Plastic surgery: new methods and refinements

Plastic Surgery

New Methods and Refinements

Tord Skoog

MD . FAC.5.(Hon.1

Professor of Plastic Surgery, University of Uppsala, Sweden

w. B. Saunders Philadelphia · London· Toronto

Copyright © 1974 by Tord Sk oog,

AlmQvist & Wik sell International, Stockholm, Sweden.

All Rights Reserved.

No pan of this publication may be reproduced or transmitted

in any form , or by any means, electronic or mechanical,

including photocopy, recording , or any information storage

and retrieval syste m, without permission in writing from the

copyright owner.

First published by

Almqvist & Wiksell International

Stockholm - Sweden

ISBN 91 ·22 00000·3 in Collaboration with W. B. Saunders Company Philadelphia, Penn., USA

ISBN O· 7216·8355·X Library of Congress Catalog Card Number: 74~11 691

Published in Italian by Piccin editore, Padova in Japanese by Igaku Shoin, Ltd., Tokyo in Spanish by Salvat Editores, SA, Barcelona

Drawings: Poul Buckhoj Photography: Per-Erik Barkman, Lars Nystrom and Tord Skoog Bookdesign: Bertil Samuelsson Layout: Bengt Hogstrom

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Contents

7

Foreword

Prefac e

9

Acknowledgements

11

Section One 14 34 II 80 III 94 IV 124 V 144 VI 156 VII 174 198

VIII IX

Congenital Facial Clefts

The Cleft Maxilla

The Cleft Nose

The Cleft Lip

Bilateral Clefts Lateral Clefts Regeneration of Facial Periosteum an d Bone; Experimental Research Cleft Palate 1; Primary Repair Cleft Palate 2; Secondary Repairs

Sectio n Two 224 X 250 XI 284 XII 300 332 382 392 412 428 456 499

The Large Nose Protruding Ears

XI II XIV XV XVI XVII XVIII

Cartilage Regeneration; Experimental Research The Aging Face Breast Hypertrophy Inverted Nipples Axillary Hyperhidrosis Syndactyly Dupuytren' s Contracture 1; Pathology, Pathogenesis

XIX

and Predisposition Dupuytren ' s Contracture 2; Surgical Treatment Biographical data

Foreword

Out of each generation of surgeons two or three "Meister A"zte" seem t o emerge. From such men a specialty derives its standards and direction. Sometimes these men excel in developing and refining in­ novative surgical techniques. Others achieve eminence through their abilities to teach and communicate the specialty, particula r­ ly in writing. Still others are honored and respected for their organizational talents in forming and fostering productive, progressive surgical units which often outlast the career of the founder. It is exceedingly rare, however, to find all of these gifts in a single individual. Such a surgeon is Tord Skoog. Along with scores of others who have traveled from every part of the world to work with him in Uppsala, we find this conclusion inescap­ able. In this text Skoog demonstrates a rare quality of honesty and directness. Although his unit at the University of Uppsala pro­ vides, with outstanding quality, the full spectrum of plastic sur­ gical services, he restricts the material here to philosophies , in­ novations, and surgical techniques which are largely his ow n. While thus limiting the subject matter, the author nonetheless manages a concise presentation of what plastic surgery is large­ ly about. An abundance of meticulously accurate and infor­ mative illustrations complete the instruction. The first section, dealing with clefts, must certainly become a classic description of a superior approach to surgical manage ­ ment of this deformity. While some of the techniques presented demand superior surgical abilities, they are described and illustrated in a way which cannot be misunderstood. The second section is devoted to innovative procedures for cor­ recting the most common aesthetic deformities . The chapters on axillary hyperhidrosis, syndactyly, and Dupuytren's contrac ­ ture are beautifully written and illustrated presentations of Skoog's original work in these areas.

, The book will be most va luable to tho se student s of plastic surgery or related specialities who seek a greater understanding of the deformed anatomy and to those who are w illing to strive to achieve the best possible surgical corrections of these defor­ mities, rather than be content with acceptable standard tech­

7

niques. Books such as thi s, w ith ra re attention to accu racy , editing and illustrations, q ui kly become classi cs and find a special place in the surge on's library. Richard C. Schultz, M.D., F.A.C. S. Head of the Department of Pla stic Surgery University of Illinois, U. SA. Paolo Santoni Rugiu, M .D. Head of the Depa rtment of Plastic Surg ery University of Pisa, Italy

8

Preface

Pla stic surgery is to o b ro ad a field to succ es sfully cover in a single book . I have thus tri ed t o limit this volume to selected topics. Only my personal p rocedures, dev elope d and improved over the years are presen t ed , w ith the early pitfalls and co mp li­ cations essentiall y eliminated . For each con di tion the pathology, surgical anatomy and func­ tional significance of the related structures are an alyzed. The problem is thus defined and a metho d of repair outl ined , g reat emphasis is then placed on the p rinci p le s of re co nstructi o n. The surgery in a typi cal case illust rates each o pera tive t ech · nique. Since pre cise knowl ed g e of all de tail s is a p rerequisite for success in treatment, col o red p hotograp hs hav e been used extensively to gi ve a true prese ntati on and all ow a thorou gh understanding of every phas e of t he procedures . Th ese p i ctures are supplemented with drawi ng s to clarify fin e poi nts and h ig h · light important aspects. With this pi cto rial approa ch , t he ac­ companying descript ions have bee n mad e concise to ex press the f acts merely on a w orking basis. From cu m u lative persona l ex perience it is felt that defi n ite co ncl usions may be drawn i n reg ard to the indications, co mp licatio ns and results of these techniques. Other aspects ent er ing into reconstructi ve t reat­ ment are occasionally entertained . The final goal of all recon str uctive surge ry is to restore no rma l anatomy and phy siology. T his is be st achieved by re con st itut­ ing the structural matrix, not just superfici ally adjusting th e integument. The value of this approach is pa rti cul arly eviden t in the treatment of facial cleft malformations, wh ere biol og ical studies and anatomical anal ysis have led to a better un der­ standing of the deformity and its aberrations, on the basis of which more functional repairs have been devised. These proce· dures co ver the primary treatment of all facets in th ese complex conditions. Many of them are evolutionary in character and modifications of the techniques w ill undou btedly be added , based on the original concepts. The trea tm ent of secondary de­ formities w ith their multitude of anatomic varieties is not w ithin the main focus of this book . An exception has been made f o r correction of velopharyngeal incompetence, persisting after an unsuccessful primary repair. In treating acquired diseases, clinical experience and patho­ logic observations form the basis for new operative methods, and this is particularl y noted in selective aponeurectomy for Dupuytren ' s contracture and in the treatment of ax illary hyper­

9

hidrosis. In aesthetic surgery, the rationale of previously sacro­ sanct techniques has been challenged and more radical proce­ dures have been introduced . The correlation between research and clinical work is apparent throughout the tex t. This interaction has germinated surgical in ­ nova tions which have proved most gratifying w hen the poten­ tials of periosteum and perichondrium were realized for gen­ erating bone and cartilage . These discoveries were here utilized for specific reconstructi ve purposes and promise even wider future developments. An effort has been made not to overburden the text with references or historical reviews. This should , howeve r, not diminish our gratitude to all those who developed the knowledge and standards on which the present work is based. The book itself is basically the culmination of my thirty years of work in plastic surgery. It has been influenced by the brilliant men who taught me the speciality-Professors Richard Faltin and Atso Soivio in Finland, Sir Harold Gillies and Sir Archibald Mcindoe in England, as well as the pioneers and great men of the United States-Sterling Bunnel, Sumner L. Koch and James Barret Brown, to name only a few. In retrospect, however, the most profound stimulus for this work has come from the men who have studied with me in Uppsala. From diverse back ­ grounds and different countries, they brought unique philo­ sophies and approaches-causing me to question, mOdify and eventually refine my methods into the techniques of which this volume is comprised. These fine men have formed a socie­ ty, and the society has done me the honor of taking my name. I am thus indebted to all the members of the Tord Skoog Society, as they were the primary inspiration in my efforts.

Tord Skoog

10

Acknowledgements

The University of Uppsala gave early recognition to the speciali­ ty of Plastic Surgery and at the University Hospital excellent conditions were made available for this new branch of surgery . I am deeply grateful to these two institutions for their continued support. The days of the lone brilliant pioneer have passed and the peripheral approach has been replaced with co-ordinated efforts. The climate of close cooperation within the medical faculty and the access to vast facilities and resources of the highly specialized modern hospital are vital to keep pace with modern developments. My special thanks go to Dr. Stephen Sohn , presently working with me in the clinic. He has been invaluable as a sounding board for my ideas. His quick mind perceived the surgical problems involved, and his considerable literary talents have offered a new dimension to the book. The clarity of the text reflects his tireless efforts. Dr. Leith Douglas embodies the spirit of the men who have come to my Department in Uppsala. He has taken time from his busy work to look over most of the book, analyzing and correct­ ing with the critical eye of an experienced plastic surgeon and talented writer.

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The detailed photographs and drawings are the cornerstone of the book . To help with these illustrations I have had the good fortune to have three most skilled people, medical artist Poul Buckhoj and hospital photographers Per -Erik Barkman and Lars Nystrom. I admire their talents and great patience in so faith ­ fully carrying out my every instruction , even when it involved tedious, repetitious work to improve on minor details. The con­ tribution of Buckhoj is of an obviously exceptional calibe r and should well serve one objective of this book : the creation of surgical illustrations which would meet the needs of the practis­ ing plastic surgeon. Our many hours of working together have been a most pleasant experience. When the writing of the book spread over a longer period than planned my debts increased to the staff of the Plastic Surgery Department. In parti cular, I am grateful to my asso ciates, Dr. Bengt Ponten and Dr. Sune Johansson for their kind and gener­ ous support during this time. My thanks are also due to my secretary, Miss Margareta Gustafsson, who has prepared the

11

final copy from dev iously interlined longhan d man uscri pts that one less familiar with my handwriting could not have man aged into serviceable form.

From the incipience of this work the M an aging Direct or of A lm ­ qvist & Wiksell Boktryckeri AB, Gbran Z. Haegg strb m, has given me the most generous cooperation . A book of this kind involves the aid of many indiv iduals and more people than I ca n name here have helped in extraordinary way s. I ca nnot om it, however, personal acknowledgements to Me. Be rtil Sa mu elsson fo r the final shaping of the book and to Mr. Bengt Hbg strom for his lucid and art istic la y out. In concluding I would like to express my sincere gra tit ude to all the patients who have made th is book po ssi bl e by ki nd ly per ­ mitting the publication of ph otograp hs related to the ir trea t­ ment. It is m y hope that throu g h d ocum e nt ary information of thi s kind we will be better able to hel p th o se affli cted .

Tord Skoog

This publication was sponsored by:

Astra AB , Sweden ;

Dav is+ Geck, Cyanamid International;

Ethicon, Inc., U.S.A.;

Johnson & Johnson, U.S.A.;

Minnesota Mining & Manufacturing Co (3M Company ), U.s.A .;

Societe Steril Catgut (SSC)' Switzerland;

Stille-Werner AB , Sweden ;

VIS Offenburg, West-Germany .

