A new principle for unilateral complete cleft lip repair, the lateral columellar flap method

This article presents a different method for unilateral complete cleft lip repair. The tissue deficiency of the medial lip segment is filled with a flap from the lateral surface of the columella, which is in continuity with the lip segment. The lateral columellar flap and the medial lip segment are lowered in one piece vertically downward to such a position that the height of the arch of the Cupid's bow is equal on both sides. No lateral advancement is done. The suture line of the medial and lateral lip segments is an uninterrupted straight line, which imitates the natural line of the philtral column. The repaired lip has more fullness than the lips repaired with the conventional methods. The procedure is described in detail.     

Alveolar bone grafting in unilateral complete cleft lip and palate patients

Autogenous bone graft of an alveolar cleft area has the following advantages: (1) assistance in the closure of buccoalveolar oronasal fistula; (2) provision of bony support for unerupted teeth and teeth adjacent to the cleft; (3) formation of a continuous alveolar ridge to facilitate orthodontic correction of malocclusion; (4) supporting the nostril floor and alar base to improve nasal aesthetics. It has been well accepted in most craniofacial centers as routine procedure in cleft lip and palate rehabilitation. A new surgical technique for alveolar bone grafting has been introduced to the Chang Gung Craniofacial Center since July 1991. It provided a good exposure of the alveolar cleft, primary closure of the fistula and adequate volume of bone graft. A review of 27 consecutive alveolar bone grafting procedures performed in unilateral cleft lip and palate patients from July 1991 to June 1992 was presented. Patients have been followed up for at least 6 months. The alveolar bone graft was evaluated clinically and radiologically at one week, six months and one year after the surgery. The preliminary results indicated that the new surgical technique produced less chance of recurrent fistula, good postoperative gingival height, and improvement of nasal aesthetics. Based on the results of this new study we strongly advocate the use of this new surgical technique.     

Sagittal craniofacial morphology in repaired unilateral and bilateral complete cleft lip and palate cases

Using guidelines, students independently complete a written preparation for class assignment to develop a knowledge base needed for active participation in one or more class activities. The authors present a two-part method that is key to developing critical-thinking skills, using case studies.     

Effects of primary bone grafting on facial development in patients with unilateral complete cleft lip and palate

The study is based on an anthropometric assessment of X-ray films obtained in 22 adult males with complete unilateral cleft lip and palate treated during childhood with primary bone grafts and in 32 males with the same type of cleft without bone grafting. In the series with bone grafts was recorded a more marked reduction of maxillary depth associated with a larger retrusion than in the series without bone grafts. This deviation was therapeutically compensated by a larger displacement of the mandible backwards which contributes to the increase of mandibular posterior rotation. This provided the possibility to attain an edge to edge bite. Our results confirmed the unfavourable effects of primary bone grafting on maxillary growth and development.     

The importance of accurate repair of the orbicularis oris muscle in the correction of unilateral cleft lip

Most of the attempts and efforts in cleft lip repair have been directed toward the skin incision. The importance of the orbicularis oris muscle repair has been emphasized in recent years. The well-designed skin incision with simple repair of the orbicularis oris muscle has produced a considerable improvement in the appearance of the upper lip; however, the repaired upper lip seems to change its shape abnormally in motion and has a tendency to be distorted with age if the orbicularis oris muscle is not repaired precisely and accurately. Following the dissection of the normal upper lip and unilateral cleft lip in cadavers, we could find two different components in the orbicularis oris muscle, a superficial and a deep component. One is a retractor and the other is a constrictor of the lip. They have antagonistic actions to each other during lip movement. We also can identify these two different components of the muscle in the cleft lip patient during operation. We thought inaccurate and mixed connection between these two different functional components could make the repaired lip distorted and unbalanced, which would get worse during growth. By identification and separate repair of the two different muscular components of the orbicularis oris muscle (i.e., repair of the superficial and deep components on the lateral side with the corresponding components on the medial side), better results in the dynamic and three-dimensional configuration of the upper lip can be achieved, and unfavorable distortion can be avoided as the patients grow.(ABSTRACT TRUNCATED AT 250 WORDS)     

Analyses of craniofacial and dental morphology in monozygotic twins discordant for cleft lip and unilateral cleft lip and palate

AIMS: To compare the efficiency of flow cytometry and computed image cytometry; and to see if a reliable set of guidelines regarding interpretation of histograms could be drawn up. METHODS: The two methods were applied to a series of 111 formalin fixed renal cell carcinomas. Data generated by both methods were compared. RESULTS: The methods agreed in 85 cases. Hypodiploidy was detected by computed image cytometry in seven cases in which flow cytometry had shown only an aneuploid peak. Aneuploidy in seven in which the corresponding flow cytometry histogram was diploid. There was an overlap in the second peak proportions on flow cytometry histograms between those classed as diploid or tetraploid by computed image cytometry. In six cases the flow cytometry histograms had unacceptably high coefficients of variation and in all of these cases computed image cytometry demonstrated aneuploidy. CONCLUSIONS: Computed image cytometry is particularly useful for clarifying difficult areas in flow histograms--specifically, high coefficients of variation, high G2M phase, as well as possible near diploid aneuploidy and hypodiploidy.     

