Björn Schönmeyr

Early Surgical Complications After Primary Cleft Lip Repair: A Report of 3108 Consecutive Cases

Objective To analyze short term surgical complications after primary cleft lip repair. Patients and Design A total of 3108 consecutive lip repairs with 2062 follow-ups were reviewed retrospectively through medical records. Patients were aged 3 months to 75 years at the time of surgery, with a median of 7 years. Setting Guwahati Comprehensive Cleft Care Center, Assam, India. Intervention Primary cleft lip repair. Main Outcome Measures Documented complications in terms of dehiscence, necrosis, infection, and suture granuloma were compiled. Logistic regression was used with dehiscence (yes/no) or infection (yes/no) as binary dependant variables. Age, cleft type, and surgeon (visiting/long term) were used as covariates. Results Among the 2062 patients who returned for early follow-up, 90 (4.4%) had one or more complications. Dehiscence (3.2%) and infection (1.1%) were the most common types of complication. Visiting surgeon, complete cleft, and bilateral cleft were significantly associated with wound dehiscence, and complete cleft was associated with wound infection according to the logistic regression analysis. Of patients with bilateral complete clefts, 6.9% suffered from some degree of wound dehiscence. Conclusion In a setting where presurgical molding is unavailable and patients present at all ages, lip wound dehiscence is a relatively common complication in patients with bilateral complete clefts. The risk of dehiscence, however, is reduced when these cases are assigned to surgeons with experience with these types of clefts. We also found that the incidence of wound infection can be kept relatively low, even without the use of postoperative antibiotics.

A review of the tensor veli palatine function and its relevance to palatoplasty

Abstract The main purpose of palatoplasty is to establish normal speech and deglutition. To enhance the chance of successful palatal repair, as well as optimal velopharyngeal competence, the anatomy of the palate has to be thoroughly understood. While carrying out the repair, some surgeons prefer to cut the tensor veli palatini (TVP) tendon, others perform a tenopexy or fracture the hamulus around which the tendon passes, to facilitate mobilisation of palatal tissue. However, the exact anatomy and function of the TVP is still controversial and severing the tendon or its path could be of potential harm. A review of the literature was conducted to summarise the current knowledge of the TVP and its relevance to palatoplasty. It was found that there is sufficient evidence that the TVP plays an important part in velar tautening and Eustachian tube opening, under normal circumstances. TVPs role in the cleft patient population is, however, less certain. Whether or not TVP tenotomy or dislocation reduces ET function further in these patients is also unclear. There is, however, little or no evidence of reduced middle ear effusions if such actions are avoided, at least not in children younger than 3 years of age.

Role of Postoperative Antimicrobials in Cleft Palate Surgery: Prospective, Double-Blind, Randomized, Placebo-Controlled Clinical Study in India.

Background: The purpose of this study was to determine whether administration of postoperative antibiotics affects the incidence of complications after primary cleft palate repair in a developing area. Methods: This study was a prospective, double-blind, randomized, placebo-controlled trial composed of 518 consecutive patients who underwent primary cleft palate repair at a single institution. Patients were aged 1 to 43 years at the time of surgery (median, 9 years). The patients were divided randomly into two groups. One group received a 5-day regimen of oral amoxicillin (50 mg/kg/day) postoperatively and the other group received placebo medication. Both groups received a single dose of cefuroxime (30 mg/kg) before incision. Patients and providers were blinded to the randomization. Patients were followed postoperatively for early complications (infection and wound breakdown) and for late complications (palatal fistulas). Results: The incidence of early complications was 13.8 percent among the patients in the placebo group and 8.7 percent among the patients in the antibiotic group (p = 0.175). Fistulas were noted in 17.1 percent in the placebo group and in 10.7 percent in the antibiotic group (p = 0.085). Logistic regression analysis identified visiting surgeons as the only covariate related to early complications (OR, 3.71; p < 0.001). However, the use of placebo (OR, 2.09; p = 0.037), female sex (OR, 2.04; p = 0.047), and Veau III and IV (OR, 3.31; p = 0.004) were observed as factors associated with the incidence of fistulas. Conclusion: The authors’ results indicate that postoperative antibiotic prophylaxis can reduce the incidence of fistulas after primary cleft palate repair in a developing area.

Speech and Speech-Related Quality of Life After Late Palate Repair: A Patient's Perspective.

