Anna Elander

Analysis of Dental Arch Relationships in Swedish Unilateral Cleft Lip and Palate Subjects: 20-Year Longitudinal Consecutive Series Treated With Delayed Hard Palate Closure

Objective: To evaluate the dental arch relationships for a consecutive series from Goteborg, Sweden, who had delayed hard palate closure. Design: Retrospective study. Setting: Sahlgrenska University Hospital, Goteborg, Sweden. Patients: The dental study models of 104 consecutive unilateral cleft lip and palate subjects. The study cohort was born between 1979 and 1994. Longitudinal records were available at ages 5 (n = 94), 10 (n = 97), 16 (n = 59), and 19 years (n = 46). Five assessors rated models according to the GOSLON Yardstick on two separate occasions each. Interventions: These patients had been operated upon according to the Goteborg protocol of delayed hard palate closure (at age 8 years). Results: 85% of subjects were rated in groups 1 and 2 (excellent or very good outcome), 12% were rated in group 3 (satisfactory), and 3% were assigned to group 4 (poor). No patients presented in Group 5 (very poor). Weighted kappa statistics for double determination of Yardstick allocation for five assessors demonstrated values between .65 and .90 for interrater agreement (good/very good) and between .70 and .90 for intrarater agreement (very good). Conclusions: Delayed hard palate closure as practiced in Goteborg since 1979 has produced the best GOSLON Yardstick ratings in a consecutive series of patients ever recorded worldwide, since the Yardstick was first used in 1983. However, it is noteworthy that a new protocol has been introduced in Goteborg since 1994, in which hard palate closure is done at 3 years due to concerns regarding speech.

Speech Outcomes in Isolated Cleft Palate: Impact of Cleft Extent and Additional Malformations

OBJECTIVE The purpose of the study was to study the speech outcome in a series of 5-year-old children born with an isolated cleft palate and compare the speech with that of noncleft children and to study the impact of cleft extent and additional malformation on the speech outcome. DESIGN A cross-sectional retrospective study. SETTING A university hospital serving a population of 1.5 million inhabitants. SUBJECTS Fifty-one patients with an isolated cleft palate; 22 of these had additional malformations. Thirteen noncleft children served as a reference group. INTERVENTIONS A primary soft palate repair at a mean of 8 months of age and a hard palate closure at a mean age of 4 years and 2 months if the cleft extended into the hard palate. MAIN OUTCOME MEASURES Perceptual judgment of seven speech variables assessed on a five-point scale by three experienced speech pathologists. RESULTS The cleft palate group had significantly higher frequency of speech symptoms related to velopharyngeal function than the reference group. There were, however, no significant differences in speech outcome between the subgroup with a nonsyndromic cleft and the reference group. Cleft extent had a significant impact on the variable retracted oral articulation while the presence of additional malformations had a significant impact on several variables related to velopharyngeal function and articulation errors. CONCLUSION Children with a cleft in the soft palate only, with no additional malformations, had satisfactory speech, while children with a cleft palate accompanied by additional malformations or as a part of a syndrome should be considered to be at risk for speech problems.

Combined Bone Grafting and Delayed Closure of the Hard Palate in Patients with Unilateral Cleft Lip and Palate: Facilitation of Lateral Incisor Eruption and Evaluation of Indicators for Timing of the Procedure

OBJECTIVE To compare outcomes of bone grafting performed before eruption of the lateral incisor to outcomes of grafting performed before eruption of the canine and to evaluate the long-term results of bone grafting combined with delayed closure of the hard palate during mixed dentition. DESIGN Seventy consecutive patients (52 men and 18 women) with complete unilateral cleft lip and palate were studied. All patients underwent bone grafting with simultaneous closure of the cleft in the hard palate at the stage of mixed dentition. The velum had been repaired in infancy. Mean age for the bone grafting procedure was 8.4 years. Bone grafting was performed to facilitate eruption of the lateral incisor in 43 (61%) of the patients and to facilitate eruption of the canine in the remaining 27 (39%) patients. Intraoral radiographs were used to evaluate the morphologic characteristics of the cleft and the stage of eruption of the permanent lateral incisor and canine before bone grafting. Mean follow-up time was 4.0 years (range, 1-10.1 years). RESULTS The mean time for the surgery, which included bone grafting and repair of the residual cleft in the hard palate, was 109 minutes, and the mean amount of bleeding was 121 ml. The rate of dehiscence in the flap covering the alveolar bone graft was 14%, and the rate of total failure of bone grafting was 3%. An oronasal fistula developed in the hard palate of 13% of patients, but the fistula was of sufficient size to serve as an indication for reoperation in only 6%. The postoperative alveolar bony height in the cleft area was more than 75% of the normal height in 94% of patients. Closure of the cleft space in the dental arch was performed or planned to be achieved orthodontically in 91% of patients. When bone grafting was performed to facilitate eruption of the lateral incisor, the cleft space was closed orthodontically in 100% of patients. The optimal indicator for timing of the bone grafting procedure from an orthodontic point of view was when the permanent lateral incisor or the canine close to the cleft was covered by a thin shell of bone (i.e., 7-9 years of age).

