Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1281_Библиотеки_им_академика_М_И_Перельмана
.pdf
Pediatric Surgical Procedures – An Updated Guide – Volume I
21
Age Issues Management Specialities
5 to 6years Nasal deformity Preschool rhinoplasty Plastic surgeon
7 to 11years Secondary deformities
13 to 18years Dental abnormalities Dental and orthodontic care Orthodontist
18years and
older
Table 1.
Summary of health issues, age and method of management of CLP and the specialities involved.
of lip and nose
Alveolar defect Orthodontic management of misaligned
Dental abnormalities Alveolar bone grafting
Maxillary hypoplasia
and malocclusion
Residual nasal
deformities
Skeletal abnormalities Definitive rhinoplasty Speech therapist
Surgical revision of lip and nose deformities Plastic surgeon
Orthodontist
alveolar arches
Endodontist
Dental implants Prosthodontist
Speech and language evaluation Plastic surgeon
Psychological assessment Psychologist
Orthognathic surgery Speech therapist
Definitive rhinoplasty
Orthognathic surgery Plastic surgeon
severely impacted by the birth of a child with CLP. Hence, holistic support of the
family is as important as the care of the child itself.
. Antenatal detection and management
The detection rates with two-dimensional (2D) ultrasonic examination at 20weeks
of gestation vary from 16 to 93% [18, 19]. The overall detection rate of facial clefts is
65%. The detection rate for CLP is 93%, 67% for isolated CL, and 22% for isolated CP
[1]. This fact is because of the difference in operator, technique, maternal body habitus,
amniotic fluid volume, fetal position, and the type of cleft influence ultrasonography.
Three-dimensional (3D) ultrasound is usually used in addition to 2D ultrasound for
early identification of clefts in the first trimester [20]. The absence of acoustic shadowing due to the non-ossification of the surrounding facial bones facilitates visualization
of the palate in the multiplanar mode at this early gestation period [20]. The sensitivity
and specificity of MRI in diagnosing CLP are yet to be proven. MRI, in addition to
conventional ultrasound, is shown to improve the accuracy of the diagnosis [21].
Stoll et al. reported a 36% incidence of other congenital malformations in children
with oral clefts, highlighting the significance of antenatal detection [22]. Parents in
these cases should be offered invasive testing for detecting chromosomal anomalies
and genetic counseling [23].
. First months of life
.. Counseling
Parents are often sad and devastated by the birth of a CLP child [24]. Formation
of a supportive parent-child relationship is a must for the child’s development [25].
Cleft Lip/Palate: Hidden Aspects beyond the Gap
DOI: http://dx.doi.org/10.5772/intechopen.115578
22
Counseling plays a pivotal role in the adaptation of the family to the child born with
CLP or detected to be afflicted with the malady in the antenatal period. It is also essential to facilitate long-term collaboration between the parents and the various healthcare professionals involved in the multidisciplinary treatment team. Information
regarding the etiology of the cleft and the treatable nature of the disease helps in
alleviating the guilt and anxiety of the parents. The counseling session should address
questions regarding feeding, growth, other health issues, and their management [15].
Complete, accurate, and unbiased information must be shared, and parents must be
made aware of the availability and accessibility of healthcare facilities. A comprehensive treatment plan must be outlined. Parents should be helped in contacting organizations that provide one-to-one support and family-centered team care. The need for
long-term follow-up extending into adulthood must be explained to the family.
.. Genetic counseling
CLPs tend to recur in families. A positive family history is found in approximately
every sixth child with CL±P [26]. The risk of a child getting affected is 3.2% if one parent
is affected with CL±P and 6.8% if the parent is affected with CP. If a sibling is affected by
CL±P, the risk of the next child getting affected is 4.4%. If a sibling is affected by CP, the
risk reduces to 2.5%. This risk increases to 9% after two affected children are born. The
risk is even higher, to the extent of 15%, if one parent and one sibling are affected [27–29].
.. Feeding and nutrition
The lip and palate play a significant role in the feeding mechanism. The palate
superiorly, lip anteriorly, tongue inferiorly, bilaterally the cheeks, and posterior pharyngeal wall posteriorly form a closed chamber to create negative pressure for sucking milk from the breast or bottle [11]. Monthly monitoring is necessary to observe
weight gain, hemoglobin level, and skeletal growth till the cleft palate is closed. After
that, the achievement of milestones and weight gain is monitored.