12

Section I

Chapter I

A head from ancie nt Corinth 16 Comments

References

Incidence of congenital clefts 20 Embryology and classification 20 The cleft palate team 22 Registration 23 Appearance and oral pathology M axi llary and dental condition Speech Middle ear and hearing Psychosocial adjustment Principles of repair 28 Clefts of the primary palate Clefts of the secondary palate Timing the repair 30 Operative mortality 31 References 32

Title page; This terracotta head of a clown,4th century B.C" was found at the Potters' Quarter in ancient Corinth . In spite of its small dimensions, the accu rat ely scul ptu red head faithfully reprodu ces the cha racterist ic stigmata of a unilateral cleft li p with the as­ sociated nasal deformity. 14

Congenital

Facial Clefts

A head from ancient Corinth

Athens, Sparta, and Corinth held preeminent position s in an­ cient Greece. Athens was the intellectual capital , Sparta, t he pinnacle of military excellence, and Corinthian craftmanship was renowned throughout the classical world . Potter's Quarter, the excavated workshops of ancient Corinth , is a lasting tribute to her well deserved fame. A wealth of material was unearthed there, including a great number of terra cotta figurines. Over twenty-three hundred of them ha ve been inventoried , and an extensive report of the findings was published by Agnes New­ hall Stillwell in 1952.

Many of the terracottas are representative of the finest work from this golden age of Greece and are considered without parallel. The significance of the figurines, according to Stillwell, is not always clear. They seem to have been made for the work­ man's own amusement or as an exercise in ingenuity, rather than as objects for sale. A large proportion of them were dis­ covered along with vases and other material. The period pieces, have thus enabled archeologists to date the figurines with fair accuracy to a time from the first half of the 7th century B.C. to about the third quarter of the 4th century B.C.

In the archeological museum at Corinth, some examples of the findings from the Potters' Quarter are exhibited. The collection includes a grotesque head, representing a comic actor. On a v isit to the museum in 1968, my daughter Gunhild noticed, that the irregular features of this face resembled the general appearance of a person born with a cleft lip. On closer examination, this observation was easily confirmed (Figs. 1-2). Stillwell gives a detailed description of this male head:

1--,2 These illustrations of the ancient figu'ine high­ light the cleft lip and nasal deformity.

16

"Brown clay. Head solid. Back handmade and too flat. Neck, small and tapering, forms projection which was doubtless in­ serted into socket in neck of figurine. Top of head slightly con­ ical. Forehead marked by long wrinkles. Brows heavy, pulled up in points, and outlined with narrow grooves. Eyeball formed by raised boss with depression in center to indicate pupil. Line of strongly marked upper lid continued in wrinkle running from outer corner of eye to ear. Nose projects nearly at right angles to forehead and is bent to right. Wings of nose strongly marked and asymmetrical. Cheek bones and jaw muscles very promi­ nent. Mouth wide open. Upper lip droops in center. Ears ren ­ dered by large shallow depressions with projecting rims.

Congenital Facial Clefts

In a general way we may connect the head with the actor molds from Terracotta Factory deposits of about the third quarter of the 4th century B. c. These also show the round eyes with wrin­ kles at the outer corners, the nose which makes a sharp angle with the forehead and which is bent to one side, the furrowed cheeks, and the wide, open mouth, but the breadth of concep­ tion and the skilful modelling set this head above most actor types. "

Observations an d medical considerations

3 This three month old boy has a congenitally cleft lip. The extent and type of the malformation corresponds .to .1h.P.dew. .•".t1;1,f> u >TFa­ cotta head. An oblique nose and a severely deformed nostril it also present.

On closer examination, particularly in a light which casts a shadow across the left side of the face, it is evident that the sculptor has depicted the classical features of a congenital cleft through the upper lip. The medial lip segment carries a phil . trum and a well developed center portion of a Cupid 's bow, though slightly displaced due to contracture along the cleft border . Thi s constant finding of cleft abnormalities was, until the middle of this century, overlooked by surgeons in their numerous designs for repair. The lateral lip segment appears small, because it is retracted towards the corner of the mouth in a clownish smile. The faithful reproduction of the anatomy justifies the conclusion that the malformation has remained un­ changed since birth. Secondary deformity from scarring or tis­ sue loss, due to unsuccessful attempts at surgical repair, would certainly not have escaped detection by the observant artist. (Compare Fig . 3.) Since the actor is posed smiling , the cleft lip is presented at maximum width, extensively exposing the alveolar processes and the anterior part of the palate. Apparently, in this case, the cleft did not severely affect the maxilla, at least alignment with­ in the alveolar region is good, and there is no obvious pro­ trusion of the premaxilla . The absence of severe maxillary d e­ formity may be explained by the presence of a Simonart's band at the le ve l of the floor of the nose, where the modelling is not distinct enough for identification. The limited lateral dis· placement of the alar base supports this assumption. Unfor· tunately, the missing lower lip and chin do not permit an eval­ uation of the relationship between the upper and lower jaws. Visible parts of the alveolar processes are edentulous. In the adult stage of a non-operated cleft, displacement, malforma­ tion and caries of the teeth bordering cleft often produce an un ­ sightly and eve n beastl y appearance . For this reason , remo val

17

of the teeth has long been considered most desirable . This seems especially indicated in a comedian , whose profession is to amuse . In clefts confined to the lip, the entire m axi lla is asym metric due to underdevelopment of the affected side . As far as th e wri n­ kled face and sty lized modelling of the terra cotta head permits an evaluation in this re spect, the left cheek b one appears to be at a lower leve l and even sma ller than on the right side. 4 This man, born with a right-sided complete cleh of the lip, had surgical re­ pair in early ch il dhood. Apparently this involv ed co nsiderable sacrifice of lip tissue. No att empt was made to correct th e nose. The persistent nasal de­ formity sh ows a str iking resemblance to that of the sculptured he ad of Corinth.

The scu lptured head, in spite of its sma! 1d im ensio ns, ac curate ­ ly repr od uce s the characteristic nasal asy mmet ry associ ated with a complete unilateral cleft lip. On a larger scale , it cou ld be a typical cas t of an un corrected cl ef t. The en tire no se is deviated to the right, away from the cl eft. The two carti lages, forming the tip of the nose, are separated by a sh allow fu rrow. On the affected side, the nasal tip is flat and due t o displace­ ment of the lower nasal ca rtila ge, the ala r rim dro op s ant erior­ ly. The abnormal attachme nt of the a lar base, as well as the buckling and outward rotation of t e lower carti lage. is also we ll dem onstrated. (Compare Fig. 4.) According to Stillwell, the head represe nts a convention al ty pe of comic. actor . They wore a short, long-s lee ved lu nic, long, tigh tly fitting trousers, a chlamys, an d usually a poi nted cap . T hey are usually chara cterized by a p ointe d be ard, open grin ­ ning mouth , wrinkled cheeks and fore head , bulgin g eyes and sharply peaked eyebrows. With minor vari ation, all are of this type . They can be dated about the middle of the 4th centu ry B.C., but canno t be later than the end of the third quarter of the century , when New Comedy replaced Middle Comedy. The occupation of the person w ho posed for th e artist is of great interest. One can easily imagine the social impli ca tions of a cleft lip deformity at a time when sur gical rehabilitatio n could not be provided. Apparently the bearer of the cleft had overcome the psychological burden of his disability and was able to use his disfigurement as an ass et in his professional life. The fa ct that other heads of comic actors had bent no ses, might even indicate the possibility that the cleft lip deformity was frequent in thi s professional group. There may have been a tendency to select people with thi s type of malformation to undertake comic parts, or alternativ ely, the occupation might ha ve been handed down within families that had a high inci­ dence of this hereditary deformity

18

Comments

From a medical point of view this portrait, made 2300 years ago, is a~ astonishing discovery. It is particularly remarkable that the unknown artist had such a complete awareness of the morphological complexity of the cleft lip and in fact accurately depicted some anatomical abnormalities, whi ch ha v e not be­ come widely recognized until recent years. The general sculp­ ture is an inspired creation of great simplicity and superio r artistic quality. The deformity of the lip and the nose has been modelled in great detail, with an almost scientific accuracy . Cleft lip malformations have also been uncovered in the early art of the new world. They were reproduced in pre-Columbian figurines found in Mexico, but compared to the sophisticated work from ancient Corinth , these Indian sculptures appear quite primitive. They express horror and fear, magnifying the grotesque for a spiritual-magical p urpose (Ortiz-Monasterio and Serrano 1971).

I am indebted to Charles Williams, Director of the excavations con­ ducted by the American School of Classical Studies at ancient Corinth, for allowing me to take and reproduce the photographs of the terra­ cotta head.

References

Ortiz-Monasterio F. and Serrano R. A. : Cultural aspects of cleft lip and palate treatment. Cleft Lip and Palate. Ed. W. C. Grabb, A. W. Rosen­ stein and K. R. Bzoch . Little, Brown and Comp., Boston, 1971, p. 130. Skoog T.: A head from ancient Corinth . Scand J Plas/ Reconstr Su rg 3 : 49, 1969. Stillwell A. N.: Corinth, vo l XV, part 2. The Pollers ' Quarter. The Terra co lIa s. Princeton, New Jersey, 1952 , p 143. 19

Incidence of congenital clefts

Cleft lip deformities, with or without an associated palatal'de ­ fect, occur in slightly more than one per thousand live births. Within the geographi cal area served by the University Hospital in Uppsala, the incidence is 1.22 per thousand. The general characteristics and genetics of our material was evaluated by Henriksson (1971). His work substantiated previous studies, that reveal a predominance of males in clefts of the primary palate and a higher incidence of females for clefts affecting the sec­ ondary palate alone. In addition, the left side of the lip was shown to be more frequently and severely affected than the right one. From a hereditary point of view, cleft lip deformities with or without a cleft palate, and isolated cleft palate mal­ formations, represent two distinct entities. For both groups, Henriksson considered polygenic inheritance to be the most ­ likely explanation.

Embryology and classification

A basic knowledge of normal embryology in the maxillo-facial region is necessary to understand the characteristics of the cleft deformity. Although some disagreement still persists as to the exact details of cleft morphogenesis, there is a general con­ sensus of opinion that the most common clefts , those of the primary palate, arise when the maxillary and merged naso­ medial processes fail to meet and unite (Fig. 5) This simple defect is distorted by dynamic factors , and though the eventual appearance demonstrates the wide range of pos­ sib le outcomes, the end result is strictly related to the exten­ siveness of the cleft. The relationship of the nasomedial proc­ esses to the primordial nasal septum is particularly important. If unrestrained by the lateral segments, the powerful, medially placed growth centers act forcefully and cause marked protru­ sion of the premaxilla. When differentiation into muscle and bone occurs, the discontinuity of these mesodermal tissues further d 'stort the cleft. The disturbed balance between inter­ acting growth centers and the asynchrony within functional tis­ sue layers themselves, accounts for the morphologic complex­ ity of clefts of the primary palate. 20

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Congenital Facial Clefts

A cleft of the secondary palate is the result of failure of the palatal shelves to fuse with each other This defect markedly influences the length and function of the soft palate as well as the general dimensions of the pharynx. Even in "submucous clefts", where the palatal halves are united, the defective mus ­ cular portion manifests an altered topographic anatomy, which results in velopharyngeal incompeten ce. In facial clefts, it has proven particularly difficult to standardize findings. Reproducable data are essential for proper clinical ana­ lysis and for initiating effective therapeutic programs. Th~ problem has been to provide an accurate and consistent termi­ nology. A classification based on embryologic patterns is ..ro w recognized as the best available system. This concept was orig­ inally proposed by Kernahan and Stark (1958) and has been ap­ proved by the International Confederation for Plastic and Re­ constructive Surgery. Recognizing clefts of the primary palate as a single entity, af­ fecting the lip, nose, and maxilla , has been particularly useful in defining the related reconstructive problems and planning an integrated program of repair.

