Srinivas Gosla Reddy

Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India

Objective: To assess the incidence of cleft lip and palate defects in the state of Andhra Pradesh, India. Design Setting: The study was conducted in 2001 in the state of Andhra Pradesh, India. The state has a population of 76 million. Three districts, Cuddapah, Medak and Krishna, were identified for this study owing to their diversity. They were urban, semi-urban and rural, respectively. Literacy rates and consanguinity of the parents was elicited and was compared to national averages to find correlations to cleft births. Type and side of cleft were recorded to compare with other studies around the world and other parts of India. Results: The birth rate of clefts was found to be 1.09 for every 1000 live births. This study found that 65% of the children born with clefts were males. The distribution of the type of cleft showed 33% had CL, 64% had CLP, 2% had CP and 1% had rare craniofacial clefts. Unilateral cleft lips were found in 79% of the patients. Of the unilateral cleft lips 64% were left sided. There was a significant correlation of children with clefts being born to parents who shared a consanguineous relationship and those who were illiterate with the odds ratio between 5.25 and 7.21 for consanguinity and between 1.55 and 5.85 for illiteracy, respectively. Conclusion: The birth rate of clefts was found to be comparable with other Asian studies, but lower than found in other studies in Caucasian populations and higher than in African populations. The incidence was found to be similar to other studies done in other parts of India. The distribution over the various types of cleft was comparable to that found in other studies.

Comparison of three incisions to repair complete unilateral cleft lip.

BACKGROUND The incision design for correcting a unilateral cleft lip is important because all subsequent stages of surgery depend on the access and maneuverability of the incision. This prospective cohort study compares the aesthetic and functional outcomes of three different skin incisions for primary unilateral cleft lip repair. METHODS Patients with complete unilateral cleft lips (n = 1200) were enrolled and divided into three groups of 400 patients. Each group of patients was operated on with the Millard incision, Pfeifer wave line incision, or Afroze incision. Outcome assessments were performed 2 years postoperatively and consisted of assessment of the white roll, vermilion border, scar, Cupids bow, lip length, nostril symmetry, and appearance of alar dome and base. RESULTS With regard to white roll, vermilion border, scar, Cupids bow, and lip length, the Afroze incision always gave superior results compared with the Millard or Pfeifer incision. Depending on the cut-off for treatment success, the Afroze incision also showed better results regarding nostril symmetry. With respect to the alar base and alar dome, all three incisions showed comparable outcomes. CONCLUSION The Afroze incision is superior regarding a broad spectrum of outcomes in a heterogeneous population of patients with unilateral cleft lip.

Assessment of nostril symmetry after primary cleft rhinoplasty in patients with complete unilateral cleft lip and palate

The aim of this study was to assess the nostril symmetry following primary cleft rhinoplasty done with either a dorsal onlay or columellar strut graft in patients with non-syndromic complete unilateral cleft lip and palate. In this retrospective study 30 consecutive patients treated with autogenous or alloplastic dorsal onlay grafts and 30 consecutive patients treated with autogenous or alloplastic columellar strut grafts for complete unilateral cleft nose reconstruction were analyzed for nasal symmetry. The autogenous grafts used were costo-chondral or septal cartilage and the alloplastic graft used was high density polyethylene (Medpore(®)). Assessment of the nostril symmetry was done using a two-dimensional nasal analysis 24-30 months postoperatively. Ratios between cleft and noncleft side nostril for three parameters were used to assess symmetry namely nostril width, nostril height and nostril gap area. None of the three parameters showed statistically significant changes. A satisfactory, though not statistically significant, difference in symmetrical outcome could be achieved in both the groups with the exception of nostril width symmetry in group treated with dorsal onlay graft.

