limb. Re-vascularisation involves all the above steps in case of limb injuries that result in a near total amputation. AIM AND OBJECTIVE: To study the functional outcome of patients undergoing replantation of hand at wrist level. MATERIAL AND METHODS: This is a retrospective study of patients who underwent replantation of total amputation of hand at wrist level within a period of Jan 2003-June 2010. We evaluated post operative functional outcome compared to uninjured hand taking into consideration: 1. The patient's overall satisfaction with the hand. 2. Recovery of flexor and extensor function of thumb and fingers. 3. Recovery of thumb opposition. 4. Recovery of sensations in the median and ulnar nerve distribution. 5. Ability of surviving hand to perform daily tasks. RESULTS: There were total seventeen patients and age range was two years to 55 years. Out of 17 patients,16 were males. All the replantations were successful except for one. SUMMARY: The results showed that, although the replanted hands were never functionally as good as the contralateral hand the patients were able to perform most of the daily activities.