Specially designed feeding bottles are available for these children. Haberman
feeder, Mead Johnson feeder, Lamb’s nipple, cross-cut nipple, and long nipple are
some of these [11]. Some of these devices deliver the fluid directly over the posterior
part of the tongue so that the baby need not depend upon the sucking phenomenon
[11]. In our country, feeding with a spoon or paladai (modified spoon with a nozzle) is
prevalent. Special bottles in which flow is either gravity-dependent or squeeze-dependent are also available. These devices deliver milk at a controlled rate. However, these
devices are expensive. Feeding techniques, such as holding the child in a semi-reclining position and patting the back to cause burping, are taught to the family. Ideally, the
feed should not last more than 30minutes, as longer feeds exhaust the baby.
.. Presurgical infant orthodontics and lip repair
The primary goal of all infant Orthodontics is to align the cleft segments into a
correct anatomical position [17]. The nasal cartilage deformity is improved with the
use of a nasal stent to reshape the nasal cartilage, lengthen the columella, and achieve
projection of the flattened nasal tip [17]. Nasoalveolar molding is the most common
form of passive infant Orthodontics used today.
The standard methods of unilateral lip repair practiced worldwide are the RandallTennison geometrical method (Figure ), Millard’s rotation-advancement method
Pediatric Surgical Procedures – An Updated Guide – Volume I
23
Figure 3.
Marking of Randall-Tennison lip repair. 5: Base of columella on cleft side. 6: Base of ala on cleft side. 5-3: Height
of philtrum on cleft side. 7-13: Perpendicular cut on cleft philtrum. 7-13=9-12=8–12. 9-8: Difference in height of
philtrum on cleft and non-cleft side, i.e., difference between 6-8 and 5-3.
(Figure ), and the Pfeiffer-Afroze method. The standard methods of bilateral cleft lip
repair practiced worldwide are those described by Veau, Mulliken, Black, and Millard.
... Randall-Tennison repair
Landmark points are marked (Figure ). The lateral philtral point is taken as the
highest point of Cupid’s bow on the noncleft side. The deepest point on Cupid’s bow
is marked. The Nordoff’s point is marked on the cleft side. The mid-columella point
is marked at the midpoint of the base of the columella. The alar base and columella
base are marked bilaterally. A vertical line is drawn from the lateral columellar base
point to the lateral philtral point on the non-cleft side, indicating the height of the
lip. Another vertical line is drawn in the midline from the mid-columella point to the
mid-philtral point at the lowest point of the Cupid’s bow. A horizontal line is drawn
from the cleft side lateral philtral point, bisecting the midline and philtral column
[30]. This is the length of the back-cut.
The dimensions from the medial element are used to design the triangular flap on
the lateral element. An arc is made from the alar base point, equal to the height of the
cleft side. Another arc is marked from the lateral philtral point to bisect the previous arc [30]. From this point, a third arc is marked, taking the length of the back cut
as a radius. A fourth arc is drawn from the previously marked point with the same
radius. These two arcs bisect to give the apex of the triangle. All points are tattooed.
Adrenaline is infiltrated along the proposed incision margins, under the mucoperiosteum of the lateral maxilla, and under the mucoperichondrium of the septum.
Incisions are made on the markings, keeping mucosa intact. Orbicularis oris is
freed from medial and lateral skin, mucosa, and vermillion. The cranial end of the
mucosal incision is extended to the buccal sulcus. The lateral and medial elements
are dissected off the maxilla sub- or supra-periosteally. The septoplasty is performed
by dislocating the cartilaginous septum from the maxillary crest. The anterior palate
is repaired using a vomer flap and lateral nasal mucosa. Excess lip skin is sometimes
used to provide a second layer of cover to the anterior palate. The lip is repaired in
three layers—orbicularis muscle, mucosa, and skin. Repair is extended to the nasal
floor. The dry roll and the red line should be matched appropriately [30].
Cleft Lip/Palate: Hidden Aspects beyond the Gap
DOI: http://dx.doi.org/10.5772/intechopen.115578
24
Figure 4.
Marking of Millard lip repair. From the proposed peak of Cupid’s bow on cleft side (point 3), incision is made to
base of columella, then extended to midpoint of philtrum, and then extended perpendicular to previous incision,
such that point 3 falls at equal height to point 2. That is why this technique is called as “cut as you go”.
