After informed consent was obtained the patient was brought to the operating room and placed in the supine position. The correct patient and procedure were identified and a Time Out was performed. After induction of general anesthesia, patient was intubated transnasally from right nostril. The table was turned to 90 degree and head was extended. 2% xylocaine with 1:100,00 epinephrine was injected over the left side of the maxillary gingivolabial sulcus.
Patient was prepped and draped in usual fashion.
Approximately 3 cm long incision was made along the mucogingival junction on the left side preserving the gingiva at the dental margin. This went from just to the right of the central incisor and over to the left molar. Supraperiosteal dissection was performed till the desired vestibular depth using predominantly a 15 blade. The periosteum was intentionally incised towards the height of the sulcus to promote attachment of the mucosa and maintain a deep sulcus with healing.
In the process of obtaining adequate release towards the intended sulcus depth, a connection to the nasal cavity was noted where the fistula was previously repaired. Tissue manipulation was done around the left nasal fistulous tract to allow for closure and it was then sutured with 5-0 vicryl in intermittent fashion.
Leak test performed showed no leak. Another suture in figure 8 fashion was then also applied over the closure to ensure no leak.
The free cut mucosal edge of the lip tissue was then sutured to the depth of the vestibular sulcus using interrupted 4-0 monocryl sutures. The remaining raw periosteal surface was covered with a 2×2 cm piece of Neox 1K membrane and was secured with intermittent sutures with 4-0 monocryl. Hemostasis was great throughout requiring very little cautery..
A periopak was created that was also mixed with doxycycline powder and applied over the surgical site. Mouth was closed to reshape the Coepack dressing to remove excess material and to prevent chipping off while eating.
Having tolerated the procedure well the patient was turned back over to anesthesia, awakened and transferred to the recovery room in stable condition.
32-month-old male with Coffin Siris syndrome, bilateral middle ear effusions, and velopharyngeal insufficiency who presents with a submucous cleft palate.
This video presents a case of a large hard palate fistula, which was repaired with an anterior tongue flap. The details of the procedure are described and demonstrated in detail, including both stages of the reconstruction, which were timed 3-4 weeks apart.
The most common of the rare craniofacial clefts, Tessier’s No. 7 cleft is represented by a deficiency of tissue that may span from the oral commissure to the ear. (1) The repair of the cleft of the lip must include especial attention to restoring continuity of the orbicularis oris muscle as well the vermillion. This case is presented as an example of the repair of the Tessier 7 cleft lip deformity.
DOI #: http://dx.doi.org/10.17797/4h2edlts5zz
Contributors: Larry Hartzell
Repair of the bilateral cleft lip deformity can be challenging to the cleft and craniofacial surgeon. The goals of an acceptable repair must include precise continuity of the cupid’s bow, maximizing philtral length, and establishing a mucosa lined sulcus. We present an example of a repair of the bilateral incomplete lip as described by Millard.
DOI: http://dx.doi.org/10.17797/qefi9lqbam
Introduction
Patients with Pierre-Robin Sequence (PRS) suffer from micrognathia, glossoptosis, and upper airway obstruction, which is sometimes associated with cleft palate and feeding issues. To overcome these symptoms in our full-term male neonate patient with PRS, mandibular distraction osteogenesis was performed.
Methods
The patient was intubated after airway endoscopy. A submandibular incision was carried down to the mandible. A distractor was modified to fit the osteotomy site that we marked, and its pin was pulled through an infrauricular incision. Screws secured the plates and the osteotomy was performed. The mandible was distracted 1.8 mm daily for twelve days.
Results
During distraction, the patient worked with speech therapy. Eventually, he adequately fed orally. He showed no further glossoptosis or obstruction after distraction was completed.
Conclusion
In our experience, mandibular distraction is a successful way to avoid a surgical airway and promote oral feeding in children with PRS and obstructive symptoms.
By: Ravi W Sun, BE
Surgeons:
Megan M Gaffey, MD
Adam B Johnson, MD, PhD
Larry D Hartzell, MD
Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
Arkansas Children’s Hospital, Little Rock, AR, USA
Recruited by: Gresham T Richter, MD
The following video demonstrates the author’s method for repairing wide unilateral complete cleft lip and cleft nasal deformities. Details of surgical markings as well as nuances of technique are demonstrated. Video documentation of immediate results as well as progress of healing over the following year are included.
This video outlines the steps taken for pre-operative markings that need to be made prior to performing unilateral cleft lip repair using the Fisher anatomic subunit approximation technique. The technique has been written about in detail by Dr. David Fisher in his article “Unilateral Cleft Lip Repair: An Anatomical Subunit Approximation Technique”. This video simply outlines the markings that are made prior to performing this technique, which are crucial for correctly carrying out the repair.