Speech development in patients with unilateral cleft lip and palate treated with different delays in closure of the hard palate after early velar repair: a longitudinal perspective.

We wanted to find out if different timing of delayed repair of the hard palate in a two-stage procedure had an impact on the speech of 26 patients with unilateral cleft lip and palate (UCLP). The soft palate was closed at the age of 7 months and the hard palate between 38 and 89 months of age. Speech audio recordings at the age of 3 years (baseline, before any repair of the hard palate) and at the ages of 5, 7, and 10 years (the latter obtained at least one year after closure) were analysed. We used standardised speech assessments at routine follow-up and assessment by one external listener. The prevalence of speech errors caused by the cleft was similar to those described in previous reports from our centre in which hard palate repair was delayed. Unexpectedly, the results showed no difference in speech production related to timing of hard palate repair, except for nasal air leakage at the age of 7 years.

The 2011 WPATH Standards of Care and Penile Reconstruction in Female-to-Male Transsexual Individuals

The World Professional Association for Transgender Health (WPATH) currently publishes the Standards of Care (SOC), to provide clinical guidelines for health care of transsexual, transgender and gender non-conforming persons in order to maximize health and well-being by revealing gender dysphoria. An updated version (7th version, 2011) of the WPATH SOC is currently available. Differences between the 6th and the 7th versions of the SOC are shown; the SOC relevant to penile reconstruction in female-to-male (FtM) persons are emphasized, and we analyze how the 2011 WPATH SOC is influencing the daily practice of physicians involved in performing a penile reconstruction procedure for these patients. Depending by an individuals goals and expectations, the most appropriate surgical technique should be performed: the clinic performing penile reconstruction should be able to offer the whole range of techniques, such as: metoidioplasty, pedicle and free flaps phalloplasty procedures. The goals that physicians and health care institutions should achieve in the next years, in order to improve the care of female-to-male persons, consist in: informing in details the individuals applying for penile reconstruction about all the implications; referring specific individuals to centers capable to deliver a particular surgical technique; implementing the surgery with the most updated refinements.

Penile reconstruction/formation.

Purpose of review To evaluate current reviews and assess scientific validity of the recent literature on penile reconstruction after trauma, penile reconstruction in gender reassignment surgery, concealed penis, and aphallia. Recent findings Technical advances in penile reconstruction have been highlighted. The few long-term follow-up studies available confirm the difficulty of such surgery, in terms of complications and the limits of the final achievable outcomes. The surgery necessitates several steps and a high number of revisions. Scientific progress in penile reconstruction seems slow, with a lack of controlled studies, high rate of loss to follow-up (especially in sex reassignment surgery) and a lack of validated assessment measures. However, a few recent studies are making the problems clearer, especially in patient selection and the avoidance of raising false expectations in patients.

TIBIA AS DONOR SITE FOR ALVEOLAR BONE GRAFTING IN PATIENTS WITH CLEFT LIP AND PALATE: LONG TERM EXPERIENCE

Tibial bone grafts were studied in 137 patients with clefts of the lip and palate. Twenty-one had clefts of the lip and primary palate and 116 had complete unilateral clefts of the lip and palate. Bone grafting was performed secondarily or late secondarily. Bone was harvested from the proximal part of the tibia distal to the tuberosity through an incision about 15 mm long. The mean follow-up time after bone grafting was 5.5 years (range 2-11). There were no operative, or early or late postoperative complications reported (such as haematoma, fracture, or shortening of the limb). Harvesting time was about 15 minutes. The possibility of operating with two teams makes the total operating time shorter. Bleeding was negligible (less than 15 ml) and the amount of bone obtained was always sufficient. Patients were mobilised the next day and were back to full physical activity by one month. Indications for tibial bone grafting included facilitation of tooth eruption into the graft, giving bony support to the neighbouring teeth, making it possible to insert a titanium fixture, raising the alar base of the nose, and closing an oronasal fistula. Compared with iliac, cranial, mandibular, and costal donor sites, using the tibia took less time, gave less bleeding, made it possible for two teams to operate simultaneously, gave a smaller scar, and there were minimal complications and satisfactory quantity and quality of bone in all cases. The results suggested that the tibia is an excellent choice of graft for residual alveolar clefts in patients with cleft lip and palate.Tibial bone grafts were studied in 137 patients with clefts of the lip and palate. Twenty-one had clefts of the lip and primary palate and 116 had complete unilateral clefts of the lip and palate. Bone grafting was performed secondarily or late secondarily. Bone was harvested from the proximal part of the tibia distal to the tuberosity through an incision about 15 mm long. The mean follow-up time after bone grafting was 5.5 years (range 2-11). There were no operative, or early or late postoperative complications reported (such as haematoma, fracture, or shortening of the limb). Harvesting time was about 15 minutes. The possibility of operating with two teams makes the total operating time shorter. Bleeding was negligible (less than 15 ml) and the amount of bone obtained was always sufficient. Patients were mobilised the next day and were back to full physical activity by one month. Indications for tibial bone grafting included facilitation of tooth eruption into the graft, giving bony support to the neighbouring teeth, making it possible to insert a titanium fixture, raising the alar base of the nose, and closing an oronasal fistula. Compared with iliac, cranial, mandibular, and costal donor sites, using the tibia took less time, gave less bleeding, made it possible for two teams to operate simultaneously, gave a smaller scar, and there were minimal complications and satisfactory quantity and quality of bone in all cases. The results suggested that the tibia is an excellent choice of graft for residual alveolar clefts in patients with cleft lip and palate.