Perceptions of Family Members of Children With Cleft Lip and Palate in Hyderabad, India, and Its Rural Outskirts Regarding Craniofacial Anomalies: A Pilot Study

Objective This pilot study aimed to understand cultural perspectives on cleft anomalies in the community of Hyderabad, India, and its rural outskirts. Design Interviews focusing on perceptions of cleft lip and palate were conducted using a 21-item interview guide approved by the director of the Gosla Srinivas Reddy Institute of Craniofacial Surgery (GSR). Settings Interviews were conducted at GSR, a specialty surgical center located in Hyderabad, India. Patients and Participants All patients who presented to GSR with either cleft lip, cleft palate, or cleft lip and palate at the time of this study were included. Results Of the 23 families interviewed, 12 mothers believed the cleft was caused by an eclipse, and two believed the scientific explanation their physician offered. Fourteen families were offered no explanation for the cleft lip and/or palate at the time of their first physician visit. No families practiced non-Western methods for treatment of the cleft. One family identified beliefs held in the community that their child with a cleft lip was bad luck. Conclusion A commonly held belief in this community in India is that cleft lip, cleft palate, or cleft lip and palate are caused by an eclipse. Physicians appear to be providing families with insufficient education on cleft impairments. Data generated from studies similar to this can be used to design educational protocols that address this gap in community understanding of orofacial clefting.

Developing and Standardizing a Center to Treat Cleft and Craniofacial Anomalies in a Developing Country Like India

The range of facial deformities is enormous. All produce some degree of disfigurement and result in the impairment of function to some degree, sometimes even to the point of incompatibility with life. Congenital facial defects in India are associated with considerable superstition, social rejection, and failure to integrate into society. In India, cleft defects occur in 1 in 500 births. Congenital facial defects are a pressing problem in India owing to the limited resources to treat such patients. Poverty is a major factor for parents of such children to get appropriate treatment. Setting up an institute to treat children with cleft and craniofacial deformities in India presents problems with financing treatment for poor patients, procuring the right infrastructure, and employing well-trained human resources. The authors have set up such an institute in Hyderabad in the southern state of Andhra Pradesh in India. The logistics of setting up such a facility in a developing country and the future of funding for cleft treatment are important factors to consider while establishing a center for patients with cleft and craniofacial anomalies. The aim of setting up such centers was to provide quality comprehensive treatment for patients from all sections of society with cleft and craniofacial anomalies.

Use of a modified Furlow Z-plasty as a secondary cleft palate repair procedure to reduce velopharyngeal insufficiency

Cleft palate repair is done to allow for normal speech by separating the oral and nasal cavities and creating a functioning velopharyngeal valve. However, despite cleft palate repair, some patients demonstrate velopharyngeal insufficiency (VPI). An attempt was made to determine the effectiveness of a modified secondary Furlow Z-plasty in improving VPI. Fifty-five children aged between 12 and 15 years, with postoperative VPI following primary palatoplasty, were included in the study. These children underwent a modified Furlow Z-plasty. Nasometry was done to determine the change in velopharyngeal function due to the secondary Furlow Z-plasty by comparing the preoperative with the 1-year postoperative nasalance scores. A test-retest study was performed to determine the reliability of the nasometric measures. Reliability measurements of the nasometer passages revealed good reliability for 18 out of the 25 speech passages. There was a statistically significant reduction in VPI at 1 year postoperative in patients who were treated with the modified Furlow Z-plasty, with a P-value of <0.001 in all passages, except velar plosives, which had a P-value of 0.002. Patients with VPI after primary palatoplasty and treated using a modified Furlow Z-plasty had significantly lower nasalance scores at 1 year postoperative, indicating significantly improved velopharyngeal function.

Options for the nasal repair of non-syndromic unilateral Tessier no. 2 and 3 facial clefts

Background: Non-syndromic Tessier no. 2 and 3 facial clefts primarily affect the nasal complex. The anatomy of such clefts is such that the ala of the nose has a cleft. Repairing the ala presents some challenges to the surgeon, especially to correct the shape and missing tissue. Various techniques have been considered to repair these cleft defects. Aim: We present two surgical options to repair such facial clefts. Materials and Methods: A nasal dorsum rotational flap was used to treat patients with Tessier no. 2 clefts. This is a local flap that uses tissue from the dorsal surface of the nose. The advantage of this flap design is that it helps move the displaced ala of a Tessier no. 2 cleft into its normal position. A forehead-eyelid-nasal transposition flap design was used to treat patients with Tessier no. 3 clefts. This flap design includes three prongs that are rotated downward. A forehead flap is rotated into the area above the eyelid, the flap from above the eyelid is rotated to infra-orbital area and the flap from the infraorbital area that includes the free nasal ala of the cleft is rotated into place. Results and Conclusions: These two flap designs show good results and can be used to augment the treatment options for repairing Tessier no. 2 and 3 facial clefts.