Mitochondrial activity of orbicularis oris muscle in unilateral cleft lip patients

To better evaluate the role of a possible mitochondrial alteration in the pathogenesis of cleft lip, we obtained and examined 38 orbicularis oris muscle specimens taken from the cleft margin of both cleft and noncleft sides of 10 unilateral cleft lip infants at the time of primary closure. Part of each sample was frozen in liquid nitrogen/cooled isopentane, while the remainder was fixed in 2.5% glutaraldehyde, postfixed in osmium tetroxide, and embedded in Araldyte resin. Ten-micrometer-thick sections were obtained from the frozen samples and stained for histologic (Gomori trichrome) and histochemical (adenosine triphosphatase, nicotinamide adenine dinucleotide-tetrazolium reductase, cytochrome c-oxidase, succinate dehydrogenase) techniques. Ultra-thin sections (70 to 100 nm) of the resin-embedded specimens were stained with uranyl acetate and lead cytrate and were examined with a Zeiss 109 transmission electron microscope operating at 80 kV. Muscular fiber-type ratio was found to be 19.2 percent type 1 and 80.8 percent type 2 fibers on the cleft side and 26.3 percent type 1 and 73.7 percent type 2 fibers on the noncleft side. We detected aspecific structural alterations, such as variations in the fiber size without fiber group atrophy or fiber-type grouping with the ATPase reaction, in all biopsies. Although Gomori trichrome revealed a dark staining and red granularity of the fibers, suggesting an increase in mitochondria activity, no ragged-red fibers or cytochrome c-oxidase-negative/succinate dehydrogenase-positive fibers were found. At the ultrastructural level, the mitochondrial morphology was always preserved, without inclusions or variations in size and/or shape. On the other hand, we invariably noticed an increase of the number of mitochondria, associated with abnormal glycogen deposits, in some areas of every specimen. Both of these two latter findings were regularly localized at the periphery of the sarcolemma, resembling the so-called lobulated fibers, an aspecific sign of muscular flogosis. Our findings, although excluding an inherent metabolic myopathy of orbicularis oris muscle in unilateral cleft lip patients, evinced both an increased oxidative metabolism and a generic inflammatory condition of that muscle, the nature of which must still be defined.     

Repair of unilateral cleft lip: a comparison of five techniques

Repair of unilateral cleft lip is a challenging procedure with no single technique satisfactory for all types of unilateral cleft deformity. This study compares retrospectively five techniques of unilateral cleft lip repair in 72 children (45 boys, 27 girls). Twenty-two children had a Millard rotation-advancement repair, 5 children had a Davies Z-plasty, 22 had a modified Z-plasty, 10 had a Tennison-Randall triangular flap repair, and 13 had a Nakajima-Yoshimura straight-line repair. Assessment was performed clinically by a plastic surgeon not involved in the original surgery. Repairs were assessed objectively by measurement of the vertical length of both the repaired and normal sides of the lip with calipers. Subjective criteria used to evaluate the repair were the symmetry of Cupid's bow, the quality of scar, the alignment of white roll, the evenness of the vermilion, and the lip pout. The mean follow-up period was 5.4 years (range, 9 months-29 years). Sixty-five of the 72 repairs measured (90%) were within two standard deviations (SDs) of normal and thus were considered to be of "acceptable" length. Seven repairs were unacceptably short (>2 SDs) on measurement, six of which included a rotation-advancement repair for a complete cleft lip. Subjective results paralleled the objective results. The outcome following repair of unilateral cleft lip was similar for all five surgical methods assessed except for complete cleft lips repaired by the rotation-advancement technique, which tended to result in an unacceptably short lip as measured on the repaired side.     

Correction of unilateral cleft lip nasal deformity with modified Bardach''s technique

Measurements were made of the intake of a WHO/UNICEF glucose-based and a rice cereal-based oral rehydration solution (ORS) by children with diarrhoea. Twenty children who presented to the Children's Outpatient Department at Port Moresby General Hospital with acute diarrhoea and mild dehydration were randomly assigned to an ORS and measurements were taken over the following 3 hours. For data analysis, the patients were paired by weight. Testing the means of the paired samples by t test showed that there was no significant difference between the amount of rice ORS and the amount of glucose ORS taken over 3 hours.     