Cle' the,

5 This schematic drawing of a human embryo, during the sixth to seventh week of gestation, is presented to show the proposed mechanism for development of a unilateral cleft lip. On the left side, the paired nasomedial processes, which are destined to form the prolabium and premaxilla, have failed to fuse with the maxillary process. On the non-cleft side , these processes have joined to­ gether and an intact arch has formed .

"""" ;'­

21

The cleft palate team

The manifold problems re lated t o cleft deformities involv e th e domains of many discipline s and logi ca lly requ ire close co­ operation betwee n the va ri o us specialists. This o rganize d, int er­ disciplinary approach ha s markedl y tran sformed the standards of treatment, and more significant results are now achieved than cou ld be expected by a simple arithmetic sum of the in­ dividual con tributions. Koepp -Saker (1971) empha siz ed the distin ct value of group intera ction , which tends to en courage modesty and reduce arbitrarine ss and authoritarian attitude s. In the id ea l setting, where complete surgical correction is p
22

Congenital Facia l Clefts

weekly clinics held by the team . The matron of our Cleft Palate Home is an essential participant. She acts as a social worker in adjusting the environment of the patient. The plastic surgeon is the natural coordinator of the cleft palate team, but any member with a sufficiently wide kn owledge of the whole spectrum of the problems could effect ively serve in this capacity.

.. Registration

Accurate registration, adhering to strict scientific standards, is necessary to establish a preopera tive baseline from wh ich further evaluation can be made at predetermined intervals. In view of the relatively limited experience obtained by each team , every effort should be made to document res ults in such a way, that will permit useful comparisons of the v arious methods employed in different centers.

Appearance and oral patnologv

The original deformity is categorized by use of a chart, where schematic drawings illustrate the possible variations and com­ binations of cleft anomalies. Standardized photographs are taken both in color and in black and white. This includes pic­ tures of the entire face "en face " and in profile. Occasionally, facial casts are made. The exact nature of the cleft is best deter­ mined at surgery, including measurements of cleft width. Simi­ lar registrations are made before and after all subsequent sur­ gery and during the entire growth period. The general appearance, proportions and profile of the face are observed with particular attention given to form and function of the lip, nose and skeletal framework . In the lip, its width and symmetry, the Cupid's bow configuration, orbicularis muscle union , and the continuity of the vermilion border are all evalu­

23

ated . At the same time , the position and shape of the philtrum, the amount of ves tibular lining , and residual scars are assessed . The nose is examined to determine dev iation of the septum , position of the pyramid , airway size , cartilaginous definition of the nasal tip , alar configuration, and depression of the base. Intraoral conditions are also observed , recording the extent of the cleft and estimating the tissue available for repair. The needs are then related not only to the size of the cleft, but also to the dimensions of the pharynx . Secondary deformities present a more complex morphology and require a careful study of the anatomy and speech before-attempting reconstruc­ tion .

Maxillary and dental condition

Recordings of maxillary de ve lopment, at regular intervals, are particularly important to assess the value of various surgical procedures . Evaluations are also made before and after each program of orthopedic and orthodontic treatment. These in­ clude:

Dental examination

A routine examination is performed. Position of the teeth , hy­

giene, and general stage of development are all noted .

Maxillary casts

Generally, the original condition is recorded at the time of primary repair of the lip or palate, at 3 months and 18 months respe ct ively. ImpreSSions are conveniently made prior to sur­ gery, when the child is anesthetized and intubated When preoperative ma xillary orthopedics is required , casts are made before initiating treatment. Similarly, the condition is re­ corded before and 'after orthodontics. Study models are ob­ tained at the age of about 5,16 and 19 years . Intermediate evaluations are made at approximately 8,12 and 14 years of age: a) after eruption of the first permanent molars, lower in ­ cisors and upper medial incisors; b) after eruption of the bi ­ cuspid s; c) after eruption of the permanent canines and second ·molars.

Photographs

, 24

Dia-slides of the full face, profile, and intraoral views are taken

at the <same intervals as the ma xillary casts.

Congenital Facial Clefts

Intraoral roentgenograms

a) Intraoral roentgenography is carried out before any surgery of the cleft region (Fig. 7). Postoperatively, roentgenograms are taken after 3-6 months and 1-2 years. b) Panoramic roentgeno­ grams of the upper and lower jaws are obtained at ages 5, 8 and 12 years.

Cephalometric roentgenograms

Cephalometric studies are made at 5, 8, 12, 14,16 and 19 years of age. These include: a) Profile cephalometric roentgeno­ graphy in the intercuspal position ; in certain cases these pic ­ tures are taken with the mouth wide open . b) Postero-anterror cephalometric roentgenography with the teeth in the inter­ cuspal position. In both the profile and postero-anterior record­ ings, the head is oriented in the cephalostat along the Frank­ fort horizontal plane.

Speech

To evaluate speech disorders and therapeutic effectiveness, careful analysis and registration is essential. Though subjective parental opinion is sought shortly after surgery, it is seldom possible to obtain meaningful information about speech pat ­ terns until the age of four years. At that time all patients are ad­ mined to the Cleft Palate Home, a rehabijitation center spon­ sored by the Swedish Red Cross.

,

Speech is tested by having the children recite standard sen­ tences, and their efforts are recorded on tape and kept as a baseline, from which future progress can be measured. The cri­ teria used to assess speech are intelligibility, open nasality, closed nasality, consonant articulation and glottic and pharyn­ geal sounds. Special attention is given to velophrayngeal func­ tion and nasal air escape. A complete study is made of the intra­ oral anatomy, velopharyngeal topography and nasal passages, and speech effectiveness is interpreted in view of these find­ ings. The magnitude of speech retardation is estimated by means of various language tests. A rough evaluation of the general maturity and receptivity of the child is also made, so that patients requiring therapy can be admitted at a time when they can fully benefit from treatment. Cineradiography is of use for diagnosing functional and anatom­ i'cal defects. This type of analysis should be carried out routine­ ly, so as to evolve an overall understanding of the complex speech mechanisms found in cleft palate patients .

25 r

... Speech is then observed at regular intervals by the pho niatri­ cian and speech therapist, at the same tim e w hen m axi ll ary development is assessed. Children requiring th erapy ar e tested before and after each course of treatment. The therapeu ti c routine is to admit the patients for periods of three weeks , twice a year, until speech is considered to be norm al o r n o further progres s is made. In the latter instance, addi t ional su r­ gical correction is usually implemented. After the second ary procedure, further speech therapy is need ed to fully utili ze the changed anatomy.

"

Middle ea r and hearing

Earl y restoration of normal hearing and a concom itant redu c­ tion and limitation of morphologi cal cha nges in the m id d le ear is part of the therapeuti cal program. Th e f ollow in g tests are used prior to and every sixth month after cl o sur e of the cl eft pal ate . Routine follow-up is made at t he age of 5, 8, 12, 14, 16 and 19 years .

Otomicroscopic examination

The ty mpanic membrane and middle ear are' ex am ined th rough a microscope. If there are signs of middle ea r effus io n a m yr­ ingotomy is performed, and when the canal contai ns thick tenacious secretions, a tympanostom y tube is inserted .

Eustachian tube function test

In patients who hav e a tympanostom y tube or have had a prev ious perforation of the tympani c mem b rane, the Eustachi an tube function is tested by a middle ear aspiration m ethod .

Hearing tes t

Pure tone audiometry is periodicall y used to evaluate hearing and this is occasionally augmented by other hea ring tests.

Middle ear functio n test

Middle ear transmission is studied by impedan ce aUdiometry.

Radiography of the m astoids

Lateral radiograms of the mastoid area are taken before closure of the cleft palate , and again at the age of 5, 12 and 16 years. Planimetric measurements of the mastoid air cell system are simultaneously performed.

26

Congenital Facia l Clefts

PsVchosocial a djustment

In addition to the usual difficulties of chi ldhood and adoles­ cence, the cleft palate patient carries with him an added bur­ den. He must cope with a prominent disfigurement and/o r speech impairment. This psychological trauma is in some cases , quite significant. Total therapy must therefore consider this aspect of the malformation. The psychosocial adjustment of the child is evaluated and an attempt is made to understand the complex family relationships and interactions. The patient is admitted to the Cleft Palate Home, where he is observed and instructed, but also where he and his parents can see how other children , with similar limitations, learn to handle their prob­ lem s. "T he wounded bird syn drome " is particularly prone to occur among families with crippled childre n. These parents have an instincti ve desire to shelter t he ch il d f rom the harsh­ ness and disappointments of life . This often results in ov er­ protection , which is harmful to child and pa ren t alike. Unless both are re-educated , the child's developmental growth may be stunted and he will never learn to "fl y" al o ne. Occasionally the parents neglect their children . This situation must be corrected, if the child is to progress normally. School age ch ildren attend classes at the Cleft Palate Home, and the teacher can thus re cognize any emo tional problems that are present. She can usually discern whether the problems are secondary to hearing or speech deficits, o r whether they are rooted in deeper maladjustments. When necessar\', refer­ rals are made for child psychiatry . Often , only minimai therapy is required. With adults, the st ay at the center is somewhat different. The various problems are discussed and local so cial workers are contacted t o fa ci litate the patient's integration into the com­ munity. Attempts are made to help the patients adapt to the pressures of society and to make them as productive as pos­ sible. Further education is encouraged and made av ailable both in the center and at home. It must be remembered , that apart from the congenital defect, these patients are normal in every respect. Many are extremely intelligent and will contribute a great deal to society. It is thus of crucial importance, that their mental health is as attentively treated as their more obvious and visible afflictions.

27

Pn"ncip/es of repair

Clefts of

the p rimary palate:

maxi lla.

nose and li p

The congenital cleft of the primary palate can be viewed as a tripartite reconstructive problem, involving restoration of the maxillary cleft, correction of the nasal deformity, and repair of the lip (Fig. 6). These three aspects of the cleft deformity are interdependent, and the treatment of one facet of the anomaly affects the out­ come of the other. The corrective techniques are performed simultaneously and are interwoven into a single, integrated procedure. At operation , one aspect is left uncompleted, while another part of the problem is handled. Exposure is thus facili­ tated, and the coincidental reconstruction of one defect com­ pliments the surgery of the associated deformities . The final effect of dealing with the entire problem as a unit results in a more satisfactory approach , than working on each component singly. For purposes of discussion, however, the various re­ constructive measures will be artificially placed into different chapters, to elucidate the individual techniques and eliminate possible confusion. If deemed necessary, each step can be used independently and performed as a separate procedure, but this type of management decreases the total effectiveness of the repair. The ultimate aim of surgery must be complete anatomical restoration. Based on a detailed analysis of the pathophysio­ logy, the advocated methods of correction rely on valid, but somewhat unconventional principles to realize this goal. For reconstruction of the maxilla, the osteogenic potential of the perios teum is utilized to produce new bone within the defect; the nasal deformity is ameliorated by radicall y shifting the alar cartilage into a normal position; a successfu l reconstruction of the lip relies on the restoration of muscle continuity and bal­ ance, as well as meticulous skin approximation using multiple flap closure. The development of these procedures has gradually evolved from experience with a considerable volume of clinical material over the past twenty years. In the la st decade, the complete operation has been utilized with minor modifications, and over one hundred and fifty cases have been successfu lly treated in the described manner.

