Bruce Richard

Fistula incidence after primary cleft palate repair: a systematic review of the literature.

Background: The development of an oronasal fistula after primary cleft palate repair has a wide variation reported in the literature. The aim of this review is to identify the reported oronasal fistula incidence to provide a benchmark for surgical practice. Methods: A systematic review was undertaken to investigate the incidence of fistula. Multiple meta-analyses were performed to pool proportions of reported fistulae, in each data set corresponding to the continent of origin of the study, type of cleft, and techniques of cleft palate repair used. Results: A total of 9294 patients were included from 44 studies. The overall incidence of reported fistula was 8.6 percent (95 percent CI, 6.4 to 11.1 percent). There was no significant difference in the fistula incidence corresponding to the continent of origin of each study or the repair technique used. The incidence of fistula in cleft lip–cleft palate was 17.9 percent, which was significantly higher (p = 0.03) than in cases of cleft palate alone (5.4 percent). Conclusions: Palatal fistulae were more likely to occur in cases of combined cleft lip–cleft palate, compared with cleft palate alone. The authors would recommend the prospective examination and recording of all fistulae to a standardized classification scheme. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Outcomes in facial aesthetics in cleft lip and palate surgery: A systematic review

BACKGROUND While there are internationally validated outcome measures for speech and facial growth in cleft lip and palate patients, there is no such internationally accepted system for assessing outcomes in facial aesthetics. METHOD A systematic critical review of the scientific literature from the last 30 years using PUBMED, Medline and Google Scholar was conducted in-line with the PRISMA statement recommendations. This encompassed the most relevant manuscripts on aesthetic outcomes in cleft surgery in the English language. RESULTS Fifty-three articles were reviewed. Four main means of determining outcome measures were found: direct clinical assessment, clinical photograph evaluation, clinical videographic assessment and three-dimensional evaluation. Cropped photographs were more representative than full face. Most techniques were based on a 5-point scale, evolving from the Asher-McDade system. Multiple panel-based assessments compared scores from lay or professional raters, the results of which were not statistically significant. Various reports based on cohorts were poorly matched for gender, age, clinical condition and ethnicity, making their results difficult to reproduce. CONCLUSIONS The large number of outcome measure rating systems identified, suggests a lack of consensus and confidence as to a reliable, validated and reproducible scoring system for facial aesthetics in cleft patients. Many template and lay panel scoring systems are described, yet never fully validated. Advanced 3D imaging technologies may produce validated outcome measures in the future, but presently there remains a need to develop a robust method of facial aesthetic evaluation based on standardised patient photographs. We make recommendations for the development of such a system.

Postauricular fascial flap and suture otoplasty: A prospective outcome study of 227 patients

The anterior scoring technique is criticised for a higher risk of haematoma related complications while the suture techniques for suture-extrusion and recurrence. Horlock et. al. described a suture otoplasty with addition of a postauricular fascial flap to reduce suture extrusion and noted recurrence rates of 8%. We report the senior authors experience with this technique in 227 consecutive cases. All cases were done by or under supervision of the senior author and the data collected prospectively. Complications, recurrence, revision rate and results as recorded were analysed. A total of 10 (7 early 3 late) complications were recorded (4.4%). Suture extrusion (n = 6, 2.64%), Keloids (n = 3, 1.32%), Infection, anterior skin necrosis (n = 1 each, 0.44%). A total of 6 unilateral and 5 bilateral cases had a recurrence (3.67% total ears) and 97% of recorded outcomes were reported as good or excellent results. The low complication rate seems to support the hypothesis that the fascial flap prevents suture extrusion and reduces risk of recurrence. Lack of Anterior dissection avoids risks of bleeding and haematoma.

Leprosy affects the tibial nerves diffusely from the middle of the thigh to the sole of the foot, including skip lesions

This study investigated where leprosy affects the posterior tibial nerve and whether neurolysis is beneficial. Nine patients with bilateral posterior tibial leprous neuropathy with no sensorimotor recovery were studied. Preoperative sensory‐muscle and nerve conduction velocity testing revealed the tarsal tunnel to be the site of a severe lesion in all cases. During surgery, the most proximal site of the nerve lesion was detected by electrically stimulating the spinal roots from the second lumbar nerve to the fourth sacral nerve, evoking efferent mixed nerve compound action potentials that were recorded from the exposed tibial nerve. In all patients, the nerve compound action potentials became normal only proximal to the sciatic nerve bifurcation. Epineuriotomy within these seemingly unaffected segments revealed fibrosis of the interfascicular epineurium. Interfascicular neurolysis was performed on all affected segments. A 2‐year follow‐up showed an increase in girth of the proximal calf musculature in six of eight patients (the ninth patient had no recordable nerve conduction velocity). It was concluded that (1) leprosy affects the tibial nerves in a scattered way from the sciatic nerve main trunk distally to the exit of the tarsal tunnel; and (2) interfascicular, microsurgical neurolysis is beneficial provided that it is performed on all affected nerve segments. (Plast. Reconstr. Surg. 107: 1717, 2001.)