Speech outcome and maxillary growth in patients with unilateral complete cleft lip/palate operated on at 6 versus 12 months of age

A prospective study of speech outcome and maxillofacial growth was carried out in cleft palate patients. Seventy-six cleft palate patients were randomly selected for the study group; 41 patients were operated on at 12 months of age, and 35 patients were operated on at 6 months of age. All patients were followed until they were 4 years of age. All patients underwent a complete speech evaluation, videonasopharyngoscopy, videofluoroscopy, and maxillofacial assessment. The rate of velopharyngeal insufficiency did not differ between the two groups (17 to 19 percent; p > 0.05). However, phonologic development was significantly better (p < 0.05) in the patients operated on at 6 months of age. Furthermore, none of the patients operated on at 6 months of age showed compensatory articulation disorder. In contrast, 62 percent of the patients with postoperative velopharyngeal insufficiency operated on at 12 months of age showed compensatory articulation disorder (p < 0.05). Maxillofacial assessment showed that there were non-significant differences (p > 0.05) in maxillofacial growth in both groups of patients. All patients showed similar degrees of maxillary collapse (p > 0.05). The results of this study suggest that cleft palate repair performed at 6 months of age significantly enhances speech outcome and prevents compensatory articulation disorder.     

Prevalence of malocclusion in the primary and early mixed dentition in a group of Egyptian children with complete unilateral cleft lip and palate

This study was carried out to investigate the prevalence of malocclusion in the primary and early mixed dentition for a group of Egyptian children with complete unilateral cleft lip and palate following surgical rep. air of the anomaly. The material consisted of 35 children (20 males and 15 females) with complete unilateral cleft lip and palate aged 3 to 7 years who were compared with 60 non-cleft Egyptian children (37 males and 23 female) of the same age.     

Changes of craniofacial growth and development in males with complete unilateral cleft lip and palate between the age of 5 to 20 years

The study is based on an anthropometric assessment of X-ray films obtained in two series of males with complete unilateral cleft lip and palate. The first series was examined at the age of 5, 10 and 15 years, the second series at 15 and 20 years. The films were assessed with Jarabak's analysis. The aim of our study was to compare the amount of growth and character of developmental changes in the prepubertal, pubertal and postpubertal period of life. The highest growth rate of skeletal structures was present in the prepubertal period, it was somewhat slighter in the pubertal period and it still continued in the postpubertal period. The high growth rate in the prepubertal period was probably related to the eruption of permanent teeth. In spite of a marked deterioration of sagittal jaw relations during the prepubertal period an improvement of an overjet was attained. However during the puberty and the postpubertal period a further improvement was not recorded. The results are in agreement with facial type of growth characterized by a slight pubertal spurt.     

Craniofacial morphology in adult patients with unoperated complete bilateral cleft lip and palate

With recent advances in DNA technology, questions have arisen as to how this technology should be appropriately used. In this article, results obtained from a survey designed to elicit attitudes of college students to prenatal testing and gene therapy for human attributes and psychiatric conditions are reported. The eleven hypothetical disease phenotypes included schizophrenia, alcoholism, tendency toward violent behavior, attention deficit/hyperactivity disorder, depression requiring medical treatment, obesity, involvement in "dangerous" sports activities, homosexuality, borderline normal IQ (80-100), proportional short stature, and inability to detect perfect pitch. Most students supported prenatal genetic testing for psychiatric disorders and behavior that might result in harm to others (i.e., tendency towards violent behavior) and found prenatal genetic testing for human attributes less desirable. However, the lack of unilateral agreement or disagreement toward any one condition or attribute suggests the potential difficulties ahead in the quest for guidelines for the application of new technologies available to manipulate the human genome.     

Modified bilateral cleft lip repair with orbicularis reconstruction and prolabial self-elongation

PURPOSE: This article describes the details of a modified method for bilateral cleft lip repair and presents some examples of patients whose condition was repaired by this technique. PATIENTS AND METHODS: Sixty-five patients ranging in age from 2 to 5 years were treated with this modified procedure. The method was characterized by prolabial lengthening and reconstruction of the orbicularis oris muscle in one stage. RESULTS: Satisfactory results were achieved with this method. The Cupid's bow and the central tubercle appeared more natural. None of the patients developed dehiscence of the wound. CONCLUSIONS: This modified procedure is of special value for complete bilateral cleft lip patients with a short prolabium. The long-term effect of muscle reconstruction on maxillary growth remains to be evaluated.     