28

0'

Congenital Facial Clefts

6 This child demonstrates the ~

-'

characteristic features of a com·

plete cleft of the primary palate. If affects the lip, nose and al­ veolar process, back to the in ­ cisor foramen . The projecting

thrust of the premaxilla ex­ aggerates the bony defect. Due to the marked protrusion, as

well as the split in the nostril, the alar cartilage has become severely displaced and dis ­ torted . The lip segments are widely separated by retraction of the nonunited muscles.

Clefts of the secondary palate

Though clefts of the secondary palate may appear less com­ plicated, superficial closure of midline tissues is insufficient to provide adequate function. Complete reconstruction of the dis­ rupted and deranged mesordermal derivates is as necessary for success in working with cle ft s of the secondary palate, as in dealing with primary palate anomalies. Again, the concept of an anatomic and functional restoration is the cornerstone of the repair. The palatal muscles must be released from their ab­ normal, fixed attachments anteriorly, and rearranged to form a muscular sling across the midline at a posterior level. This allows for unrestricted movements. Elongation of the palate is then accomplished by reconstructing the aponeurotic section. The secondary treatment of cleft deformities are not included in this book. An exception has been made for correction of velo­ pharyngeal incompetence, persistent after an unsuccessful primary repair. Since this sizable group of patients is of great practical importance, the principles of treatment will be dis­ cussed and a method of palato-pharyngoplasty described.

29

Timing the repair

At birth, the individual cleft is maximally deformed an d if not surgically altered, the condition in the newborn remains la rgely unchanged throughou t life. There is therefore no urgent ne ed to institute a hasty repair. The optimal time for reconstruction is determined by deve lopmental , biological, patho-physiological and surgical considerations. Surgical intervention in this area will to some exte nt interfe re with growing tissues. Treatment should thus not be carri ed out if tissues will be unduly damaged by the trauma of a repair. This decision must, howev er, be weighed ...vith the desire to utilize growth potentials for co rrective pu rp oses. The restoration of disrupted functional anatomy is obviously of paramount importance, but neither in clefts of the primary palate , nor of the secondary palate, does thi s dicta te an im ­ mediate repair. The diffi culty with di st urbed feeding in a cleft infant has been overcome by numerous techniques, incl ud in g special made nipples or spoons. Complications related to the malformation, such as repeated middle ear and respir ato ry in ­ fections may, howeve r, ne cessitate early surgical interve ntion, but with the present standard of pediatric care, these indica­ tions have become increasingly rare. At surgery, the child should be in good general hea lth, gaining weight , and have normal blood values. In addition, to attai n a proper anatomical repair , tissues must have reached a certain size and stability. With aI/ these factors duly considered, clefts of the primary palate are rarely operated upon before the age o f three months, and in clefts of the secondary palate, reconstruction is post­ poned a t least until the ag e of eighteen months.

It is important to re-emphasize , that the overall rehabilitation of the patient should not be jeopardized by injudicious haste Anxious parents, who may be greatly distressed by the ap ­ pearance of the disfigurement, must be reminded that social considerations cannot be permitted to compromise the child's best interests.

30

Operative mortality

I

Over the past twenty years, in more than 1 500 primary and secondary operations performed on children wi th cl eft l ips and / or palates, there has never been a death. Sev eral factor s ac­ count for this result, but a marked advancement in anest hetic techniques and impro ve d control of fluid balance are th e major reasons for the enjoyed safety of these procedures.

7 Roentgenograms are taken prior to surgery to reco rd the anatomy of the maxillary cleft.

"

The intubated child is maintained on Penthrane ®, or Halothane, and usuall y breathes spontaneously, though he can be ventilated by hand using the modified Magill's attachment. An i.v . cannula is inserted, usually in the foot, and is used during surgery for blood replacament a'n d to maintain fluid and electrolyte balance for the first few hours postoperatively. The small su ction trap, which is at the child's feet, accu rately measures blood loss. To the right of this bottle is placed the electrothermometer, which is connected to a rectal electrode. The thermostatic heater-pump unit of the water mattress maintain s the child's temperatu re between 36 and 37°C. The ECG oscilloscope, at the end of the operating table, is connected to limb or chest elec­ trodes to keep constant surveillance of heart rate and rhythm ,

31

Additional contributing factors are: a thorough examination of the child at birth , where concomitant malformations or diseases are diagnosed, and cured if possible , before the cleft is repaired; adequate preoperative treatment to ensure a satisfactory gen­ eral condition ; proper timing of surgery; and meticulous post ­ operative care. Invaluable contributions in organizing the registration program were

made by members of the Cleft Palate Team: Rune Hellquist, D.D .S.

(orthodonticsl, Hans lindholm, M.L. (phoniatrics) and Carl-Eric lind­ holm, M.D. (ENT).

References

Henriksson T.-G.: Cleft Lip and Palate. A Genetic and Clinicallnvesti­ gation. Pub!. by the Institute for Medical Genetics, University of Upp­

sala, Sweden, 1971. Kernahan D. A. and Stark R. B.: A new classification for cleft lip and cleft palate. Plast Reconstr Surg 22: 435,1958. Koepp-Baker H.: The cleft palate team. Cleft Lip and Palate. Ed . W. C.

Grabb, S. W . Rosenstein and K. R. Bzoch, little, Brown and Camp., Boston, 1971, p 108.

32

,

Maxillary restoration fo r bone formation

utilizing the periosteum

Chapter II

Introduction 36

Surgical treatment 38

Bone graft ing Pe ri o stea l repai r

Age at op eratio n

Preoperative treatment

Operative procedures 42

I. Complete clefts 43

A. Primary periosteoplasty alone 43

Operative technique

Resu lt

Com m ent s

B. Prim ary periosteoplasty with an implant 49

Operative t echnique

Ea rly result

Late res ul t C. Repeate d periosteoplasty 53

t

D. Delayed pe ri osteop lasty 54

Co mments

II. Inco mpl ete clefts 55

Operative t echn ique

Varia ti o n in operativ e techni que

Result

111. Minimal clefts 58

Result

Maxillary orthopedics and orthodontics 60

Early i nfancy

De cid uou s dentition

M ixed dentition

Permanent dentition

Comments

Results of periosteoplasty 65

Bo ne fo rmation

Growth of th e lateral segment

Mig rati on of te eth

Comments 71

Conclusions 74 Reference s 76

34

Title page: In thi s illu stration of a

complete unilateral cleft a drawing of

the underl yi ng maxillary defect has bee n superi mposed over the soft tis ­ sue fe atures of the malform ation.

The Cleft Maxilla

-----

/ ,,, .. , ,

A method o f reconstruction •

Introduction

Nature is often hidden,

sometimes overcome, seldom extingUished.

Francis Bacon: Essays (1625) Early surgical treatment of cleft anomalies focused on the grossly obvious lip deformity. Not until the past few decades has the importance of the associated maxillary defect been fully appreciated. This bony discontinuity disrupts facial harmony detracting from appearance as well as impairing function. 1-2 This complete uni­ lateral cleft demonstrates the characteristic maxillary asymmetry. The premaxil­ la protrudes markedly be­ tween the lip segments and the impaired growth of the disunited lateral segment is reflected in the displaced alor base .

1 With the presence of a maxillary cleft, the septovomeral growth centers cannot exert an equal influence on the disjoined com­ ponents. Medially, this results in deviated protrusion, the pre­ maxilla being propelled excessively forward on the cleft side . Laterally, the dis connected maxilla is not carried along with the medial segment but is left in a posterior position and thus be­ comes partly responsible for the severe asymmetry that char­ acterizes the malformation. In the normal fetus the connected muscles of the lip mold the developing bony structures, but in the cleft child, with this shaping process absent, the unopposed muscles pull in divergent directions, further deforming and twisting the anatomy.

In addition to the displacement of existing structures, there is a substantial tissue deficiency. This deficit reflects stunted bone growth resulting from the entrappment of the lateral maxillary segment in an enclosing periosteal wrapping.

The wedge -shaped maxillary flaw is widest at the nasal floor and tapers to the alveolar ridge, while the superficial defect is greatest at the lip border and narrows as it approaches the nose. These consistent findings are probably the consequence of different embryonic pathways for mesodermal and ecto­ dermal closure.

36

The Cleft Maxilla

The fact that the superficial malformation hallmarks a much more extensive maxillary rent is graphically demonstrated in incom­ plete clefts. Even when the surface cleft is minimal , as in the un­ treated adult shown in Figs. 3-5, there is evident fascial asymmetry .

3-4 When this thirty-two year old man brought his son for treatment of a complete unilateral cleft, his minimal, almost inapparent lip de­ formity was recognized. No surgical correction had been performed . There is characteristically an associated severe malformation of the maxilla, evidenced by pronounced facial asymmetry with dislocation of the alar base . The view from below highlights this deformity. On contraction of the orbicularis muscle incomplete union of that struc­ ture could also be demonstrated. 5 A panoramic roentgenogram shows a wide piriform aperture on the affected side with a depressed nasal floor. The tooth roots are spread apart by the wedge shaped deficiency of bone within the cleft region.

37

Surgical treatment

For many years , reconstruction of the cleft maxilla was essen­ tially ignored. Authorities warned against freeing the perios­ teum from the maxilla for reasons summarized by Holdsworth (1951). It was fe-ared that facial expression might be disturbed by interfering with the bony attachments of the muscles and that maxillary growth in general might be hampered, thus ex­ aggerating two characteristic stigmata of the cleft patient. Furthermore, since underdevelopment of the maxillary seg­ ments was considered to be the result of disturbed growth potentials, the neighboring tissue was felt to be unresponsive, inadequate, and a poor choice for any reconstructive purposes. These views were never substantiated by critical clini cal ana­ lysis, and the extensive research done 0'1 this subject, referred to in Chapter VII, clearly refutes these early assumptions.

~

I

Bone grafting

To restore maxillary continuity bone grafting techniques were implemented at early ages (Nordin and Johanson 1955, and Schmid 1955). Bone positioned in this way, though providing immediate stability, did not develop with the child (Thiland er and Stenstrom 1967, Friede and Johanson 1974, and others). When retardation of facial growth became apparent this method of treatment was widely abandoned.

Periosteal repair

In the last decade new principles were introduced and uncon­ ventional techniques for reconstruction of the cleft maxilla were developed (Skoog 1965, 1967, 1969 and 1971). The periosteal membranes, bordering the cleft, were utilized for bone forming purposes. When rearranged into a pre-designed position, the new bone was molded to fit the defect.

Though Oilier (1867) clearly demonstrated the osteogenic capacity of the periosteum, his work was not completely ac­ cepted. This persistent dissentation is reflected in the extensive literature on the subject. Two separate clinical observations prompted the development of a technique of periosteoplasty. In performing a maxillectomy on a four month old child, suffering from a semi malignant tumor (melanotic progonoma), the periosteum was left in place. Complete bone regeneration fol­ lowed. This was confirmed by an X-ray taken two years later, which showed a normal maxilla, except for the missing teeth. The second case, stimulating the conversion to the current

38

6 In this preoperative photo­ graph of the above mentioned child the premaxilla is bord ered on each side by a complete cl eft. A staged repair was started at the age of three months.

7 Following lip closure the late ra l ma xi llary segments hav e shifted medially against the pre­ maxilla. On the left side, which was repaired first, alignment is good . The entire alveolar arch has, howeve r, become too nar­ row and corrective jaw ortho­ pedic therapy was periormed at the age of six years.

