Donnell F. Johns

Timing of hard palatal closure: A critical long-term analysis

The controversy about timing of cleft palate surgical procedures is focused on early palatoplasty for improved speech versus delayed hard palate repair for undisturbed facial growth. Timing and technique of palate repair are the most important influences on speech and facial growth, yet there is no consensus on the age or technique for surgery. The Oxford Cleft Palate Study was initiated to evaluate critically the long-term follow-up of 44 patients with early versus late closure of the hard palate. A multidisciplinary approach was used to determine the incidence of speech deficiencies, palatal fistulas, maxillofacial growth disturbances, and hearing abnormalities and to assess objectively the long-term effects of two different treatment modalities on the cleft palate patient. The 44 patients were selected randomly, interviewed, and examined by the multidisciplinary Oxford Cleft Palate Study team. The average age at follow-up in the early closure group was 17.0 years versus 18.2 years in the late closure group. There was a similar number of unilateral and bilateral clefts in both the early and late closure groups. The hard palate was closed in the early group at an average age of 10.8 months versus 48.6 months in the late closure group. All operative procedures in each group were performed by the same senior plastic surgery consultant. Both consultants have since retired and did not participate in the study. Each patient was evaluated by the same plastic surgeon, speech pathologist, orthodontist, and otologist. All examiners were blinded in that they were unaware of the type or timing of the surgical technique and had no prior knowledge of or access to the patients medical records. Furthermore, none of the examiners participated in the initial care and surgery of these patients. Statistically significant greater speech deficiencies were noted with delayed hard palate closure, especially in articulation, nasal resonance, intelligibility, and substitution pattern assessment (overall intelligibility, p < 0.01). Likewise, the persistent palatal fistula rate in the late closure group was 35 percent in comparison with 5 percent for the early closure group (p <0.02). No significant differences in hearing or maxillofacial growth impairment were delineated in either group. Our data suggest that delaying hard palate closure results in significant speech impairment without a beneficial maxillofacial growth response.

Optimal timing of cleft palate closure.

Treatment objectives for the cleft palate patient--normal speech, normal maxillofacial growth, and normal hearing--are closely related. Controversy about the timing of cleft palate surgery is directed at the need for early palatoplasty for improved speech and hearing versus delayed hard palate repair for undisturbed facial growth. This controversy as to the value of early versus delayed closure continues into the present. The authors present an updated argument regarding this controversy along with a comprehensive literature review. They also present a logical algorithm based on the literature and their personal experience.

Velopharyngeal incompetence: a guide for clinical evaluation.

Various causes of velopharyngeal disorders and the myriad of diagnostic methods used by speech-language pathologists and plastic surgeons for assessment are described in this article. Velopharyngeal incompetence occurs when the velum and lateral and posterior pharyngeal walls fail to separate the oral cavity from the nasal cavity during speech and deglutination. The functional goals of cleft palate operations are to facilitate normal speech and hearing without interfering with the facial growth of a child. Basic and helpful techniques are presented to help the cleft palate team identify preoperative or postoperative velopharyngeal incompetence. This information will enable any member of the multidisciplinary cleft palate team to better assist in the differential diagnosis and management of patients with speech disorders.

The self-lined superiorly based pull-through velopharyngoplasty : plastic surgery-speech pathology interaction in the management of velopharyngeal insufficiency

We present a rationale and step-by-step description of a previously unpublished innovative surgical technique designed to overcome velopharyngeal insufficiency. This procedure maintains the anatomic integrity and physiologic function of the velopharynx by limiting interpalatal dissection and incorporates a method for flap attachment through the velum that is accessible, predictable, and versatile. The efficacy of this procedure in eliminating velopharyngeal insufficiency was evaluated by using rigorously controlled quantitative psychophysical scaling procedures of presurgical and postsurgical perceptual ratings of resonance, nasal emission, and intelligibility and instrumental acoustic analyses. The results indicated significantly better postsurgical speech outcomes by individuals treated with the pull-through velopharyngoplasty than did patients treated with other procedures designed for the secondary management of velopharyngeal insufficiency. Based on our experience with more than 150 patients, we believe that the self-lined superiorly based pull-through velopharyngoplasty represents an advancement in the surgical treatment of velopharyngeal insufficiency.

Hearing and ultrasound-assisted liposuction: The effect on surgeon and patient

Ultrasound-assisted liposuction has become an important tool in body-contouring surgery. Although ultrasound frequency is by definition outside the range of normal human hearing, an audible sound is heard during ultrasound-assisted liposuction. This study measured sound intensity during ultrasound-assisted liposuction performed with two commercially available systems. Sound intensity was measured at the surgeons ear, surgical site, and patients glabella. All measurements obtained with both machines fell within acceptable standards as defined by the Occupational Safety and Health Administration. Use of ultrasound-assisted liposuction does not pose a risk to the patient, the surgeon, or operating room personnel.