Krisztián Nagy

No evidence for long-term effectiveness of early osteodistraction in hemifacial microsomia.

Background: The authors performed a critical literature review to find evidence of the long-term stability after early distraction osteogenesis of the mandible in patients with hemifacial microsomia. Methods: The PubMed, Cochrane, MEDLINE, EMBASE, CENTRAL, and CINAHL databases were searched systematically for studies performed between 2002 and 2008. Abstracts from the 89 relevant articles were reviewed for evidence. Results: Thirteen articles met the inclusion criteria. Data were tabulated with respect to the length of follow-up, number of patients, age group, Pruzansky-Kaban classification of the patients, methods of analysis and validation, and level of evidence. Methods for long-term follow-up studies were not standardized, and no objective studies have been published on stability after growth cessation. Conclusions: Thus far, no randomized controlled trials on early distraction osteogenesis in hemifacial microsomia patients have been published. The authors conclude that there is a lack of statistical evidence to support the use of early distraction osteogenesis for correcting hemifacial microsomia as a single treatment modality. The results call into question its rationale.

Primary septoplasty in the repair of unilateral complete cleft lip and palate.

Background: The purpose of this study was to assess and compare nasal symmetry in patients who underwent correction of a complete unilateral cleft lip using the Afroze incision without and with primary septoplasty using a standardized two-dimensional photographic analysis. Methods: A prospective cohort study of 190 consecutive patients with complete unilateral cleft lip and alveolus with cleft palate treated with or without septoplasty using the Afroze incision technique was conducted at a high-volume center. Eighty-two patients operated on without primary septoplasty and 76 patients operated on with primary septoplasty were evaluated. Nasal symmetry was compared between patients using two-dimensional photographic analysis. Ratios between the cleft side and the non–cleft side for five parameters were used to assess symmetry: alar base–to–interpupillary line distance, columella-to–Cupids bow distance, nostril gap area, nostril width, and nostril height. The Mann-Whitney U test was used to calculate differences between the two groups. Results: Patients operated on with primary septoplasty showed more nasal symmetry compared with patients operated on without septoplasty. This difference was statistically significant for columella-to–Cupids bow distance, nostril gap area, and nostril height (p = 0.008, p < 0.001, and p < 0.001, respectively) and for the distance between alar base and the alar base–to–interpupillary line distance (p = 0.145) the difference was present but not statistically significant. For nostril width, no difference was found (p = 0.850). Conclusion: Patients treated with primary septoplasty showed better results in terms of nasal symmetry when analyzed using two-dimensional photographic analyses.

Analysis of the cleft lip–nose in the submental-vertical view. Part II. Panel study: Which is the most important deformity?

BACKGROUND In part I, we presented an anthropometric measurement instrument that uses standardized facial pictures in the submental-vertical view, Adobe Photoshop 7.0, and Scion Software for Windows to determine both form and symmetry of the cleft nose. This instrument was found to be both reliable and universally suitable for comparing results of cleft rhinoplasties. However, the quality of the overall result needs to be based on weights assigned to different measurable parameters/deformities. Therefore, we carried out a panel study to evaluate the relative importance of the different parameters/deformities according to the parents of the patients. MATERIALS AND METHODS A questionnaire with both pictorial and textual representations of 10 distinct nasal cleft deformities was sent twice to the parents of 14 complete unilateral and 14 complete bilateral cleft lip-nose patients. The deformities were rank-ordered by the parents, and the responses were analyzed for intraobserver and interobserver reliabilities. RESULTS The most important deformity according to both groups was the asymmetric position of the nose within the facial frame. Alar position was also important whereas nostril form was least important. There was fair test reliability for both intraobserver and interobserver rankings. CONCLUSION Rankings of the different nasal cleft deformities by the parents of cleft patients are reproducible and, hence, a useful preparatory guide for surgeons.

Advanced s(t)imulator for cleft palate repair techniques.

Objective: Our aim was to create a simple, inexpensive, reproducible, and life-size model of the oral cavity of a cleft palate patient. A step-by-step description of the assembly of our cleft palate simulator and its usefulness is presented. Materials: This model was made with readily available components, such as alginate impression material, impression plaster, paper template, latex examination gloves, ink pad, disposable water cup, rubber dam, rubber band, and water-based and fast-setting glue. Result: Repeated trials showed that the model can be assembled in a fast and straightforward way. The model was appropriate for simulating the structure of a cleft palate, and the Furlow double-opposing Z-plasty could be readily performed on this model. Conclusion: Our cleft palate simulator enables both the novice and keen cleft surgeons to simulate the intraoral situation of a cleft palate patient and to stimulate them to practice surgical techniques of palatal repair.

Postoperative Wound Management After Cleft Lip Surgery

Objective Our aim was to describe the postoperative management and wound care protocol after primary cleft lip closure, as it has been used in the Bruges Cleft and Craniofacial Center at the supraregional teaching hospital AZ St. Jan, Bruges, between June 1, 1991, and July 1, 2009. Materials The postoperative management and wound care included the use of a Logan bow, long-acting local anesthetic, elbow restraints, antibiotic therapy, crust removal with normal saline solution, and a special local wound ointment that was prepared at our center. Results During the last 19 years, 199 unilateral and 103 bilateral cleft lip patients have been repaired. 2.6% showed postoperative infection and/or dehiscence. One percent required readmission for reoperation. In 1.6%, inflammatory reaction was treated with oral antibiotics. Conclusion The specific wound dressing ointment, as it is prepared in our department, could meet the requirements of primary wound management after cleft lip closure.