8 The lateral segments have been re-expanded, thereby re­ producing the cleft on the pa­ tient's right side. Quite un­ expectedly, new bone was found to have formed w ithin the left cleft , where the arrow indicates a substantial bony bridge that unites the premaxilla and the lateral segment.

techniques for maxillary re con struction , was that of a child with co mplete bilateral cleft (Figs. 6-8). The patient was first operated in 1957, and following soft tissue repair new bone formed spontaneously within one cleft. The interpretation of this find­ ing was, that the periosteal membranes unintentionally were united across the cleft at the primary operation and solid bone had subsequently appeared (Skoog 1966).

39

In this chapter operative procedures are described, which re­ construct the bony deficit in the cleft maxilla. For this purpose periosteal continuity is established across the defect by use of a periosteoplasty. The technique is based on three major pre­ mises. (1) The periosteum covering the maxillary segments possesses normal growth potential. (2) Denuded maxillary bone regenerates normal periosteum similar to other bones. (3) The reestablished interaction between growth centers on the medial and lateral sides, and the biomechanics of the en­ vironment, determine the growth and development of the united maxilla.

L

The original techniques were later refined to obtain a larger volume of bone. The illustrative example of the ossifying frontal bone hematoma in childhood initiated these innova ­ tions. There, the subperiosteal collection of blood lifted the periosteal layer off the bone and thus stimulated rapid bone growth. In the search for a suitable periosteal prop, Surgicel '" was used and found to aid bone formation. It must be em­ phasized, however, that it is not the intrinsic nature of the substance itself that enhances bone production. The material merely acts as a scaffold to create a large pocket and thus artificially stimulates the void induced, in the clinical state , by an expanding hematoma. The blood soaked material can be molded to conform to the defect and thus is effectively used to build up depressed contours. Surgicel is known to be well tolerated , and completely absorbed with minimal tissue reac­ tion (Lebendiger et al 1960, Jantet and Rob 1960) .

Age at operation

The growing bones of the developing face reflect periosteal ac­ tivity . As this dynamic force has little or negligible function in the adult, the mature face retains a relatively static configura ­ tion. Clinical experience has shown that there is little decrease in the osteogenic capacity of the periosteum until five years of age . After this period, substantial bone forming activity still re­ mains, and operations can be considered up to the teenage level, but after this time juvenile adaptability of the periosteum expected Iy lessens. 1 Absorbable hemostat (oxidized regenerated cellu lose), Joh nson & Jo hn so n, New

Brunswick, N.J .. U.S.A.

40

The Cleft Maxilla

For practical purposes it has been found most satisfactory to coordinate the maxillary and lip repairs. This means that the primary procedure is performed at three months in unilateral clefts and in the first side of a bilateral cleft. Maxillary recon­ struction can also be conveniently added to other reconstructive efforts in the total scheme of rehabilitating the cleft patient.

Preoperative treatment

.

Many schools of thought suggest maxillary adjustment prior to surgery. This tedious process involves using cumbersome headgear and various other apparatus in attempts to bend the premaxilla towards the separated lateral segment. The un ­ natural pressure placed on the premaxilla is both harmful a,nd unnecessary. The best way of producing alignment is to repair the lip. The natural forces then provide constant, but not in­ appropriate pressure. Technically, there has never been a case in our series, where any preoperative treatment was required . An exception to this practice is made when the original malfor­ mation presents with collapse of the lateral segment. Expansion of the maxillary arch to a suitable position is then recom­ mended. It is easily accomplished just prior to surgery as de­ scribed on p. 60 .

•

41

Operative procedures

Ge n eral co nsiderations

In maxillary cleft, the bony deficit is directly related to the under­ development of the lateral segment . The reconstructive task is thus precisely defined, and correction has been accordingly planned. A further consideration is the widely different char­ acteristics and surgical requirements of the two sides of the cleft.

Lateral border (1) The bony defect is char­ acteristically quite large.

Medial border (1) The bon y deficit is generally negligible.

(2) Local tissues can be used for repair, since the perios­ teum in the area is of good quality. This primitive tissue vigorously responds to the stimulus of manipulation. Utilizing this mechanism for reconstruction requires ex­ tensive exposure .

(2) The periosteum lining the premaxilla is of poor quality. Thus, freeing it will not provide a substantial osteogenic source. The limited need for mucosal lining and flap attachment requires minimal exposure .

(3) There is no need to fear wide exposure of the bone as no bony sutures or other growth sites are present in this area.

(3) Important growth centers bordering the cleft mediall y, demonstrate their poten­ tials in overgrowth. They should be left undisturbed; fun ctional restoration of the adjacent anatomy will gradually normalize their activity.

Based on these considerations, the principles of surgical re­ construction have been to extensively mobilize and utilize tis­ sues on the lateral aspect and to minimally expose and not interfere with the more vulnerable medial side. Clinical experi­ ence as well as extensive animal experiments by Sarnat and Wexler (1968) and Sarnat (1970) support these views. Their con ­ clusion was, that in cleft repair surgical trauma to the septo­ vomeral region might have an untoward effect upon growth of the upper jaw. Each cleft anomaly has its accompanying set of idiosyncracies. The operative design is thus amended accordingly, to fit the particular clinical setting.

42

I. Complete clefts

A. Primary peristeoplastyalone

In treating the complete cleft the surgica l approach must reo concile the extensive dimensions of the maxillary defect with the limited tissue available for reconstruction. In closure, there will undoubtedly be persistent are as which remain in direct continuity with the mouth; used initially, Surgicel, or other foreign implants, would thus invite infection. Correction is therefore planned in stages, with the primary operation con· sisting of periosteoplasty alone, supplemented at a later stage by rep eated periosteoplasty combined with implantation of Surgicel.

Operative techn ique

Preoperative condition 9-10 These illustrations of a three month old child w ith a complete unilateral cleft show his condition at the time of the primary operation. The palatal view demonstrates a substantial defect within the primary palate and the char ­ acteristic protrusion of the premaxillary segment. A periostepolasty is planned for maxillary re­ construction in accordance with the principles

given on the preceeding page. The repair will involve the alveolar process and the anterior half.of the hard palate.

~""''---''----

Prema xilla

....,...'--~----- Lalera l max illary

segment '---,~-'t.::t-----

Nasal septum

43

Reconstructing the inner periosteal lining 11-12 At the medial border, an incision is made approximately 1.5 cm behind the premaxilla and carried between the palatal and septal mucosa. It is continued over the anterior aspect of the free border of the prema xilla, to the base of the columella. The incision is made through mucosa and peri­ osteum. The mucoperiosteum is raised from the protruding cleft surface of the premaxilla. This thin tissue requires careful dissection in order that the flap can be used to line the defect. It aids in bridging the greatest expanse of the cleft. Care must also be exercised to keep the fragile tooth buds from being injured. In the palate the mucoperichondrium is slightly elevated off the septum.

13 The lateral border of the cleft is incised at a level comparable to the medial side. The incision is extended forward between the upper and lower nasal cartilages.

44

The Cleft Maxilla

14 When the lateral incision is carried down to bare bone the retracted border of the piriform aperture and the edge of the maxillary cleft are exposed . The peri­ osteum can now be separated from the inner aspect of the bone along the entire length of the incision. Wide undermining will permit this substantial flap to be med­ ially advanced and sutured to the contra­ lateral flap.

15 The flaps are approximated with 5/0 in­ terrupted catgut sutures, tied on the nasal side. In this suture line there is always re­ traction of the periosteum, particularly along the lateral side. A second row of 4 / 0 Dexon ' sutures on the oral side, assures periosteal continuity and reinforces the mucosa closure.

16 The anterior periosteal suture is being placed which completes reconstruction of a nasal floor.

I

Poiyglycol ic aci d suture, Davis + Geck, Cyanamid International.

45

Reconstructing the outer periosteal lining I

17 In the final stage of repair a second la ye r of periosteal lining is produced by a flap from the outer aspect of the lateral maxillary segment. This flap is rotated through an arc of more than 90 0 and placed on the anterior aspect of the alveolar cleft. In this manner the creation of a periosteum-lined sleeve between the bony surfaces of the cleft is completed. The flap includes most of the periost eu m over the ant ero -Iateral aspect of the maxilla and is based over the nasal process of the maxilla, on the lateral border of the nasal pyramid.

\

18 In order to raise the periosteal flap from the adjacent maxilla exposu re is gained by extension of the o riginal incision laterally, along the buccal sulcus . The incision is made through mucosa and periosteum down to bone.

19-20 Using a dental elevator the entire cheek, including periosteum, is dissected off the maxilla. In the yo ung infant the perios­ teum in this area forms a su bstantial mem­ brane w hich can ea si ly be stripped off the underlying bone. The outer layer of this membrane is composed of coarse fibrous connective tissue whic h lacks elasticity and, therefore, is not ve ry pliable when tran s­ ferred is a flap. For this reason the fl ap is generously designed, up to the infraorbital foramen, and posteriorly as far back as possible, usually up to the origin of th e, zygomatic process.

46

21 Th e upper border of the flap lies just

22 The perio steal flap is dissected free from

bel ow the infraorbital foramen . As this in­ cision is made, the bu ccal fat protrudes and aids in protecting the infraorbital neuro­ vascular bundle from injury.

the cheek tissues .

23-24 The mobilized periosteal flap is rotated as sh ow n in the previous drawing , into its new position across the cleft, with Its deep periosteal surfa ce still facing in­ wards. It is sutu red to the mucoperiosteal edg e on the anterio r asp ect of the premaxil­ la. The upp er border may also be united to the periosteal fla p s o f th e previously con­ structed nasa l floor. 5/0 catgut is used in this approximati on. W hen the flap is inade­ quate, it is p laced h ig h up at the level of the fl oor of the nose, rather than downwards on th e oral aspect

47

Result

25 This child demonstrates a complete bilateral cleft with marked protrusion of the premaxilla, relative to the lateral seg­ ments, and typical abscence of the colum ella. Periosteoplasty of the alveo lar clefts was carried out with lip closure at th ree and six months respectively.

26 This photograph is taken at eighteen months. The premaxilla has become con ­ solidated into the alveolar arch and approximation of the maxillary segments is most satisfactory .

27 The left alveolar cleft has been ex­ posed at th e time of palate closu re. A bony process extend s from the latera l maxillary segment to the premaxilla and a nasal floor is thus formed. Thi s bridge of new bone is fairly thin and cor­ responds in size to the periosteal flap shifted from the lateral segment during a periosteal repair.

28 Most important, however, the entire lateral border of the cleft has advanced medially by the growth of new bone . The development was almost identical on the right side . In this case there was no pre- or post­ operative maxillary orthodontic treat­ ment. Realignment of the maxillary seg­ ments is en tirely the result o f lip rep air and adjustment of the periosteum.

48

The Cleft Maxilla

Com m ents

When a com pletely lined periosteal cavity cannot initially be obtained, incomplete bony restoration is acceptable at the out­ set, for on this matrix a more normal anatomy can be con ­ structed during a further procedure . The anatomical relation­ ships present at th is se condary operation are comparable to the less complicated morphology of an incomplete cleft (see p . 55). Even in complete clefts, it would, however, be possib le to create a closed cavity by utilizing sufficiently large septal flaps or turning a separate mucosal flap from the inside of the lip into the cleft alveolus. These techniques are contraindi ca ted as they depart from the concept of an anatomic repair and concomitant­ ly violate the principle of minimal medial exposure, which serves to safeg uard the important facial growth centers. Furthermore, transferring tissues into unnatural positions would disturb lip symmetry. Used on the outer aspect, the periosteal flap often must be rotated on such a narrow base that its blood supply can hardly be adequate. It then serves as a free graft, providing lining for the cavity and preventing rapid invasion of non-specific con­ nective tissue . In animal experiments, RitsiUi et al. (1972 a) demonstrated co nsistent bone formation from free periosteal grafts. In a limited series of patients they used free grafts of tibial periosteum to form the outer lining of a periosteoplasty. Definite bone formation was observed to overbridge the cleft. It will be of great interest to learn if bone obtained with this technique differs from that produced by maxillary periosteum.