AbstractMany patients with cleft palate deformities worldwide receive treatment at a later age than is recommended for normal speech to develop. The outcomes after late palate repairs in terms of speech and quality of life (QOL) still remain largely unstudied. In the current study, questionnaires were used to assess the patients’ perception of speech and QOL before and after primary palate repair. All of the patients were operated at a cleft center in northeast India and had a cleft palate with a normal lip or with a cleft lip that had been previously repaired. A total of 134 patients (7–35 years) were interviewed preoperatively and 46 patients (7–32 years) were assessed in the postoperative survey. The survey showed that scores based on the speech handicap index, concerning speech and speech-related QOL, did not improve postoperatively. In fact, the questionnaires indicated that the speech became more unpredictable (P < 0.01) and that nasal regurgitation became worse (P < 0.01) for some patients after surgery. A total of 78% of the patients were still satisfied with the surgery and all of the patients reported that their self-confidence had improved after the operation. Thus, the majority of interviewed patients who underwent late primary palate repair were satisfied with the surgery. At the same time, speech and speech-related QOL did not improve according to the speech handicap index-based survey. Speech predictability may even become worse and nasal regurgitation may increase after late palate repair, according to these results.

Lessons Learned From Two Consecutive Cleft Lip and Palate Missions and the Impact of Patient Education.

Abstract Two consecutive cleft missions were conducted in Guwahati, northeastern India in December 2010 and January 2011. In the later mission, a standardized patient education program for postoperative care was introduced. The objective of this study was to retrospectively evaluate the impact of the patient education program on cleft lip complications in terms of wound infection and dehiscence. Two hundred ninety-eight cleft lip repairs were performed in the first mission and 220 (74%) returned for early follow-up. In the second mission, 356 patients were operated on and 252 (71%) returned for follow-up. From the first mission, 8 patients (3.7%) were diagnosed with lip wound infection and 21 patients (9.6%) with lip dehiscence. After the second mission, only 1 patient (0.4%) returned with a wound infection and 16 (6.4%) were diagnosed with dehiscence. Using binary logistic regression including age, cleft type, postoperative antibiotics, surgeon, and patient education program as covariates, the patient education program stood out as the only variable with a statistically significant impact on the incidence of postoperative wound infections. Even though the incidence of lip dehiscence was reduced by one third when the patient education program was utilized, our regression model singled out the surgeons as the only factor significantly related to this type of complication. Moreover, no benefits of postoperative antibiotic prophylaxis were found. Further analysis of the data also implied that the use of tissue adhesive as a compliment to sutures does not reduce the risk of dehiscence.

The efficacy of vomer flap for closure of hard palate during primary lip repair.

BACKGROUND AND AIM This study presents the institutional experience of the use of vomer flap for early closure of hard palate during unilateral complete cleft-lip repair. The purpose of this study was to determine the survival rate of the vomer flap and to investigate its effect on the subsequent palatoplasty. PATIENTS AND METHODS This retrospective analysis includes 101 non-syndromic patients with complete unilateral cleft lip who received a vomer flap for the closure of the hard palate during cleft-lip repair. Patients were aged 6 months to 28 years (median 1 year). Success rates of the vomer flaps were assessed clinically and through pre-operative photographs taken at the time of subsequent palate repair. Ninety-two patients returned for second-stage palate repair, and 74 patients with adequate post-operative follow-up information were statistically analysed. RESULTS Of the 101 patients who were operated with primary lip repair and simultaneous vomer flap, only 54 (52.4%) vomer flaps healed completely. Out of 92 patients who returned for subsequent palatoplasty, 71 (77.2%) were operated with the two-flap technique, and 19 (20.7%) received von Langenbeck repairs. Seven (9.1%) patients had a surgical complication. The failure of previous vomer repair and von Langenbeck surgical technique were identified as factors associated with post-operative complications. CONCLUSIONS We conclude that failed vomer flaps increased the risks of complications in the subsequent palate repair. Furthermore, efforts to use von Langenbeck technique rather than the two-flap technique also resulted in increased surgical complications. As a result, we have abandoned the use of the vomer flap with primary lip repair.

Limited Chances of Speech Improvement After Late Cleft Palate Repair.

AbstractLate primary palatal repair is a common phenomenon, and many patients across the world will be operated on at a far later age than is suggested for normal speech development. Nevertheless, little is known about the speech outcomes after these procedures and conflicting results exist among the few studies performed. In this study, blinded preoperative and postoperative speech recordings from 31 patients operated on at Guwahati Comprehensive Cleft Care Center in Assam, India, older than 7 years were evaluated. Six non-Indian speech and language pathologists evaluated hypernasal resonance and articulation, and 4 local laymen evaluated the speech intelligibility/acceptability of the samples.In 25 of 31 cases, the evaluators could not detect any speech improvement in the postoperative recordings. A clear trend of postoperative improvement was only found in 6 of the 31 patients. Among these 6 patients, lesser clefts were overrepresented. Our findings together with previous studies suggest that late palate repairs have the potential to improve speech, but the probability for improvement and degree of improvement is low, especially in older adolescents and adults with complete clefts.