A comparative study of two different techniques for complete bilateral cleft lip repair using two-dimensional photographic analysis

Background: The aim of this study was to compare the clinical outcomes of two techniques to repair complete bilateral cleft lip by using indirect two-dimensional photographic analysis. Methods: One hundred eight bilateral cleft patients were included in this study, 54 patients operated on with the Millard technique and 54 patients operated on with the Afroze technique. Each group of patients was further separated into two subgroups containing symmetrical and asymmetrical cleft lips. All patients were photographed preoperatively and 4 years postoperatively in frontal and submentovertical views in a reproducible way. Eight measurements were performed on the photographs. From these measurements, seven ratios were calculated to compare the two techniques. Results: The outcomes of the interobserver and intraobserver measurements were analyzed using the Pearson correlation test. There was a statistically significant reliability in the intraobserver and interobserver ratios. Analysis of the ratios was performed using the independent samples t test (5 percent level of significance). The authors found that the Afroze technique was better than the Millard technique in six of the seven parameters for symmetrical clefts and in four of the seven parameters for asymmetrical clefts; however, there was no statistically significant difference seen between the two techniques. Conclusions: The Afroze technique seems to have good clinical outcomes on bilateral cleft lip patients, but more research and long-term follow-up are needed to determine the full outcome of the technique in various parameters. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Intraoperative vascular anatomy, arterial blood flow velocity, and microcirculation in unilateral and bilateral cleft lip repair

Background: Cleft lip repair aims to normalize the disturbed anatomy and function. The authors determined whether normalization of blood circulation is achieved. Methods: The authors measured the microcirculatory flow, oxygen saturation, and hemoglobin level in the lip and nose of controls (n = 22) and in patients with unilateral and bilateral cleft lip–cleft palate. The authors measured these parameters before lip repair (n = 29 and n = 11, respectively), at the end of lip repair (n = 27 and 10, respectively), and in the late postoperative period (n = 33 and n = 20, respectively). The arterial flow velocity was measured in unilateral groups at the same time points (n = 13, n = 11, and n = 12, respectively). Statistical differences were determined using analysis of variance. Results: Before surgery, the arterial flow velocities and microcirculation values were similar on each side of the face and between groups. The microcirculatory flow was significantly higher in the prolabium of bilateral patients than in the philtrum of controls. All circulation values in unilateral and bilateral patients in the late postoperative period were within the range of controls and of those before surgery. Intraoperatively, the authors consistently found a perforating artery on the superficial side of the transverse nasalis muscle. Conclusions: There appears to be no intrinsic circulatory deficit in unilateral and bilateral cleft lip–cleft palate patients. The increased flow in the prolabium indicates a strong hemodynamic need in this territory, compelling its vascular preservation. Whether surgical preservation of the nasalis perforator artery is of long-term benefit should be addressed in future studies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Maxillofacial growth and speech outcome after one-stage or two-stage palatoplasty in unilateral cleft lip and palate. A systematic review

BACKGROUND The number of surgical procedures to repair a cleft palate may play a role in the outcome for maxillofacial growth and speech. The aim of this systematic review was to investigate the relationship between the number of surgical procedures performed to repair the cleft palate and maxillofacial growth, speech and fistula formation in non-syndromic patients with unilateral cleft lip and palate. MATERIAL AND METHODS An electronic search was performed in PubMed/old MEDLINE, the Cochrane Library, EMBASE, Scopus and CINAHL databases for publications between 1960 and December 2015. Publications before 1950-journals of plastic and maxillofacial surgery-were hand searched. Additional hand searches were performed on studies mentioned in the reference lists of relevant articles. Search terms included unilateral, cleft lip and/or palate and palatoplasty. Two reviewers assessed eligibility for inclusion, extracted data, applied quality indicators and graded level of evidence. RESULTS Twenty-six studies met the inclusion criteria. All were retrospective and non-randomized comparisons of one- and two-stage palatoplasty. The methodological quality of most of the studies was graded moderate to low. The outcomes concerned the comparison of one- and two-stage palatoplasty with respect to growth of the mandible, maxilla and cranial base, and speech and fistula formation. CONCLUSIONS Due to the lack of high-quality studies there is no conclusive evidence of a relationship between one- or two-stage palatoplasty and facial growth, speech and fistula formation in patients with unilateral cleft lip and palate.