B. Primary periosteoplasty _ __ with an implant (Surgicel®)

When the cleft is li m ited to the primary palate, there is sufficient periosteum to completely line the defect. This permits the sur' gical constr uction of a tight, non-communicatin g pocket. For­ ei gn material can then be successfu lly implan ted when the periosteal membranes are positi oned.

49

Operative techn ique 29 In this three month old chi ld the defect is confined to the primary palate. The maxil­ lary segments are in close approximation at the free border.

31 The well-defined pocket, lined with peri­ osteum and denuded bone, is packed with Surgicel soaked in blood . Since blood provides an ideal medium for bone forma ­ tion and Surgicel mainly serves as a scaf­ fold, the material must be loosely placed in the cavity. The Surgicel extends subperios­ teally across the deficient lateral segment.

50

30 The maxillary defect is exposed , char­ acteristically revealing a large opening in the alveolar process at the floor of the nose, continuing along the retra cted border of the piriform aperture. The mucoperiosteum, raised from the inner aspect of the lateral segment and advanced to meet the cor­ responding flap from the premaxilla, com­ pletely lines the bottom of the cavity.

1 The Cleft Maxi/la

32 A periosteal flap has been raised, as previously described, to cover the implant and form an anterior lid for the pocket.

33 Lip and nose correction have been ac­ complished , using procedures described in the following chapters.

Early result

34 A roentgenogram taken two months postoperatively demonstrates extensive bone formation within the cleft. The arrow points to the thin fissure, which marks the forward edge of growth from the lateral segment. This line may be indicative of the bony suture which normally occupies this site. The premaxilla contribu tes linle to bone regeneration .

51

Late result

•

35 At five years of age permanent tooth buds have migrated into the new bone and occupy the original defect completely .

36 Spontaneous dental arch alignment is well demon­ strated. As often occurs, the decidious teeth are slightly irregu lar in shape and position in the immediate cleft area .

52

37 Genera l facial dev elopment is

normal.

The Cleft Maxilla

C. Repeated periosteoplasty

The periosteum that regenerates over the new bone is of good quality. When raised, this thick, virile tissue rapidly forms ad· ditional bone. Thus, it can be used most effectively in further reconstructive procedures.

•

In the second operation an incision is made along the buccal sulcus and the bone that has developed within the cleft is ex­ posed. The periosteum covering the new bone is incised trans­ versely and elevated to the desired level, where it is maintained by packing the pocket with Surgicel. This maneuvre is generally extended across the maxilla and along the lateral border of the piriform aperture. Relaxing incisions in the periosteum are sometimes required laterally, to allow medial advancement of the periosteal layers; no periosteal flap transfer is required in this procedure. The mucosal incision is accurately closed with catgut mattress sutu res. These subsequent operations have generally been performed three to fifteen months following the initial procedure and can conveniently be carried out in conjunction with some other facet of corrective surgery.

38 This photograph of a three months old boy demonstrates bilateral, complete clefts, the vomero-premaxillary stem thrusts the premaxillary segment into prominent protrusion . The left-sided cleft was closed first. At the same time a periosteoplasty was used to repair the associated cleft of the maxilla. Three months later, du ring su rgery to reconstruct the right side, the area of the left cleft was exposed and a narrow bridge of bone was observed to have formed in this previously open space. The covering periosteum was easily stripped from the new bone, and Surgicel was used as a scaffold to elevate the periosteal layers and thus allow for the production of more bone.

39 One year later, the regenerated bone is exposed in con­ junction with a palate repair. The original, extensive bony defect has been filled with new bone which is almost in­ distinguishable from the neighbouring bony surface. A periosteal elevator marks the reconstructed nasal floor. Just below this instrument, a furrow indicates where the lateral segment has joined the premaxilla. Roentgenograms taken at this time indicate that tooth buds have migrated into the new bone.

53

D. Delayed periosteoplasty

Periosteoplasty as a primary operation may also be successfully performed at later stages. When maxillary reconstruction is not carried out at the primary repair of a cleft, there is, however, a great tendency for maxillary arch collapse . This requires lengthy orthodontic expansion prior to surgery. a nd highlights a major disadvantage in delaying the periosteal repair. Other drawbacks, associated with performing delayed periosteoplasty , are the technical difficulties arising from the presence of fistulae and a generally distorted anatomy.

40 In the primary repair of this three months old boy periosteal continuity was achieved across the deep aspect of the cleft, but no periosteal flap was raised to cover the bony defect an­ teriorly. The resulting new bone was later found to be incomplete.

41 Expansion to correct moderate maxillary collapse at the age of 6 t years revealed the ex· tent of the persistent bony defect. Periosteo ­ plasty was then carried out. This photograph shows a retention lingual arch with splints in position.

42 Six months after surgery roentgenograms demonstrated remarkable bone formation. This panoramic view was taken two years later. A tooth and a tooth bud have moved from the lateral segment towards the new, bridging·bone. It is our experience with these situations, that eruption will Occur within the cleft.

54

The Cleft Max illa

Co mments

The results of delayed periosteoplasty are somewhat unpre­ dictable. This varying response is possibly related to tissue scarring, either from previous surgery , or chronic irritation of the abnormal anatomy that has persisted . When bone forma ­ tion is inadequate, repeated periosteoplasty ilas proved quite effective in adding new bone in spite of the older age of these patients.

II. Incomplete clefts Since the actual extent of the maxillary defect always exceeds clinical expectations,. the bony deficien cy which accompanies incomplete clefts of the lip deserves close attention . Periosteal repair offers new possibilities for reconstruction ; the technique is simple and effective, and should be an integral part of the routine treatment of incomplete clefts, regardless of the degree of deformity. The incisions required for the lip repair generally offer adequate exposure to work on the maxilla. The size and shape of the cleft permits the use of Surgicel along with the periosteoplasty, where the implant is packed away into a well­ confined, closed pocket.

55

43-44 The frontal view of this child w ith an incomplete cleft lip barel y suggests the associated maxillary defect . The vi ew from below, how­ ev er, dem onstrates a depre ssed nasal flo o r and alar base that marks a substantial bony defect .

Operative tec hniqu e 45 The preoperati ve condition of this patient is sh own in Figs . 43-44. A h o rizontal incision has been made through the periosteum at a level with the bottom of the bony defe ct. Throug h this incision , the periosteal layer, cove ring the w idened nasal floor is raised . To correct unde r­ deve lopment laterall y, and to yield enough peri­ osteum, the elevation must be extended across the maxilla as well as along the border of the piriform aperture . If left in this stage, the flat sub­ periosteal po cket, created by the maneuvre, ha s a great tendency to collapse.

46 The new position of the perio stea l membrane is maintained with loosely packed, blood soaked Su rgicel. In minor defects the anterior o pening is small , when compared to the bon y and periosteal sur­ faces , and the cav ity may thus not need a lining anteriorly. Larger openings are covered by ad­ vancing the periosteum from the lateral side, after a relaxing incisi o n has been made . A formal perios teal flap transfer from the cheek region is rarely required .

56

Variation in operative technique

In deeper incomplete clefts of the maxilla, the bordering peri­ osteum appears to be of inferior quality. This deficient tissue is carefully dissected off the bone and is not used for periosteal lining along the nasal floor. Instead, after mobilization, the dense more superiorly placed periosteal mem~ranes are united with catgut or dexon sutures, or as an alternative technique, a periosteal flap is raised lateral to the defect, rotated, and at­ tached to the base of the septum as shown below.

47-48 The incomplete cleft was corrected when this girl was 18 months old. Despite minimal soft tissue deformity, there was a marked bony defect. The diagram depicts the widened piriform aperture on the left side, and the peri­ osteal flap that was rotated to build up the nasal floor.

_/_..:.,:I.......~"

57

Result 4~50

Four years postoperatively symmetry has been attained . The X-ray demonstrates the pres­ ence of a bony nasal floor corresponding to the positi on of me periosteal flap. Tomog rams showed that behind the flap the nasal fl oor re­ mained depressed. The photograph was taken at the age of ten years.

III. Minimal clefts 51 This three month old boy suffers from a bilateral cleft deformity, though minimal on the right side. The depression of the left alar base, due to the con­ comi tant maxillary defect, is quite apparent. When the completely cleft side was repaired a periosteoplasty was included in the procedure.

58

52 Six months postoperatively the maxillary development, which had previously appeared normal o n the right, demonstrates an obvious depression when compared with the restored left side .

., r

53 Exposure of the repaired cleft shows ex­ tensive bone formation with a normally posi­ tioned nasal floor. New bone has formed along the lateral border as well as on the outer aspect of this segment. The result is a united and level maxilla .

54-55 Raising the periosteum on the right side reveals a defect of the nasal floor as well as the retracted lateral border of the piriform aperture. This graphically demonstrates the extensive max­ illary deficien~y associated with even a minimal cleft lip. Correction was then accomplished by subperiosteal implantation of Surgicel.

59 (

Result

56 Panoramic roentgenogram at the age of 7 yea rs shows maxillary continuity and largel y restored symmetry. Teeth and tooth buds hav e migrated into the new bone.

Maxillary orthopedics and orthodontics

Early infancy

When marked maxil lary co ll ap se is present prior to surgery, ex­ pansion of the maxillary arch is indicated. This is particularly important in complete bilateral c lefts, where rea djustment is blocked by en croaching lateral segments that lock behind the protruding premaxilla. Following repositioning subsequent pas­ sive retention is required, while alignment is furnished by the molding forces of the repaired lip. The mechanics of preoperativ e co llapse are such , that there is a need for anterior expansion . A special technique has co n­ sequently been devised to achieve this without unnecessari ly widening the cleft at the level of the tuberosities (Hellquist 1971). Correction is generally comp leted in 4 t08 weeks after which time surgical repair and periosteoplasty can be carried out. Postoperatively, a retention plate maintains the pOSition of the maxillary segments for 3 to 6 months.

57 The appliance used for pre­

surgical co rre ctio n of maxillary co l­ lapse. The acrylic plate acts through a fan expansion sc rew. Lateral rotation of the lateral seg ­ ment widens the cleft anteriorly .

60

The Cleft MaxJJla

Deciduous dentition

•

•

Soft tissue repair sets maxillary growth in a new milieu of changing environmental forces. The subsequent development is therefore checked at regular intervals and should any un­ favourable results occur, they are rectified at the age of 4 to 5, when deciduous dentition can be utilized, Anterior or buccal crossbite with forced bite, and co llapse of the maxillary arch are the recognized indications for maxillary Or1hopedics. In our series the latter group is mainly comprised of patients, who initially presented with some degree of collapse that was not corrected before surgery . Since periosteoplasty became part of the primary treatment, the postoperative complication of max­ illary co llapse has been reduced (Hellquist and Skoog 1973) Correction of unilateral cross bite with forced bite prevents the development of mandibular dysplastic asymmetry , Or1hodontic treatment at this stage also serves to establish good anatomic conditions for the emergence of permanent teeth and the de­ velopment of proper patterns of speech .