... Millard repair
Landmark points are marked (Figure ). The lateral philtral point is marked as
the highest point of Cupid’s bow on the non-cleft side. The deepest point on Cupid’s
bow is marked. The corresponding lateral philtral point is marked on the cleft side
at the point. The mid-columella point is marked at the midpoint of the columella
base. The alar base and columella base are marked bilaterally. On the lateral lip
element, the lateral philtral point is marked at the point where the white line begins
to fade. Castroviejo caliper is used to measure the heights of the lip on the cleft and
non-cleft sides (The second part of Figure demonstrates a case with philtral height
of 10mm and 4mm on the non-cleft and cleft sides, respectively). This difference
gives a rough idea as to the amount of back cut required [16].
After adrenaline infiltration, the cleft edges are pared, and the frenulum is cut.
The rotation incision is started from the tattooed point of Cupid’s bow. The incision
ascends up to the base of the columella with a gentle convexity facing the cleft [16]. It
hugs the columella base for about two-thirds of its distance and ends with a back cut
made perpendicular to the incisions. This back cut should stop short of the non-cleft
Pediatric Surgical Procedures – An Updated Guide – Volume I
25
side philtral column. As shown in the second part of Figure , the incision at the base
of the columella is approximately 3mm, and the back cut is 3mm. These incisions
bring about adequate rotation. As in Randall-Tennison repair, all false attachments of
the orbicularis oris muscle are released. Septum correction, repair of anterior palate,
and closure in three layers are done, as described in Randall-Tennison repair.
Conventionally, the anterior palate is closed along with the lip [18]. Previously,
surgeons used an inferiorly based nasal septal and vomerine flap from the medial
aspect and the mucoperiosteum from the lateral shelf. This led to growth problems,
and these flaps were abandoned. Pichler and Sommerlad popularized the use of a
superiorly based vomer flap and sutured it to the mucoperiosteum of the cleft-side
palate to close the anterior palate in a single layer.
Correction of cleft lip nose deformity is accepted worldwide. McComb, Coghlan,
and Salyer et al. popularized the concept of addressing the nose deformity along with
cleft lip. Gradually, it was accepted worldwide, and now, it has become an integral
part of cleft lip repair in many centers (Figure ) [18, 19]. There are many variations
in practices among surgeons involved in cleft care [20]. A total of 43% of surgeons
do primary rhinoplasty at the age of 3–4months, along with cleft lip repair, whereas
33% wait for 6months. A total of 31.2% of surgeons believe in minimum dissection,
whereas for 62.7%, dissection varies according to the deformity; 89.7% of surgeons
feel primary correction reduces deformities; and 54.1% of surgeons feel one-fourth of
patients may require revision before 7years of age [20]. If the deformity is too much,
a preschool rhinoplasty (at the age of 4–5years) or intermediate rhinoplasty (at the
age of 9–12years) is advisable. According to Chang et al., the patients who underwent
a combination of nasoalveolar molding, primary rhinoplasty with over-correction
of the ala, and the use of nasal conformer for 6 months postoperatively, had the best
outcome [21].
Figure 5.
In primary rhinoplasty, via lip incision or marginal incision, the lower lateral cartilage of cleft side is freed from
overlying skin and fixed in a more superior, anterior and medial position via sutures, using either percutaneous
sutures or direct sutures.
Cleft Lip/Palate: Hidden Aspects beyond the Gap
DOI: http://dx.doi.org/10.5772/intechopen.115578
26
.. Hearing assessment and management
Regular otological examination and audiological surveillance using impedance tympanometry for hearing assessment are done. If required, ventilating tube
(grommet) are inserted. Grommets are inserted into the anteroinferior quadrant of
the tympanic membrane. These aerate the middle ear and prevent fluid collection,
thus, preventing chronic otitis media [22]. These tubes are spontaneously extruded
in 6–24months. Prophylactic insertion of a grommet is no longer recommended.
Indication of grommet is recurrent otitis media (more than three episodes in
6months) or audiological evidence of hearing loss greater than 55dB [23]. Aggressive
otological and audiological surveillance and timely intervention improve hearing and
speech outcomes in these children. Hearing aids are an excellent noninvasive option
for improving hearing with minor morbidity. They are used to manage mild effusion,
which is expected to resolve spontaneously in a few months [31, 32].
. to months
.. Palatoplasty
Hard palate repair techniques: Various techniques are utilized depending on the
extent of the cleft. If the cleft extends to the entire length of the palate and the cleft
is not too wide, von Langenbeck’s bipedicle flap technique is employed (
Figure ).
