Live tweeting the PLASTA Webinar Series by Mr Amir Sadri (GOSH) @AmirSadri4 - 'Cleft Surgery for FRCS(Plast)' via Zoom
A thread of live tweets, followed by a Summary
Link: us02web.zoom.us/webinar/regist…
A thread of live tweets, followed by a Summary
Link: us02web.zoom.us/webinar/regist…
2/ Objectives: Approach, Principles, Timing and whether you have seen it or read the books - important for the FRCS
3/ Common question - neonatal cleft: Assess airway (Pierre Robin), Breathing, Feeding, Other anomalies, refer to cleft unit, a timeline of operations.
NB: babies with cleft can swallow but cant suck (no negative pressure)
NB: babies with cleft can swallow but cant suck (no negative pressure)
4/ GOSH Protocol (@GreatOrmondSt Protocol):
1. Cleft CND wihtin 24 hours (to estbalish feeding)
2. Cleft MDT at 6/52
3. Lip and Hard Palate (HP)repair at 3-4/12
4. Soft palate repaired at 9-12 months. Repair before baby starts to talk to avoid cleft speech characteristics.
1. Cleft CND wihtin 24 hours (to estbalish feeding)
2. Cleft MDT at 6/52
3. Lip and Hard Palate (HP)repair at 3-4/12
4. Soft palate repaired at 9-12 months. Repair before baby starts to talk to avoid cleft speech characteristics.
5/
5. Speech surgery if required (SLT assessment >2.5 years)
6. Alveolar bone grafting at age 9 (approx.)
7. Jaw surgery at skeletal maturity (MDT with orthodontist)
8. Rhinoplasty and Lip revision if required at maturity.
9. Discharge at age of 20
5. Speech surgery if required (SLT assessment >2.5 years)
6. Alveolar bone grafting at age 9 (approx.)
7. Jaw surgery at skeletal maturity (MDT with orthodontist)
8. Rhinoplasty and Lip revision if required at maturity.
9. Discharge at age of 20
6/ Rules of 10 by Millar is not really clinically applicable anymore. Recent evidence just suggest the baby needs to be healthy prior to surgery.
7/ Anthropomortric points: more educational than clinically relevant
8/ Principles of cleft repair: CLOSE THE GAP
"layered repair with muscle repair. Break up cutaneous scar so not a straight line"
1. Lengthen cleft lip height
2. Reorientate muscle
3. Balance cupid bow
4. Continuity white roll & vermillion
5. Address nose - maybe
"layered repair with muscle repair. Break up cutaneous scar so not a straight line"
1. Lengthen cleft lip height
2. Reorientate muscle
3. Balance cupid bow
4. Continuity white roll & vermillion
5. Address nose - maybe
9/ Multiple techniques: Millar, Fisher, Tord Skoog, Jean Deailre 1978, Afroze 2009, Lester Mohler.
NB: The muscle repair more important the cutaneous repair
NB: The muscle repair more important the cutaneous repair
10/ Mark complete cleft lip
1.cupid bow trough
2.cupid bow peal
3.Philtral column
4.Where cupids bow should be on cleft side
5.Columellar base
6.Alar base
7.Nordoffs Point (where dry VB disappears)
8.Wet dry junction
9.Curved millard rotation incision, C flap, back-cut
1.cupid bow trough
2.cupid bow peal
3.Philtral column
4.Where cupids bow should be on cleft side
5.Columellar base
6.Alar base
7.Nordoffs Point (where dry VB disappears)
8.Wet dry junction
9.Curved millard rotation incision, C flap, back-cut
11/ Palate Repair
Vomerine Flap - UK
Straight lint repair woth intravelar veloplasty - UK
Many other techniques (von Langneback, Bardach, Furlow).
NB: Growth is always an issue
Vomerine Flap - UK
Straight lint repair woth intravelar veloplasty - UK
Many other techniques (von Langneback, Bardach, Furlow).
NB: Growth is always an issue
12/ Why repair cleft palate?
Not for feeding.