, When the cleft maxilla collapses the lateral segment is dis­ placed medially, behind the overriding premaxilla, This is apt to disturb normal development, since membranous ossification does not take place under pressure. Early correction is thus im­ por1ant and can successfully be accomplished during deciduous dentition, The lateral segment is brought into a fairly normal position in 2 to 4 months, Bone, supplied by periosteoplasty, is then needed within the widened cleft to maintain and stabi­ lize the segments. For 12 to 15 months after surgery, maxillary arch alignment is suppOr1ed by a retention lingual arch,

The early observation (Skoog 1966) that new'bone, induced by local periosteum, will enlarge during expansion treatment has been confirmed repeatedly in our late series. When a broad bony union has been established, separation of the ma x illary segments is, however, sometimes met with con siderable resist­ ance. For this reason we advice that clefts with primary collapse of the maxillary arch should be expanded prior to periosteo­ plasty.

The technique and results of maxillary expansion combined with repeated periosteoplasty are shown in the following case; or1hodontically treated by Hellquist. who developed the fixed or1hopedic appliance used for this expansion, 61

58 This incomplete cleft of the lip is associated with a complete cleft of the ma xilla and palate.

59 This illustration depicts the orig i nal bony defect. In conj unction with lip repair, when the child was three months old, a periosteo­ pia sty was performed to the alveo lar cleft .

60-61 Two years later, lip tissues have healed without tension and moderate preoperative collapse of the lateral segment has remained unchanged . Re­ exposure of the alveolar process demonstrates considerable new bone forma­ tion extending from the lateral segment, but a narrow cleft still persists. After removal of all scar tissue from thi s area a periosteoplasty was performed wi th implantation of Surgicel.

62

62 Maxillary expansion was carried out at the age of 5 years. The posterior teeth are lo cked to the splints and thereby immobilize the apparatus. The spring is held in place by vertical tubes and by means of triangular locks in the premolar and molar regions. By activating th e spring the lateral segment will be rotated or expanded . To ensure stability in unilateral cases, the spli nt on the non cleft side is often extended to cover all the teeth in that segment, whereas in bilateral cases anchorage is re ciprocal.

63 Expan sion was completed in 2 months . As a result, the distance between the canines has increased 7 mm. A retention lingual arch with cap splints was kept in place for 12 months.

64 At the age of 7 years the deg ree of expa ns ion is shown in the positions of + 1 and +3 as compared with the pictures above. No appliances have been used for the last 1 ~ years . The exposed cleft area demonstrates the forma­ tion of a large amount of new bone, which completely restores a normal configuration. It is evident that bony continuity was achieved by repeated periosteoplasty and that the new bone has expanded during treatment. X-rays co nfirm that permanent tooth buds lie within the new bon e.

63

Mixed dentition

Since presurgical collapse of the lateral segment is eliminated in early infancy or in the deciduous dentition period , it is reaso nable to find permanent teeth erupting in normal posi ­ tions. However, as a direct result of the original malformation, the permanent teeth bordering the cleft are often rotated, tip pe d or inverted. The first molars may grow in crossbite arrange m ent or diso cc lusion. As a rule, in the mixed dentition period , simple appliances can intersept a developing malocclusion.

Permanent dentition

In the earlier ages, whole maxillary segments are moved by orthopedic procedures. With permanent dentition , it is more a question of individual tooth positioning. For this purpose the edgewise appliances are used almost exclusively. When in­ dicated the dentition is prepared for bridge therapy.

Comments

The nature and magnitude of the cleft deformity requires ex­ tensive maxillary orthopedic and orthodonti c treatment. Even with marked improvements in reconstructive techniques, pro ­ longed dental therapy is still usually required. The work of Hell ­ quist, often referred to in this chapter, has added much to the total rehabilitation of the cleft palate patient. I am especially in­ debted to Dr . Hellquist for his close cooperation , and wish to acknowledge his kindness in allowing me to use his material to illustrate part of this chapter. His skill in expanding the co l­ lapsed lateral segment. complemented by the use of periosteal flaps to regenerate new bone, has radically transformed pre­ vious methods of co rrecting maxillary defe cts .

~

I

64

•

Results of periosteoplasty

Bone formation

Periosteoplasty dep osits needed bo ne to the cle ft area. The newly developing bone aris es almo st excl usively fr om the lateral maxillary segment. Separated fr om the m edial growth centers and consequently dwarfed by co m pari son w ith the normal sized premaxilla , this lateral ti ssue u nde rgoes an osteo­ genic renaissan ce, when its pe rio steum is freed to li ne t he cleft. This initiates a rapid proliferation of new bone . Th e thickened , heavier periosteum that forms the posterior asp ect of the created pocket reflects its most vigorous activity, as does the substantial output of bone that it p rodu ces. There is often a slight malunion between th e p remaxilla and the regenerated bone . During bone develo p m ent in sta bi lity of the maxillary segments may acc o unt for th is ph en omenon . Po s­ sibly this fissure-like line is the rep roduction of a bony suture. In any event, approx imation of th e two ends is cl o se en ough t o assure good function and stab il ity, ev en in co mp lete b il ateral clefts. B~oad bony continuity is general ly only achieved after a second stage p rocedure . In some cases, the regenerated perio steu m has an ad ded vi ta l­ ity and in subsequen t p rocedures has pro ved to be pa rti cu larly osteogenic, and more bone has form ed than follo w i ng the primary o peration. Overcorrection is in fact possi ble with staged repairs . The nasal floor can be made too hi gh and ad­ vancement of the lateral bord er of the piriform apert ure can narrow the nasal o pening too much . Th is is, however, easily rectified. The new bo ne has a soft, cancellous character a nd is covered with its own, normally appearing periosteum. It has a rich blood supp ly, and is more susceptible t o bleeding . Thi s in itial hyper­ vascularity gradually subsides and the regenerated b on e be­ comes indistinguishable from the adjacent bon e. Ca lcification and total os sifi cation take several months to occur and often this process is even more prolonged . Therefore , bone forma­ tion cannot always be studied or well documented in early roentgenograms. Generally the degree of reg eneration is inversel y pro portional to the w idth of the cleft. Broad defect s require longer periosteal flaps to bridge the gap . The blood supply is corres pondin gly more tenuous and the osteogenic activity is thus expectedly less . Conversel y, in narrow clefts there is impressive bone forma­ tion following primary periosteoplasty. This massive generation of ne w tissue effectiv el y prevents fistulae from dev eloping within the vestibular and alveolar regions .

65

65-68 These autopsy photomicrog raphs are from a six months old child with multiple congenital malformations; the patient finally suc­ cumbed to cardiac insufficiency . Three months prior to death , the left side of the lip was closed and the maxillary defect was repaired with a Surgicel filled periosteal pocket. At postmortem, the entire maxilla was removed with the surrounding layer of soft tissues. The specimen was prepared by histologic tech­ niques and transverse serial sections were cut in the plane of the alveolar arch . The diagram depicts a section through the maxilla, about one cm above the free borde r of the alveolar arch. Cancellous bone, marked in blue, has joined the left lateral segment to the separated premaxilla, whereas the unoperated side has remained disconn ected . The areas marked a, band c in the diagram correspond to similarly labelled microphotographs on the next page .

a

c __

~

b

•• I Prem axilla

66

L Maxillary segment

1­

(a) Within the cleft, the new bony trab eculae show an orderly longitud inal architecture. The original border is dif­ ficult to distinguish . ( x 15)

(b) The cancellous bone, formed as an appositional layer over the lateral seg­ ment, displays irregular ly arranged trabeculae. This micro-structu re reflects a lack of any functional demands, which would serve to establish order in the newly fo rmed ti ssue. ( x 100)

(e) The well defined, laminated char ­

acter of the original bone on the non­ operated side is offered for a com parison . ( x 100) ,.

lo~·· •

;".,..c. j

. .

~ 67

Growth of the lateral segment

The periosteum , stripped from the lateral segment to furnish tissue for the flaps, regenerates over the denuded bone, thick­ ened at first but then assuming a normal character . Under­ neath this hypertrophied periosteum a layer of new bone gradually matures as was demonstrated in the previous case. Thus , contrary to what had been anticipated , surgical interfer­ ence stimulates bone formation and appositional growth . This is in an area , where the bone surface is usually resorptive . Factors contributing to this rapid bone development include the release of the lateral segment from a firm , inelastic periosteal capsule , the stimulus of an existing bony deficiency, and the reestablishment of continuity between growth centers on the medial and lateral sides. This development of the lateral seg­ ment tends to restore symmetry .

..

69 The general growth of the lateral segment has been well documented . This incomplete cleft lip was closed at th ree months. A large periosteal flap , raised from the outer aspect of the left maxilla, was utilized to bridge the maxillary defect.

70 At four years facial develop­ ment and bone growth hav e con­ tinued without any impairment

In particular the left side, de­ prived of its covering perio s­ teum , shows no evidence of retardation.

The normal pattern of development of the lateral segment is also demonstrated by alveolar arch restoration. In the un­ operated state the separation is associated with an upward slope of the segments, tangential to the normal plane of the alveolar arch . After periosteoplasty and subsequent union of the maxilla , the undisturbed action of posterior maxillary growth centers elongates the alveolar process and aligns it with the repositioned premaxilla . Simultaneously, there is marked

68 I

The Cleft Maxilla

downward growth or rotation anteriorly, and the entire segment shifts into a normal masticatory plane . The repa ired lip , with its restored muscle function, aids in this adjustment, and the rapid proliferation of new bone within the cleft prevents co l­ lapse. This all permits a more exact approximation as shown in the following case .

71 Periosteoplasty, in conj unctio n with a lip repair, wa s performed in this three month o ld boy with an exceptiona ll y wide unilateral cleft, ranging from 12 mm at its nar­ rowest point to 18 mm at the estimated level of the fl oo r of the nose. When the palate was closed, eighteen m on ths later, the maxi l­ lary defe ct was in spected and found to be compl et ely obliterated.

72-73 These photog raph s, taken at three years of age, show a sy m­ metrica l dental arch and an even bite with good occlusio n. Note the normal appearance of the lower border of th e former cleft. A slight gap, corresponding to a missing tooth (+ 2) persists. This tooth, ab­ normally lo cated to the lateral seg­ ment, has erupted ectopically into the palate . The patient required no jaw orthopedic treatment, either before or after surgery .

69

Migration of teeth

Several cases reported in this chapter demonstrate that peri os ­ teoplasty of the cleft maxilla permits the permanent teeth to erupt normally through the newly formed bone. With more space available, the dislocated crowded tooth buds within the lateral segment gradually take their intended positions within the repaired cleft. In complete clefts, the most anterior tooth bud usually moves into the bony thickening produced on the oral aspect and will consequently arise ectopically in the palate, as was described in the previous case. This is easily corrected by orthodontics. Delayed eruption commonly occurs in the cleft area, particularly in the presence of supernumerary teeth as demonstrated in the patient shown in Figs. 74-76.

74 This patient, born with a left-sided cleft, was treated by periosteo­ plasty at the age of three months. In this radiograph, taken two years after surgery, tooth buds of the permanent dentition have mig rated into · the new bone, which has filled the former cleft . The site of the original bony defect is delineated by a gap in the deciduous dentition. 75 This is a detail radiograph of the cleft area at the age of two and a half years.

70

76 At 8 years of age, general dental development is satisfactory, but on the cleft side the medial and lateral incisors, as well as a super­ numerary tooth, are still impacted. The can ines lie at the same level. Considerable autonomous adjustment may be expected following removal of the supernumerary to oth and as the ca nine erupts.

