Robert A. Hardesty

Radiographic and aerodynamic measures of velopharyngeal anatomy and function following Furlow Z-plasty.

&NA; Recent studies have shown that the Furlow doubleopposing Z‐plasty has several advantages that make it an attractive procedure for cleft palate repair and treatment of velopharyngeal insufficiency in selected cases. The anatomic changes associated with this procedure have never been documented prospectively. The purpose of this study was to describe radiographic dimensions of the velopharynx and aerodynamic measures of velopharyngeal function in a group of patients before and after Furlow Z‐plasty for the treatment of velopharyngeal insufficiency. Twelve consecutive patients with cleft palate and velopharyngeal insufficiency, ranging in age from 3 to 19 years, were selected as candidates for Furlow Z‐plasty based on perceptual, endoscopic, and radiographic findings. Eight patients had repaired cleft palate with a residual muscle diastasis and four patients had unrepaired submucous cleft palate. Subjects received aerodynamic and cephalometric assessments before and after Z‐plasty. Cephalometric x‐rays were measured for velar length, thickness, and pharyngeal depth. Mean nasal airflow during pressure consonants (Vn) was calculated from pressure/flow studies, and patients were categorized as having complete closure (<10 cc/sec Vn) or incomplete closure (>10 cc/sec Vn). After Z‐plasty, there was a significant increase in velar length (p = 0.002) and velar thickness (p = 0.001). After surgery, patients with complete velopharyngeal closure had significantly greater velar length than the incomplete closure group (p = 0.05) with nearly twice the increase in length. Similarly, following surgery, the complete closure group had significantly greater thickness than the incomplete closure group (p = 0.01), with a greater postoperative increase in velar thickness (p = 0.005). Finally, there was a significant negative correlation between percent increase in length and percent increase in thickness for patients in the complete closure group (r = ‐0.91, p = 0.03). Findings demonstrate that following Furlow Z‐plasty, patients with cleft palate and velopharyngeal insufficiency obtained significant increases in velar length and thickness. Greater velar length and greater velar thickness both were associated with complete velopharyngeal closure. Patients in the complete closure group tended to demonstrate large percent gains in either length or thickness or moderate gains in both. Patients in the incomplete closure group tended to demonstrate relatively small percent gains in both dimensions. Results suggest there may be important anatomic features (such as pharyngeal depth/velar length ratio) that can be evaluated before surgery to predict which patients may be most likely to benefit from Furlow Z‐plasty as a form of treatment for velopharyngeal insufficiency. (Plast. Reconstr. Surg. 106: 539, 2000.)

Cleft palate and craniofacial teams in the United States and Canada : A national survey of team organization and standards of care

Objective This study is the first comprehensive national survey of the organization, function, and composition of cleft palate and craniofacial teams in the U.S. and Canada. Complete descriptions of cleft and craniofacial teams are not currently provided in the literature, and this study will provide an overview for health services research and policy use. Conducted by a national organization, this study examines teams in detail using a pretested and standardized methodology. Design All known (n = 296) North American cleft palate and craniofacial teams were contacted for team listing purposes using a self-assessment method developed by an interdisciplinary committee of national stature. Team clinical leaders classified their teams into several possible categories and provided data on team care. The response rate was 83.4% (n = 247). Results The distribution of listed teams was: 105 (42.5%) cleft palate teams, 102 (41.3%) craniofacial teams (including craniofacial teams that are both cleft palate and craniofacial teams), 12 (4.9%) geographically listed teams, and 28 (11.3%) other teams (including interim cleft palate teams, low-density cleft palate teams, and evaluation and treatment review cleft palate teams). Eighty-five percent of all teams systematically collected and stored clinical data on their teams patient population in the past year. Furthermore, 50% of all teams had a quality assurance program in place to measure treatment outcomes. Other findings presented include the annual number of face-to-face team meetings; new and follow-up patient censuses; and surgical rates for initial repair of cleft lip/palate, orthognathic/osteotomy procedures, and intracranial/craniofacial procedures. Conclusions Two of five North American teams classify themselves as having the capacity to provide both cleft palate and craniofacial care. An additional two of five teams limit their primary role to cleft palate care. Issues are raised regarding the distribution of teams, the regionalization of craniofacial services, health policy, and resource allocation.