Improve hearing
Improve speech (repair doesn't make you talk, it makes you sound clearer)
Improve nasal regurgitation
Not for feeding.
Improve hearing
Improve speech (repair doesn't make you talk, it makes you sound clearer)
Improve nasal regurgitation
13/ Example:
Von Langebak: bipedicled flap
V-Y pushback: poor growth outcomes, granulation tissue. poor maxilla expansion
Furlow: Double-opposing Z- plasty - good speech.
Vomerine: transposition flap of mucoperostium off vomar to reconstruct palate - a single layered closure.
Von Langebak: bipedicled flap
V-Y pushback: poor growth outcomes, granulation tissue. poor maxilla expansion
Furlow: Double-opposing Z- plasty - good speech.
Vomerine: transposition flap of mucoperostium off vomar to reconstruct palate - a single layered closure.
14/ Alveolvar bone grafting
Defect in alveolus is not repaired primary (generally speaking - its controversial). Secondary bone grafting is common during phase of mixed dentition and 2/3 of the canine root is developed
NB: A common exam question
Defect in alveolus is not repaired primary (generally speaking - its controversial). Secondary bone grafting is common during phase of mixed dentition and 2/3 of the canine root is developed
NB: A common exam question
15/ Cancellous bone from hip. A cortical segment to reinforce the nasal floor. Cancellous segment impacted in the actual cleft
16/ Speech surgery
Assessment at 2.5 years
Velopharyngeal dysfunction: incompetence vs insufficiency
Hypernasality vs nasal escape/emission
Assessment at 2.5 years
Velopharyngeal dysfunction: incompetence vs insufficiency
Hypernasality vs nasal escape/emission
17/ Speech Assessment 101:
" Oral Pressure Consonants" - B,D,P
M, N come out from nose (not dependent on oral pressure)
Easier to remember than "fricatives and plosive sounds"
" Oral Pressure Consonants" - B,D,P
M, N come out from nose (not dependent on oral pressure)
Easier to remember than "fricatives and plosive sounds"
18/ Speech Assessment - History:
1. Nasal regurgitation
2. Incomprehensible Speech
3. Peers - can they understand you
4. School
1. Nasal regurgitation
2. Incomprehensible Speech
3. Peers - can they understand you
4. School
19/ Speech Examination
Oral pressure consonants
Bob is a baby boy
I saw sam sitting on a bus
Karen is baking a cake
"They can say Nanny but not Daddy"
Look in mouth for fistula
Oral pressure consonants
Bob is a baby boy
I saw sam sitting on a bus
Karen is baking a cake
"They can say Nanny but not Daddy"
Look in mouth for fistula
20/ Speech: Video Fluoroscopy
Visualizes the soft palate moving.
Look for soft palate touching the posterior pharyngeal wall
Visualizes the soft palate moving.
Look for soft palate touching the posterior pharyngeal wall
21/ Speech Surgery: "Optimise the palate, look at the throat"
1. Fix clift
2. Fix fistula
3. Put muscles into place
4. Lengthen palate by adding tissue if short palate (buccinator flap)
5. Pharyngoplasty (after optimizing the soft palate)
1. Fix clift
2. Fix fistula
3. Put muscles into place
4. Lengthen palate by adding tissue if short palate (buccinator flap)
5. Pharyngoplasty (after optimizing the soft palate)
22/ Hyne Pharyngoplasty
Making the soft palate do less work.
Two transposition flaps
Creates bulk
Making the soft palate do less work.
Two transposition flaps
Creates bulk
23/ Q&A: syndromic cleft protocol - a different protocol to usual. heart needs fixing before cleft
24/ Q&A: difference between Millard 1 and 2 - its essentially a back cut. increases movement
NB: think of cleft surgery like plastic surgery - it'll make it easier to understand.
NB: think of cleft surgery like plastic surgery - it'll make it easier to understand.
25/ Q&A: Hard Palate repair at 3-4/12 as peri-operative morbidity is the lowest (around 5kg)