Lip adhesion revisited: A technical note with review of literature.

Context (Background): Lip adhesion is a direct edge approximation without changing lip landmarks or disturbing tissue required for definitive closure. This converts a complete cleft into an incomplete cleft, facilitating and enhancing subsequent definitive lip and nose repair. Aim: The study aims to describe our technique of lip adhesion and its morbidity, and discuss the rationale for its use. Settings and Design: Retrospective follow-up study of complete clefts operated upon in the Bruges Cleft and Craniofacial Centre, at the supra regional teaching hospital AZ St. Jan, Bruges, between June 1, 1991 and May 1, 2009. Methods and Material: The group comprised 33 unilateral and 24 bilateral lip adhesion procedures. The medical files were reviewed for changes in surgical technique, morbidity, and complications and their treatment. Results: The lip adhesion procedure was performed at the age of two to eight weeks postnatal, and definitive lip closure, at the age of four to six months. In all cases, segment repositioning was further controlled by a palatal guidance plate. Wound dehiscence occurred in eight patients (14.0%), and three patients (5.3%) required reoperation. Conclusions: Although complications occurred, the beneficial effects of lip adhesion in combination with a guidance plate outweighed the risks for anatomical reconstruction of a platform for definitive lip and nose repair. Modifications are suggested to reduce these complications.

Management of Prominent Premaxilla in Bilateral Cleft Lip and Alveolus

Our aim was to describe the early management protocol of the prominent premaxilla in bilateral cleft lip and alveolus and its rationale, as used in the Cleft Centre at the 1st Department of Pediatrics and at the Department of Pedodontics and Orthodontics at the Semmelweis University Budapest. The non-surgical and surgical procedures included lip taping, nasoalveolar molding, lip adhesion and definitive one-stage lip closure. With this treatment sequence, arch management was satisfactory and at the time of the definitive lip closure the position of the premaxilla did not interfere with adequate surgical repair.

Oral Mucosal Z-Plasty in Combination with Intravelar Veloplasty.

Summary: Our aim was to establish a reliable, functional surgical technique for soft palate closure. A step-by-step description of the operative procedure is presented. A cross-over procedure has been developed by combining the principles of a mucosal Z-plasty only on the oral side of the cleft palate, the intravelar veloplasty following Sommerlad’s principles and a straight line closure on the nasal side. In the last 2 years, 25 patients have undergone the operation at the Cleft Centre of the 1st Paediatric Department of the Semmelweis University Budapest, Hungary. In all cases the operative technique could be adapted, operations were uneventful and straightforward. This technique was appropriate to close all the soft palate clefts, even the wide ones. This procedure combines the advantages of both procedures and has shown very good early postoperative results.

Three-dimensional simulation of the nasoalveolar cleft defect.

This study describes the planning process for a three-dimensional (3D) model of a nasoalveolar bone graft in patients with unilateral cleft lip and palate. A 3D reconstruction of the alveolar cleft based on cone-beam computed tomography was performed in 10 patients. Graft models were planned using a 3D planning software (iPlan ENT 3.0, Brainlab, Feldkirchen, Germany) and printed using a 3D printer (Objet30 Pro, Objet Ltd., Rehovot, Israel). A reproducible, step-by-step planning method was established, which is manual rather than automatic. Still, the 3D visualization and a life-size graft template could be useful during secondary alveolar osteoplasty.

Postoperative Respiratory Complications After Cleft Palate Closure in Patients With Pierre Robin Sequence: Operative Considerations

Background: In cleft palate surgery, there is currently no consensus on the management of patients with Pierre Robin Sequence (PRS). The authors aimed to evaluate the treatment strategy of cleft palate in our centers, with emphasis on patients with PRS, as the authors noted some patients with severe respiratory distress. Moreover, the authors aimed to investigate the prevalence of postoperative respiratory complications, using a modified-Furlow palatoplasty in combination with intravelar veloplasty in both patients with PRS and patients with non-PRS. Methods: The authors retrospectively identified all consecutive patients, both PRS and non-PRS, who underwent palate repair between January 1, 2012 and December 15, 2014 at 2 cooperating cleft centers (Bruges, Belgium; Budapest, Hungary). The treatment modality was uniform and performed by the same 2 surgeons. Results: In 92 consecutive patients, 4 patients experienced respiratory distress after palate repair. The female-to-male ratio was 1:1. The mean age at surgery in these 4 patients was 15 months (range 13–19 months). Fifteen percent (2/13) of patients with PRS experienced respiratory distress in comparison to 3% (2/79) of non-PRS (&khgr;2 = 4.43; P = 0.035). Conclusions: This is the first report of postoperative respiratory difficulties, while using a modified-Furlow palatoplasty in combination with intravelar veloplasty. In the present authors experience, the authors suggest to perform a 2-stage closure of the cleft palate in patients with PRS and to do so at a later age, when the palatal tissues and airway structures are more mature. Moreover, patients with PRS should be monitored closely, as they can present with different degrees of respiratory distress after palatoplasty.