Intrauterine Repair of Surgically Created Defects in Mice (Lip Incision Model) with a Microclip: Preamble to Endoscopic Intrauterine Surgery

We compared the difference between a nonpenetrating silver microclip and suture on wound healing, inflammatory response, and application time in the repair of surgically created standardized unilateral cleft lip type defects in fetal mice. Excellent lip continuity and dermal reconstitution were achieved by both methods of repair. Furthermore, collagen accumulation did not occur. Occasional mononuclear cells were seen around sutured repairs in contrast to microclipped repairs. The most significant difference, however, was in application time with the microclip requiring an average of 7 seconds (+/- 2) compared to 90 seconds (+/- 15) for suture. We conclude that the microclip offers distinct advantages for intrauterine cleft lip repair: (1) nonpenetrating tissue approximation; (2) less inflammatory response than suture; (3) technically more rapid and less difficult to apply than suture; and (4) can be utilized more readily than suture for endoscopic approaches limiting the risks of fetal surgery for both the mother and the fetus.

Endoscopic excision and repair of simulated bilateral cleft lips in fetal lambs

&NA; The use of nonpenetrating clips to accomplish wound closure as an alternative to suture in the repair of simulated cleft lips in partially exteriorized fetuses has been described previously. In this study, the fetus is approached endoscopically, and clipped (n = 8) and sutured (n = 4) intrauterine endoscopic repairs in six lambs (90‐ to 95‐day gestation) are compared. Also used was a newly developed harmonic scalpel to create the defects in the fluid environment. Clipped repairs were nearly 10 times faster than sutured repairs (2.7 ± 0.5 minutes compared with 24 ± 4 minutes, respectively). Furthermore, suture incited foreign body inflammation, recruited monocytic inflammatory cells, and exhibited notable scarring. The comparison between clipped and sutured repairs extends the previous observations to the realm of endoscopy and reinforces the previous conclusions of this group that the nonpenetrating clip is more rapid and incites less inflammation than suture in fetal wound approximation and repair. (Plast. Reconstr. Surg. 102: 1, 1998.)

Successful reattachment of a nearly amputated ear without microsurgery.

Traumatic ear loss is functionally and aesthetically disabling. Replantation of an amputated ear, with1–7 or without8,9 microsurgical techniques, has been reported before and offers the best reconstructive results. In contrast, ear salvage using the modified pocket technique,10–12 coverage with temporoparietal fascia flap and skin graft,13 or recreation of the cartilaginous framework using autologous tissues14 is inferior to primary ear repair with regard to shape and color mismatch. However, the outcome of primary ear salvage is limited by reestablishment and/or preservation of the existing perfusion to the severed tissue, which may be complicated by partial or complete tissue loss. Few existing reports describing the survival of avulsed yet still connected ear fragments underscore the uncertainty of successful nonmicrosurgical auricle replantation. To illustrate, Tomono and Hirase described reattachment of an ear based on a 3 x 1.5-cm pedicle at the lobule resulting in necrosis of the concha.15 Yotsuyanagi et al. reported successful survival of an auricle based on a 1-cm skin pedicle at the helical crus after resection of the congested lobule.16 According to another report, a 3-mm pedicle at the helical rim provided adequate circulation to the nearly amputated middle and inferior auricle yielding necrosis of the lobule.17 Similarly, Bill and colleagues noted satisfactory recovery of a partly detached ear with inferior pole ischemia after hyperbaric oxygen application.18 Adjunctive therapies, such as hyperbaric oxygen, dextran-40, aspirin, and leeches, have been described in the literature to augment survival of tissues with compromised perfusion, but the combination of all these modalities has not been previously applied in nonmicrosurgical ear rescue. In the current report, a case of complete nonmicrosurgical salvage of a nearly amputated ear with adjunctive multimodal therapy is described.