Karoon Agrawal

Cleft palate repair and variations

Cleft palate affects almost every function of the face except vision. Today a child born with cleft palate with or without cleft lip should not be considered as unfortunate, because surgical repair of cleft palate has reached a highly satisfactory level. However for an average cleft surgeon palatoplasty remains an enigma. The surgery differs from centre to centre and surgeon to surgeon. However there is general agreement that palatoplasty (soft palate at least) should be performed between 6-12 months of age. Basically there are three groups of palatoplasty techniques. One is for hard palate repair, second for soft palate repair and the third based on the surgical schedule. Hard palate repair techniques are Veau-Wardill-Kilner V-Y, von Langenbeck, two-flap, Aleveolar extension palatoplasty, vomer flap, raw area free palatoplasty etc. The soft palate techniques are intravelar veloplasty, double opposing Z-plasty, radical muscle dissection, primary pharyngeal flap etc. And the protocol based techniques are Schweckendieks, Maleks, whole in one, modified schedule with palatoplasty before lip repair etc. One should also know the effect of each technique on maxillofacial growth and speech. The ideal technique of palatoplasty is the one which gives perfect speech without affecting the maxillofacial growth and hearing. The techniques are still evolving because we are yet to design an ideal one. It is always good to know all the techniques and variations so that one can choose whichever gives the best result in ones hands. A large number of techniques are available in literature, and also every surgeon incorporates his own modification to make it a variation. However there are some basic techniques, which are described in details which are used in various centres. Some of the important variations are also described.

Vitiligo: Repigmentation with Dermabrasion and Thin Split-Thickness Skin Graft

BACKGROUND Vitiligo is a common benign condition of great concern. Though a large number of medical and surgical treatment methods are available, none of them is fully dependable in all the areas. OBJECTIVE Split‐thickness skin grafting (STSG) has been used for the treatment of vitiligo for over three decades, but it did not gain popularity. This presentation evaluates the degree of repigmentation achieved with this technique, its complications, and drawbacks. METHODS A case series of 21 patients with 32 localized, stable, and refractory vitiligo patches treated institutionally by dermabrasion and thin STSG has been presented. The patients have been followed up for 1–6 years. Three patients lost to follow‐up before 1 year have not been included. RESULTS The graft take was 100% in 27patches and 90–95% in the remaining five. One hundred percent repigmentation was achieved in 22patches and 90–95% in 10. Time taken for satisfactory color match was 4–9 months (average, 6.3 months). The complications encountered were all minor and did not affect the results. CONCLUSION This is a simple, outpatient procedure performed under local anesthesia resulting in an excellent color match on a long‐term follow‐up. This technique can be used over any part of the body, including the hair‐bearing areas, without compromising the end results.

Use of Vomer Flap in Palatoplasty: Revisited

Objective To present a new comprehensive and simple classification of vomerine flaps for palatoplasty. Design This classification has been developed on the basis of a literature search and our clinical experience. The vomerine flaps have been classified into three types, each with A and B subtypes. Patients, Participants Vomerine tissue has been used in more than 1000 palatoplasties over the past 17 years. The analysis includes 678 cleft palate patients for whom detailed records were available. Type II-A vomerine flaps were used most commonly in unilateral cleft palate patients, whereas Type II-B1 flaps were used in bilateral cleft palate patients. Results The overall fistula rate at the hard and soft palate junction was 2.95%. Although facial growth pattern was not recorded, obvious midface growth abnormalities were not observed in any of these patients. Conclusions Vomerine tissue is available in the vicinity of the palatal defect. Raising of the vomerine flap is simple and safe. If properly designed, it can be used judiciously for closure of the nasal and oral defects in the cleft palate. We have used these flaps only to augment the nasal mucosal defect. This comprehensive classification will be useful in understanding, designing, and implementing these small, but very important, flaps.

Surgical outcome in children undergoing hypospadias repair under caudal epidural vs penile block

Aim and Objective:  To evaluate the effect of penile block vs caudal epidural on the quality of analgesia and surgical outcome following hypospadias repair.

Vitiligo: surgical repigmentation of leukotrichia.

BACKGROUND Patients with vitiligo frequently have premature gray hair. Until recently the literature was silent about its management. While surgically treating vitiligo, we incidentally observed repigmentation of gray hair. OBJECTIVE Based on our observations we undertook this study to see the effect of surgical treatment of vitiligo on repigmentation of leukotrichia, as well as to evaluate the percentage of repigmentation, if any, in the different hair‐bearing areas, and the time taken for it. METHODS A case series of eight patients with nine patches of localized, stable, and refractory vitiligo with leukotrichia of 3–12 years duration is presented. The patients were followed up for 2–6 years. One patient was lost from follow‐up after 2 months. The vitiligo was treated by dermabrasion and thin split‐thickness skin grafting under local anesthesia, as outpatients. RESULTS Repigmentation of the hair occurred in all the areas but it was seen earlier (3 months) and was more complete in the eyebrows (70–95%). In the scalp and the beard areas it started later (6–9 months) and was around 50–60% only. The degree of pigmentation increased until about 3 years after surgery. No complications in the form of graft loss or alopecia were observed. CONCLUSIONS Partial to near‐total repigmentation of leukotrichia can be achieved surgically. Contrary to the present theory, we hypothesize that melanocytes also migrate from the repigmented epidermis to the hair follicle, resulting in repigmentation of the hair.

Xeroderma Pigmentosum: resurfacing versus dermabrasion

Three patients of Xeroderma Pigmentosum (XP) have been managed for recurrent tumours. Improvement in pigment pattern was observed at both the donor as well as the recipient sites. An attempt has been made to prevent further occurrence of tumours over the exposed parts of the body by resurfacing and also by dermabrasion. A comparative study of the two procedures is being carried out and the preliminary results are discussed. Deep dermabrasion appears to be preferable as a prophylactic procedure.