Surgical complications in 1408 primary cleft palate repairs operated at a single center in Guwahati, Assam, India

Objective To analyze surgical complications after primary cleft palate repair in a setting with limited resources. Patients and Design A total of 1608 consecutive cleft palate repairs with 1408 follow-ups, operated upon between 2011 and 2013, were reviewed retrospectively through medical records. Patients were 10 months to 50 years old at the time of surgery, with a median age of 9 years. Setting Guwahati Comprehensive Cleft Care Center, Guwahati, India. Intervention Primary cleft palate repair. Main Outcome Measures Postoperative complications in terms of necrosis, dehiscence, fistula, infection, and “hanging palate” were assessed, as was perioperative bleeding. Logistic regression was used with complication (yes/no) as the binary dependent variable and with age, cleft type, and surgeon (visiting/long-term) as covariates. Results The overall incidence of postoperative complications was 16.9% with a fistula rate of 13.6%. The incidence of perioperative bleeding was 1.8%. Logistic regression analysis identified cleft severity (P ≤ .001) and visiting surgeon (P ≤ .01) as factors related to the incidence of postoperative complications. Age at surgery was related to both the incidence of postoperative complications (P ≤ .001) and perioperative bleeding (P < .05). Conclusion Due to increased risks of surgical complications, older patients with complete clefts should only be operated upon after careful consideration. In addition, these patients should be assigned to surgeons experienced with this cleft type.

An analysis of complications in secondary bone grafting in patients with unilateral complete cleft lip and palate

Abstract Aim: The aim of this investigation was to assess the outcome of secondary alveolar bone grafts 6 months after the procedure and examine the possible influence of patient sex, age at surgery, cleft width, and dehiscence of mucosa and sequestered bone at 2 weeks. Methods: Thirty-nine consecutive patients with unilateral complete cleft lip and palate were reconstructed with secondary alveolar bone grafting. Age at surgery ranged from 7.3–12.5 years (mean = 8.6). Cleft width varied between 2.2–14 mm (mean = 7.3). Bone was harvested either from the iliac crest or from the chin. Two-dimensional dental radiographs of the cleft area were taken before and 6 months after surgery. Results: Two weeks after surgery, 10 patients had minor dehiscence of the sutured gingival tissues and five had bone sequesters. However, only one of the treatments turned out to be unsuccessful with a Bergland index of IV. Twenty-nine patients had an initial uneventful course; but, at a follow-up 6 months later, two patients had a Bergland index of III and four a Bergland index of IV. In three of these cases, there were circumstances that could have contributed to the lack of success; but, in the remaining three, no such circumstances could be identified. Conclusion: The success rate of secondary bone grafting is high, and initial wound healing problems do not necessarily lead to a failed reconstruction. Failure may be related to factors such as exposed tooth enamel during an operation, postoperative infection, and poor compliance. Still, failed operations occur without any obvious causes.

Speech in 5-Year-Olds With Cleft Palate With or Without Cleft Lip Treated With Primary Palatal Surgery With Muscle Reconstruction According to Sommerlad

Objective: To evaluate speech in 5-year-olds with cleft palate with or without cleft lip (CP±L) treated with primary palatal surgery in 1 stage with muscle reconstruction according to Sommerlad at about 12 months of age. Design: Retrospective study. Setting: Primary care university hospital. Participants: Eight 5-year-olds with cleft soft palate (SP), 22 with cleft soft/hard palate (SHP), 33 with unilateral cleft lip and palate, and 17 with bilateral CLP (BCLP). Main Outcome Measures: Percent oral consonants correct (POCC), percent consonants correct adjusted for age (PCC-A), percent oral errors, percent nonoral errors, and variables related to velopharyngeal function were analyzed from assessments of audio recordings by 3 independent speech-language pathologists. Results: The median POCC was 75.4% (range: 22.7%-98.9%), median PCC-A 96.9% (range: 36.9%-100%), median percent oral errors 3.4% (range: 0%-40.7%), and median percent nonoral errors 0% (range: 0%-20%), with significantly poorer results in children with more extensive clefts. The SP group had significantly less occurrence of audible nasal air leakage than the SHP and the BCLP groups. Before age 5 years, 1.3% of the children underwent fistula surgery and 6.3% secondary speech improving surgery. At age 5 years, 15% of the total group was perceived as having incompetent velopharyngeal function. Conclusions: Speech was poorer in many children with more extensive clefts. Children with CP±L had poorer speech compared to normative data of peers without CP±L, but the results indicated relatively good speech compared to speech of children with CP±L in previous studies.