Effects of presurgical orthopedic treatment in infants with complete bilateral cleft lip and palate

Recently, it has been demonstrated that the endothelium of corpus cavernosum (CC) plays an important role on smooth muscle relaxation, which is crucial to initiate and maintain erection. We investigated the effect of long-lasting additional testosterone propionate (TP) therapy on endothelium-dependent and -independent relaxations of isolated rabbit CC. Isolated CC strips were mounted in organ baths and isometric tension was recorded. Addition of a specific inhibitor of nitric oxide synthesis, NG-nitro-L-arginin methyl ester (L-NAME), into the organ bath had no effect on the relaxation responses to adenosine (ADO), adenosine 5'-triphosphate (ATP) and sodium nitroprusside (SNP) in isolated CC strips precontracted with phenylepherine, but completely inhibited relaxation responses produced by ADP. Adenosine and adenine nucleotides relaxed the phenylepherine-induced contractile response in control strips with the potency order: ADO (62.8 +/- 3.2%) > ATP (37.1 +/- 5.2%) > ADP (25.8 +/- 2.5%). The relaxation responses to ADO, ATP and SNP in isolated rabbit CC strips were not significantly altered by additional TP therapy. The relaxation responses produced by ADP were significantly enhanced following 1 and 2 months TP therapy as compared with controls. However, in the group treated with TP for 2 months followed by a 2 months drug-free period, relaxation responses were significantly reduced compared to 1 and 2 months treatment groups, and approached control values. Increased relaxation responses to ADP following 1 and 2 months additional TP therapy may be a result of increased endothelial purinergic receptor density, or it may be due to stimulation and/or release of endothelial nitric oxide (NO) by TP.     

Nomogram for assessment of restoration of a positive overjet in unilateral cleft lip and palate

In 92 patients with unilateral cleft lip and palate investigated on a long-term basis correlation-regression analysis of the development of overjet according to the development of interalveolar relations assessed in a defined method from X-ray films at the ages of 5, 10, 15 years and in adult age was implemented. The limits comprising 95% of the assembled data were also defined. Based on this analysis a formerly elaborated nomogram for age 10-15 years was extended for the whole postnatal period. Nomogram makes it possible to estimate from a single X-ray cephalometric parameter the risk of failure of the restoration of a positive overjet according to the age of the patient. The system defines critical boundaries which must be achieved for safe restoration of a positive overjet and makes it possible to check the course of treatment. The simple work with the nomogram and readily obtainable baseline data (age and X-ray cephalometric parameter on the interalveolar relations) make its application in clinical practice possible. It can serve as part of the documentation of the patient's therapy.     

Fetal unilateral cleft lip and palate: detection of enzymic anomalies in the amniotic fluid

BACKGROUND: Tracheal intubation frequently results in an increase in respiratory system resistance that can be reversed by inhaled bronchodilators. The authors hypothesized that insertion of a laryngeal mask airway would be less likely to result in reversible bronchoconstriction than would insertion of an endotracheal tube. METHODS: Fifty-two (45 men, 7 women) patients were randomized to receive a 7.5-mm (women) or 8-mm (men) endotracheal tube or a No. 4 (women) or No. 5 (men) laryngeal mask airway. Anesthesia was induced with 2 microg/kg fentanyl and 5 mg/kg thiopental, and airway placement was facilitated with 1 mg/kg succinylcholine. When a seal to more than 20 cm water was verified, respiratory system resistance was measured immediately after airway placement. Inhalation anesthesia was begun with isoflurane to achieve an end-tidal concentration of 1% for 10 min. Respiratory system resistance was measured again during identical conditions. RESULTS: Among patients receiving laryngeal mask airways, the initial respiratory system resistance was significantly less than among patients with endotracheal tubes (9.2+/-3.3 cm water x 1(-1) x s(-1) [mean +/- SD] compared with 13.4+/-9.6 cm water x 1(-1) x s(-1); P < 0.05). After 10 min of isoflurane, the resistance decreased to 8.6+/-3.6 cm water x 1(-1) x s(-1) in the endotracheal tube group but remained unchanged at 9.1+/-3.3 cm water x 1(-1) x s(-1) in the laryngeal mask airway group. The decrease in respiratory system resistance in the endotracheal tube group of 4.7+/-7 cm water x 1(-1) x s(-1) was highly significant compared with the lack of change in the laryngeal mask airway group (P < 0.01). CONCLUSIONS: Resistance decreased rapidly only in patients with endotracheal tubes after they received isoflurane, a potent bronchodilator, suggesting that reversible bronchoconstriction was present in patients with endotracheal tubes but not in those with laryngeal mask airways. A laryngeal mask airway is a better choice of airway to minimize airway reaction.