Speech in Children With an Isolated Cleft Palate: A Longitudinal Perspective

Objective To describe articulation and speech symptoms related to velopharyngeal impairment in children born with an isolated cleft palate. Design Blind assessment of speech at 3, 5, 7, and 10 years of age was performed. Two subgroups were formed based on the results at age 5 years, the no-VPI group and the VPI group, and they were compared with controls. Setting A university hospital. Patients Twenty-six children born with isolated cleft palate. Seventeen children served as controls. Interventions Soft palate closure at 7 months and hard palate closure at a mean age of 3 years and 11 months if the cleft extended into the hard palate. Main Outcome Measures Perceptual assessments of four variables related to velopharyngeal function and of articulation errors were performed at all ages. Phonetic transcriptions of target speech sounds were obtained at 5, 7, and 10 years and nasalance scores were obtained at age 10 years. Results The no-VPI group continued to have no or minor difficulties. The VPI group improved but continued to have moderate velopharyngeal impairment. Both groups differed significantly from the controls at age 10 years. Persistent velopharyngeal impairment, as well as glottal misarticulation, were mostly found in children with the cleft as a part of a syndrome or together with multiple malformations. Conclusion Small changes in velopharyngeal impairment were found across ages. Improvement seemed to be related to surgical intervention, and persistent problems seemed to be related to the presence of additional multiple malformations or syndromes.

Dynamic cranioplasty for brachycephaly.

In craniofacial surgery, the most common techniques for treatment of brachycephaly have been either to let the forehead float on the brain or to fix it in an advanced position. Since neither of these techniques renders acceptable results with enough consistency, we have developed a different way of addressing the problem. In principle, the design of the operation is to restrict upward and transverse growth of the cranium but to allow anterior and posterior expansion. This is accomplished by producing transverse tension across the skull and letting it expand anteriorly by means of a superiorly hinged fronto-orbital flap and posteriorly by an inferiorly based occipital flap. To prevent upward expansion at the squamosal sutures when still open, these junctions are bridged with miniplates. This surgical technique has brought definite improvement to the results even in some Apert syndrome children. During a 2-year period, we have treated 14 infants with this technique and followed 10 of them with roentgencephalometry, 3 for more than 1 year, and 4 for more than 6 months. The diagnoses were the following: nonsyndromal bicoronal synostosis (4), Apert (7), bicoronal synostosis with midline cleft, Saethre-Chotzen, and Antley-Bixler (1 each). The mean age of surgery was 6.6 months (range 3 to 16 months). There were no major complications.

Complications of abdominoplasty after weight loss as a result of bariatric surgery or dieting/postpregnancy.

Abstract It is well known that the risk of complications after abdominal contouring surgery is high. Sparse data in published reports exist, suggesting that complication rates are higher in postbariatric patients compared with patients who have lost weight by dieting. The aim of this study was to analyse the incidence of complications after abdominoplasty in postbariatric patients compared with in patients who have not had weight loss surgery. The aim was also to identify predictive factors associated with the development of postoperative complications. This study retrospectively analysed 190 consecutive patients operated on with abdominoplasty due to abdominal tissue excess from January 2006 to December 2008 at Sahlgrenska University Hospital. Variables analysed were sex, age, max body mass index (BMI), delta BMI (max BMI minus preoperative BMI), preoperative BMI, method of weight reduction, resection weight, and complications. The early complication rates were significantly higher in postbariatric patients (48%) than in patients who had not had weight loss surgery (29%). Resection weight was significantly higher for patients with early local complications compared with patients without early local complications. Max BMI, delta BMI, or preoperative BMI had no influence on the incidence of complications. In conclusion, this study confirms in a fairly large sample that the complication rate after abdominoplasty seems to be higher in postbariatric patients compared with patients who have not had weight loss surgery. However, no predictive factors could be identified explaining these differences. Further studies need to be conducted to identify predictive factors for the occurrence of complications after abdominal contouring surgery.