Facial Aesthetic Outcomes of Cleft Surgery: Assessment of Discrete Lip and Nose Images Compared with Digital Symmetry Analysis

Background: High-quality aesthetic outcomes are of paramount importance to children growing up after cleft lip and palate surgery. Establishing a validated and reliable assessment tool for cleft professionals and families will facilitate cleft units, surgeons, techniques, and protocols to be audited and compared with greater confidence. This study used exemplar images across a five-point aesthetic scale, identified in a pilot project, to score lips and noses as separate units and compared these human scores with computer-based SymNose symmetry scores. Methods: Forty-five assessors (17 cleft surgeons nationally and 28 other cleft professionals from the UK South West Tri-centre units), scored 25 standardized photographs, uploaded randomly onto a Web-based platform, twice. Each photograph was shown in three forms: lip and nose together, and separately cropped images of nose only and lip only. The same images were analyzed using the SymNose software program. Results: Scoring lips gave the best intrarater and interrater reliabilities. Nose scores were more variable. Lip scoring associated most closely with the whole-image score. SymNose ranking of the lip images related highly to the same ranking by humans (p = 0.001). The exemplar images maintained their established previous ranking. Conclusions: Images illustrating the aesthetic outcome grades are confirmed. The lip score is reliable and seems to dominate in the whole-image score. Noses are much harder to score reliably. It appears that SymNose can score lip images very effectively by symmetry. Further use of SymNose will be investigated, and families of children with cleft will trial the scoring system. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reporting of Randomized Controlled Trials in Cleft Lip and Palate: A 10-Year Review

Objectives Reviews of the quality of reporting of randomized controlled trials (RCTs) have recently been conducted in different surgical specialties. In this review of RCTs relating to cleft lip, cleft palate, and cleft lip and palate (CL/P), we investigate the quality of reporting against the Consolidated Standards of Reporting Trials (CONSORT) checklist. Design A systematic review of CL/P RCTs published from 2004 to 2013, with the included articles scored against the CONSORT checklist. Patients, Participants The literature search identified 174 articles. Studies were selected for participants with CL/P who were involved in an RCT with prospective data collection and reported in a full journal article. A total of 6352 participants were included from 65 CUP RCTs during the study period. Main Outcome Measures The methodological quality of RCTs was assessed using the CONSORT checklist and Jadad scale. Results The mean CONSORT score was 15.8, and the mean Jadad score was 3.3. There was a significant positive correlation between the CONSORT and Jadad score (P < .0001, ρ = .47). The only significant correlation showed that with an increasing number of authors, both the CONSORT and the Jadad score increased. Conclusion This analysis has shown that that there are deficiencies in the transparent reporting of factors such as randomization implementation, blinding, and participant flow. Interventions, outcomes, and the interpretation of results are well presented. We would recommend that RCTs are conceived and undertaken using the CONSORT checklist and reported in a clear and reproducible manner.

Absent maxillary lateral incisor as evidence of poor midfacial growth in unilateral cleft lip and palate

OBJECTIVE The absence of a maxillary permanent lateral incisor in patients with unilateral cleft lip and palate (UCLP) may affect the dental arch relationship. An analysis is performed to investigate the relationship between the maxillary-mandibular dental relationship and the status of the maxillary permanent lateral incisor. STUDY DESIGN Patients with non-syndromic UCLP were analysed using the GOSLON Yardstick to assess maxillary-mandibular dental relationship on pre-expansion orthodontic study models. Absence of the permanent upper lateral incisor on the cleft side was assessed from medical records and dental radiographs. RESULTS A total of 83 subjects were identified: 54 males and 29 females, with 54 having a missing lateral incisor on the cleft side. There was a significant relationship between the GOSLON Yardstick score and the absence of the maxillary permanent lateral incisor on the cleft side (p<0.05). Of those in GOSLON categories 4 and 5, 78% had a missing lateral incisor compared to 42.3% in GOSLON 1 and 2. CONCLUSIONS Missing lateral incisor may be an indicator of severity of dental arch discrepancy.

Congenital cutaneous lymphadenoma

Cutaneous lymphadenoma is an uncommon benign neoplasm often considered to be an adamantinoid variant of trichoblastoma. Lesions present in both sexes, between 14 and 87 years of age, and are mainly located on the head and neck. Cases in children are rare and there is only 1 previous case of a congenital lymphadenoma. An 8‐year‐old Asian girl presented with a congenital lesion on her forehead comprising 4 pink papules, the largest 5 mm in diameter. Microscopy revealed a well‐circumscribed tumor within the dermis and subcutis comprising well‐demarcated epithelial lobules of basaloid and clear cells with subtle peripheral palisading, growing in a collagenous stroma but lacking retraction artefact. A relatively dense accompanying predominantly lymphocytic inflammatory cell infiltrate including both T‐cells (CD3+) and B‐cells (CD20+) permeated the nodules and spilled into the stroma. CD68+ histiocytes and CD1a+ Langerhans cells were moderately numerous. This is the second case of congenital lymphadenoma which—in spite of its rarity in childhood—widens the diagnostic possibilities of cutaneous lymphoepithelial tumors in children.