The effect of insulin-like growth factor 1 on craniofacial bone healing

&NA; Human insulin‐like growth factor 1, a known regulator of bone formation, was investigated for its possible effect on membranous bone formation in a rat model. Full‐thickness bone defects (10 × 10 × 1 mm) were created in the rat calvarium, and insulin‐like growth factor 1 was administered by an osmotic minipump directly into the defect enclosed by the periosteum and dura mater. The dose of insulin‐like growth factor 1 was 100 &mgr;g every 2 weeks. The defects were studied radiographically, macroscopically, and microscopically at 3, 6, 9, and 12 weeks. The group treated with insulin‐like growth factor I showed qualitative and quantitative differences when compared with the control group. The amount of new bone formation in the group treated with insulin‐like growth factor 1 was significantly larger than that of the control group. In the insulin‐like growth factor 1 group, the location of new bone formation occurred in the center and at the margin of the bone defect. In the control group, bone was formed only around the margin of the bone defect. This study suggests that insulin‐like growth factor I improved membranous bone healing in vivo and that insulin‐like growth factor 1 makes mesenchymal precursor cells of bone differentiate directly into bone‐forming cells. (Plast. Reconstr. Surg. 97: 1129, 1996.)

A status report on management of cleft lip and palate in India

Introduction: This national survey on the management of cleft lip and palate (CLP) in India is the first of its kind. Objective: To collect basic data on the management of patients with CLP in India for further evaluation. Materials and Methods: A proforma was designed and sent to all the surgeons treating CLP in India. It was publicized through internet, emails, post and through personal communication. Subjects: 293 cleft surgeons representing 112 centers responded to the questionnaire. Most of the forms were filled up by personal interview. Results: The cleft workload of the participating centers is between 10 and 2000 surgeries annually. These centers collectively perform 32,500–34,700 primary and secondary cleft surgeries every year. The responses were analyzed using Microsoft excel and 112 as the sample size. Most surgeons are repairing cleft lip between 3-6 months and cleft palate between 6 months to 1 year. Millard and Tennison repairs form the mainstay of lip repair. Multiple techniques are used for palate repair. Presurgical orthopedics, lip adhesion, nasendoscopy, speech therapy, video-fluoroscopy and orthognathic surgery were not always available and in some cases not availed of even when available. Conclusion: Management of CLP differs in India. Primary surgical practices are almost similar to other studies. There is a lack of interdisciplinary approach in majority of the centers, and hence, there is a need for better interaction amongst the specialists. A more comprehensive study with an improved questionnaire would be desirable.

Flexible Laryngeal Mask Airway for Cleft Palate Surgery in Children: A Randomized Clinical Trial on Efficacy and Safety

Objective: To evaluate the efficacy of a flexible laryngeal mask airway in children undergoing palatoplasty. Design: Prospective, randomized, single-center study. Setting: Jawaharlal Institute of Postgraduate Medical Education and Research. Patients: Sixty-six children (American Society of Anesthesiologists physical status 1 and 2) scheduled to undergo palatoplasty were assigned randomly to an endotracheal intubation group (RAE group, n  =  33) and a flexible laryngeal mask airway group (FLMA group, n  =  33). Main Outcome Measures: Peak airway pressure, inspired and expired tidal volume, end-tidal carbon dioxide, lung compliance, and airway resistance were continuously measured after placement of the assigned airway. The percentage leak around the airway was quantified as the leak fraction. Parametric data between groups were analyzed using an unpaired Students t test and within groups using a one-way analysis of variance. Nonparametric variables were analyzed using the Fisher exact test. Results: In two children, the flexible laryngeal mask airway was displaced from its original position; whereas, one endotrachial tube advanced endobronchially. The leak fraction was significantly higher in the RAE group when compared with that in FLMA group (13.34% ± 13.74% versus 5.96% ± 3.78%, p < .05) until the throat pack was applied. Peak airway pressure and resistance were significantly higher in the RAE group compared with the FLMA group at all time intervals, p < .05. During emergence, frequency of coughing, desaturation, and laryngospasm were increased in the RAE group. Conclusion: A flexible laryngeal airway mask is suitable for maintaining the airway and helps in smooth emergence in children undergoing palatoplasty.

A modified surgical schedule for primary management of cleft lip and palate in developing countries.

Introduction In developing countries cleft lip and palate (CLP) patients arrive late, and there is a risk of drop out for functionally important palatoplasty after lip repair. Patients may be underweight, anemic, and prone to recurrent infections. Objective To repair cleft palate at an appropriate time and secondly to avoid the drop out after the first surgery. Protocol A new surgical protocol has been designed for patients with CLP in whom the cleft palate is first repaired at 6 to 9 months of age or whenever the patient presents at the clinic. The cleft lip is repaired 3 to 6 months after the first surgery. Patients and Results When cleft lip repair was performed before palate repair (conventional protocol group) in 89 patients with CLP, the median interval between first and second surgery was 290 days. However, when the modified protocol was followed in 330 patients over 13 years, the median interval was 193 days (p < .0002). The reduction in the interval is statistically significant. In eight patients cleft palate fistula encountered after palatoplasty was repaired during cleft lip repair thus avoiding a third surgery. Conclusions The compliance for two surgeries in CLP has improved. Apart from achieving the main aim of the new protocol, a number of advantages were noticed. The palate repair was easier in the presence of an unrepaired cleft lip. The anterior palate repair was more dependable with reduced incidence of anterior palatal or alveolar fistula.