Bardach’s two-flap technique gives the best results if the entire palate length is cleft
Figure 6.
Von Langenbeck’s bipedicle flap palatoplasty.
Pediatric Surgical Procedures – An Updated Guide – Volume I
27
and the gap is wide. If the cleft is very wide and the palatal shelves very narrow, it
may be advantageous to do alveolar extension palatoplasty. For incomplete cleft of the
posterior palate, the Veau–Wardill–Kilner VY technique (Figure ) or the Dorrance
pushback technique offer good repair.
Soft palate repair techniques: In cases where the cleft extends only to the soft
palate and the hard palate is not involved, the focus is on repairing the fibers of
LVP, along with the closure of the nasal and oral mucosa. Furlow’s double opposing Z-plasty (Figure ), modified Furlow’s technique, primary closure of mucosa
with intravelar veloplasty, or Sommerlad’s radical muscle dissection techniques are
practiced.
In many countries, including ours, many patients do not return for palatoplasty
after the correction of a cleft lip due to various reasons. To tackle this social problem,
Agrawal et al. started practicing a protocol of repair of CP at 6 to 9months of age or
whenever the patient first presents to the clinician and repair of cleft lip 3 to 6months
after palatoplasty. Compliance with the second surgery (lip repair) improved significantly with this schedule. Also, when the functionally important palatoplasty is
done first, and the second surgery of cheiloplasty is delayed for any reason, it is not
a significant disadvantage to the child [33]. In children older than 3years of age, a
Figure 7.
Veau–Wardill–Kilner VY pushback palatoplasty.
Cleft Lip/Palate: Hidden Aspects beyond the Gap
DOI: http://dx.doi.org/10.5772/intechopen.115578
28
Figure 8.
Furlow palatoplasty.
“whole-in-one” procedure has been popularized by Charles Pinto, wherein lip and
palate repair are done in the same sitting [34].
. to years
.. Velopharyngeal dysfunction
Velopharyngeal sphincter closure is achieved by synchronous movement of the
posterior pharyngeal wall anteriorly, the lateral wall medially, and the soft palate
posteriorly [35]. A firm diagnosis of velopharyngeal dysfunction may not be possible
before the age of 3years because appropriate testing is complex in such young children. For most children, reliable testing can be performed when the child is between
3 and 5years of age. Once the diagnosis of velopharyngeal dysfunction has been
made, treatment may consist of nonsurgical speech therapy, corrective palate surgery,
reconstructive pharynx surgery, obturation with a speech bulb, or placement of a
palatal lift prosthesis [35]. Once the diagnosis is confirmed and it is ascertained that
the treatment will be surgical, the timing of intervention should be early to prevent
long-term speech difficulties and abnormal articulatory compensations that are difficult to correct later in life [11].
Pediatric Surgical Procedures – An Updated Guide – Volume I
29
Depending on the site and cause of pathology, the following surgical options are
available for managing velopharyngeal dysfunction. For repair/reinforcement of
LVP, following procedures may be done: Redo-intravelar veloplasty, Furlow’s double
opposing Z-plasty and radical muscle dissection palatoplasty. Palate lengthening is
achieved using a buccal myomucosal flap [36]. In rare cases, genu enhancement using
fat can suffice. If the velum is functioning well and the closure of the velopharyngeal
sphincter is inadequate in the anteroposterior axis, superiorly based pharyngeal flap
or augmentation pharyngoplasty can take care of the deficit in closure. Hynes or
sphincter pharyngoplasty are procedures to correct the closure of velopharyngeal
sphincter in transverse axis. Sometimes, there may be a need to combine multiple
procedures [37]. Tables and summarize the choice of procedure with the findings
on nasoendoscopy and video fluoroscopy, respectively.
. to years
.. Secondary alveolar bone grafting (SABG)
The alveolar cleft in complete CLP is addressed at the time of primary cleft lip repair
or secondarily. Nowadays, the practice of primary bone grafting (also called “boneless
bone grafting” or gingivoperiosteoplasty (GPP)) has been abandoned, as it was shown to
be associated with more scars, the need for SABG in a significant proportion of patients
and more pronounced maxillary hypoplasia [38, 39]. For doing GPP, the alveolar gap is
narrowed using presurgical orthopedic devices like the Latham’s device or nasoalveolar
molding. Gingioperiosteal flaps then bridge the alveolar gap. The gingivoperisteosteal
flaps induce the formation of bone. Hence, this procedure was dubbed “boneless bone
grafting”. This practice was pioneered by Skoog [40].
Closure pattern Choice of procedure
Coronal Furlow’s palatoplasty, redo palatoplasty, augmentation
Sagittal Pharyngeal flap, Furlow’s palatoplasty
Circular with or without Passavant’s
ridge
Table 2.
Decision of surgery based on closure pattern of velum on nasoendoscopy.
Length of soft palate Choice of procedure
Soft palate shorter by <20% Furlow’s palatoplasty
Soft palate shorter by >20% Furlow’s palatoplasty
Length is adequate, but uvula knee is forming anteriorly or
the range of motion is inadequate
Table 3.
Decision of surgery based on video fluoroscopic findings.
pharyngoplasty
Muscle redo/Furlow, sphincter pharyngoplasty
Pharyngoplasty alone
Lengthening with buccal myomucosal flaps
Furlow’s with pharyngoplasty
Redo intravelar veloplasty Furlow’s palatoplasty
Cleft Lip/Palate: Hidden Aspects beyond the Gap
DOI: http://dx.doi.org/10.5772/intechopen.115578
30
SABG is practiced at all centers these days. SABG is preceded by orthodontic treatment, during which the arches are aligned, and the teeth are derotated and erupted
uniformly. Just before the permanent canine appears to erupt, SABG is performed.
This allows the canine to erupt through the bone graft. This increases the likelihood
of a parallel root positioning, with more excellent stability of the canine [30, 41, 42].
This also lessens the possibility of graft resorption. PostSABG, orthodontic treatment
aids in “retention” of the result, as other than the alveolus, the rest of the cleft area
is covered only with soft tissue. The disrupted maxilla is more prone to relapse in the
initial days, and thus, orthodontic treatment is crucial after SABG.
In those children who present later after eruption of canine in the cleft or whose
canine is affected with caries, tooth extraction is advised. After that, SABG is done
with tooth implant placement. The long-term success of the tooth implant is good,
and the implant acts as a functional stimulus to maintain the bone. However, a significant number of the implants require tertiary grafting [43].
. Mid-adolescence to early adulthood
.. Maxillary advancement
Completion of maxillary development happens around 17years in females and at
about 18years in males. This can be determined by identifying the carpal sesamoid
(pisiform) bone in hand and wrist radiographs or by studying the lower border, height,
and shape of the cervical vertebral body [16, 43, 44]. Midface hypoplasia has been
reported by several authors to occur between 25 and 70% of all cleft patients, with an
estimated 25 to 48% needing surgical treatment for skeletal correction [45, 46].
Some patients with mild midface hypoplasia, mild malocclusion, and good cosmesis can be offered orthodontic camouflage. Maxillary advancement procedures with
preoperative and postoperative orthodontic treatment are necessary for the rest of the
patients. The mainstay of surgical options in cleft midface hypoplasia is the advancement of the maxilla by Le Fort I osteotomy and rigid fixation using plates and screws
[45]. Low Le Fort I level osteotomy about 4 to 5 millimeters above the floor of the
pyriform aperture results in a harmonious facial profile in most cases [45]. A maximum advancement of 7 to 8mm is possible in one go. Beyond this, the bone-to-bone
contact is not enough for bony union. The use of bone grafts can allow advancement
of about 2 millimeters more [46]. Too little contact between the bony segments leads
to healing by the fibrous union (instead of the bony union), which has poor stability
and may lead to mobile tooth-bearing segments.
The advancement of maxillary bone stretches the soft tissues. The soft tissues
around the maxilla are scarred to varying degrees, having undergone many surgical
procedures in the lifetime of the cleft patient. The scarred and stretched soft tissues
cause a relapse of malocclusion in these patients. Therefore, maxillary advancement
of more than 8–10 millimeters is always accompanied by a distractor device application, which works on the principle of “distraction histogenesis.” Distraction histogenesis is a slow process, taking weeks to months. The patient has to retain the bulky
device for that long.
Another strategy is to combine maxillary advancement with mandibular setback.
This distributes the required correction between the upper and lower jaws. Thus,
each bone’s mobilization is reduced while better stability of the osteotomized fragments is ensured. Several authors have reported that bimaxillary surgery gives overall
better esthetic and functional results and stability than maxillary advancement or
Соседние файлы в папке Библиотека им академика М.И. Перельмана