Comments

Criticism of this technique of maxillary reconstruction has re­ fle cted anxiety about ope rating on the juvenile maxilla. Fear of endangering future development has engendered this feeling . Recent investigations and detailed postnatal craniofacial growth studies have blunted these major objections. Maxillary growth does not occur anterior to the zygomatic pro­ cess. Th is outer surface is in fact normally resorptive . Growth proceeds by new bone deposition on posterior areas, thus moving the maxilla forward and downward as illustrated in the diagram in Fig. 77.

71

I I

~

77 This schematic drawing, based on Enlow' s (1966) cephalographic analysis of facial growth , shows how elongation of the maxilla and downward mov ement of the dental arch is a result of progressive bone deposition on the posterior surfaces of the ma x illary bone. The nasa l portion of the maxilla and the distal half of the nasal bones are ori­ ented in such a way that periosteal bone deposits carry this region in a forward, lateral and superior direction. In marked contrast, during development the outer surface of the maxilla is resorptiv e. Thi s is the area from whi ch the periosteum is raised and transferred in the peri­ osteoplasty procedure.

In a study, using implant techniques, Bjork (1966) confirmed that the anterior portion of the ma x illa was never a growth site. There is thus little to suggest that maxillary development would be iatrogenically impaired when performing a periosteoplasty . At no site do the employed techniques interfere with bony sutures. Furthermore, in animal experiments the removal of periosteum from facial bones has not harmed growth (Hell­ quist 1972). In full y evaluating max illary growth and development in cleft conditions the principles and techniques of soft tissue repair are of paramount importance as an integra l part of any maxil­ lary restoration. The basic requirement of any soft tissue clo­ sure is that the full width of the lip be maintained, since even a moderately tight lip will hamper max illary growth and produce deformity or collapse with subsequent malocclusion of per ­ manent dentition . In the normal individual cheek muscles also playa role in determining the size and form of the dental arches. In this respect the importance of the buccinator was recently emphasized by Brodie (1971). Special attention should therefore be taken to restore the muscular anatomy, for normal 72

The Cleft Max illa

function and balance. In clefts, lip and cheek muscles have ab ­ normal insertions onto the malformed skeletal framework . These irregularities are for the most part corrected when th e periosteum is raised off the bone and a periosteoplasty per­ formed. In this chapter several selected examples, illustrating the effect of maxillary periosteal reconstruction , are presented . The results of the initial lip repair are shown in some of these cases to emphasize the importance of a supple lip, with a re­ stored muscle matrix for molding the maxillary arch without restricting growth. The preferred method of lip management is discussed in Chapter IV. The described treatment of maxillary clefts is based extensively on clinical experience, consisting of more than 150 cases treated over a ten year period. In a study from infancy to the age of five, a series of 36 complete unilateral cleft lip and palate patients treated with primary periosteoplasty was compared to a series of 30 patients, born with the same deformity and treated in an identical manner, except that no periosteal repair was carried out (Hellquist and Skoog 1973). Recordings in­ cluded photographs, X-rays and impressions, taken at the time of lip and palate repair, as well as in the deciduous dentition period. After this stage, cephalograms were also made. Al­ together 28 variables were studied. The results showed that periosteoplasty did not retard or impair the antero-posterior growth of the lateral maxillary segment, furthermore, there was an increased frequency of anterior positioning of this segment following periosteal reconstruction (69.4 %), as compared to the control series (56.7 %). In addition, there was no higher in­ cidence of anterior crossbite, even after repeated periosteo­ pia sty. This investigation demonstrates that neither periosteo­ plasty nor new bone formed by the procedure distorts maxil­ lary growth in any way. Long term follow-ups have been most satisfying and support an unreserved recommendation for peri­ osteoplasty as an integral part of any program to repair cleft deformities.

1

The clinical results have been confirmed by extensive inves­ tigative projects. This research had four principal aims . It tried to acquire an understanding of the reciprocal relationship of periosteal osteogenic potential to environmental factors; it at­ tempted to determine the effect of periosteal resection on grow­ ing facial bones; the influence of Surgicel® on the bone forming process was evaluated; and lastly, explanations were sought as to the difference in behavior of grafted bone, and new bone 73

formed from local periosteum alone. In the former instance, there was a marked retardation of bone growth , w hile there was no disturbance of facial development in the latter group. The results of these studies are summarized in Chapter VII. In recent years there hav e been an increasing number of favor­ able reports on the use of periosteoplasty . Such observations were made by Santoni -Rugiu 1966, 1971 , 1972 ; O'Brien 1970; Bruck 1970; Joss 1972; Jackson 1972, 1973; Ritsilii et al 1972 b, Tortil 1973; Robbe 1973; and others.

Conclusions

• The periosteum covering the maxillary segments in cleft de­ formities possesses a remarkable growth potential , but this force remains inactive until the periosteum bordering the bony defe ct is surgically manipulated. • When the periosteum is shifted across a cleft, its osteogenic capacity is harnessed to rebuild the bony defect. The cambium layer, separated from the bone and placed in contact with a hematoma, induces the characteristic tissue reactions of bone repair . • Properly arranged , the periosteum will lay down more bone than conventional bone grafting procedures. In fact, the skeletal anatomy can be restored extensively, including the hypoplastic piriform border and the underdeveloped portion of the lateral segment. This segment is the best source of bone forming peri­ osteum, the thick membrane on the inner aspect being partic­ ularly potent. Also, extensive mobilization of the periosteum of the lateral maxillary segment can be carried out without inter­ fering with bony sutures or other growth centers. • Periosteoplasty is most effective at an early age and is pre-· ferably performed in conjunction with the primary lip repair. The operation has, however, proved to be quite effective up to the age of five and in a few cases up to eleven years of age. • Following periosteoplasty the tendency for maxillary col­ lapse is reduced by the rapid formation of new bone within the cleft.

74

The Cleft Maxilla

• Periosteum induced new bone grows with the individual, un­ like the static transplanted bone. • In addition to growing with the individual, this bone re­ sponds to maxillary orthopedics. If maxillary collapse should occur in cases of major deficiency, up to 9 mm extension of the bone bridge has been achieved by expansion treatment. Bony substitution of the original defect will thus be completed. • Bone formed by the local periosteum is of " dento-alveolar character.

•

• The tooth buds, compressed within the reduced volume of the lateral segment, will regularly migrate into a more normal position when new bone has formed , and in the cleft area they will erupt through this bone. • Periosteoplasty is useful to correct the extensive bony de­ ficiency associated with even a minimal cleft lip. The technique is recommended as an integral part of repair in clefts of all degrees. • Surgicel ® can be used advantageously as a scaffold to sup­ port the raised periosteum at the desired level , thereby regulat­ ing the volume and shape of the newly formed bone. • Bone surfaces deprived of periosteum in the flap transfer will regenerate a new periosteal layer, which will be thickened and hyperactive at first, but will gradually acquire a normal appear­ ance. • The regenerated periosteum has good osteogenic quali­ ties, which permit repeated periosteoplasties to be performed , resulting in additional bone formation. • Experimental studies on maxillary bone and periosteal re­ generation substantiate the empirical basis for periosteoplasty and firmly support the recommended procedures. These tech­ niques have now been used over a ten year period. • By mobilizing the periosteum over the lateral maxillary seg­ ment, lip and cheek muscles are detached from their abnormal insertions along the piriform aperture. This aids soft tissue re­ construction.

75

References

Bjork A. : Sutural growth of the upper face studied by the implant method. Acta Odont Scand 24: 109, 1966. Brodie A. G.: Emerging concepts of facial growth. Angle Orthodont 41: 103, 1971. Bruck H.: In the discussion of Skoog T.: Cleft lirr--a plastic surgical problem. Read at the First Meeting of the Association of German Plastic Surgeons, Munich, September 29,1970. Enlow D. H.: A morphogenetic analysis of facial growth . Amer J Orthodont 52: 283, 1966. Friede H . and Johanson B.: A follow-up study of c left children treated with primary bone grafting . Scand J Plast Reconstr Surg 8: 1, 1974. Hellquist R. : Early max illary orthopedics in relation to maxillary cleft and palate patients in the Uppsala region of Sweden. Scand J Plast Reconstr Surg 4 : 11, 1970. Hellquist R.: Early maxillary orthopedics in relation to maxillary cleft repair by periosteoplasty. Cleft Palate J 8: 36.1971. Hellquist R.: Facial skeleton growth after periosteal resection. An osteometric, roentgenographic and histologic study in the rabbit and guinea pig. Scand J Plas! Reconstr Surg, Suppl 10, 1972 . Hellquist R. and Skoog T. : The influence of primary periosteoplasty on maxillary growth and deciduous occlusion. Reported at the 2nd Internat Congr Cleft Palate, Copenhagen, August 28, 1973. To be published. Holdsworth W. G.: Cleft p 36.

Lip and Palate. W.

Heinemann, Lond on. 1951,

Jackson I. T.: A functional reappraisal of cleft lip repair. Read at the meeting of Societe Francaise de Chirurgie Plastique et Reconstructive, Deauville, June. 1972. Jackson I. T.: Maxillary deficiencies in partial lip clefts. Abstracts 2nd Internat Congr Cleft Palate, Copenhagen, August 2&-31 , 1973, P 186 Jantet G . H. and Rob C. : An experimental and clinical investigation of a new haemostatic absorbable gauze . Brit J Su rg 48, 270, 1960. Joss G.: (Norwich , Norfolk, England) Personal communication, 1972.

76

The Cleft Maxilla

Lebendiger A., Gitlitz G . F., Hurwitt E. S ., Lord G . H. and Henderson J.: Laboratory and clinical eva lu ation of a new absorbable hemostatic material prepared from oxidized regenerated cellulose. Surg Forum 10: 440, 1960. Nord in K.-E. and Joh anson B.: Freie Knochentranspla ntation bei De­ fekten im Alveolarkamm nach kieferorthopadischer Einstellung der Maxilla bei Lippen-Kiefer-Gaumenspalten. Fortschr Kiefer-Gesichtschir 1.168,1955. O'Obri en B ,MeC. : The maxillary periosteal flap in primary palate sur­ gery. Austral New Zeal J Surg 40: 65,1970. Oilier L.: Traite experimental et clinique de la regeneration de s os et de la production artificielle du IIssu osseux. V. Masson et fils, Paris, 1867. Rant a R.' The development of the permanent teet !1 in childre n wit h complete cleft lip and palate. Proc Finnish Dent Soc 68, Suppl3, 1972. Ritsilii V ., Alhopuro S., Gy"ing U . and Rintala A . : The use of free periosteum for bone formation in congenita l clefts of t he maxilla. Scand J Plast Reconstr Surg 6: 57, 1972 b. Robbe N.: (Roeselaere, Belgium) Personal communication, 1973. Santo ni-R u giu P. : La ricostruzione dell'arcata alveolare con lembi peri­ ostei nella labiognatopalatoschisi completa. Bollet Soc Med Chir Pisa 34 1, 1966. Santoni-Rugiu P. and Massei A .: La reconstruction de la fissure max­ illaire avec des lambeaux de perioste dans Ie cas de fente labio­ palatine complete. Ann Chir Plast 16: 326, 1971. Santon i-Rug;u P., Salimbenl·Ughi G . and Massei A.: Procedimenti integrativi nella schisi del palato primario. Minerva Chir 27: 953,1972. Sarnat B. G.: Postnatal growth of the upper face: Some experimental considerations. Angle Orthodontist 33: 139, 1963. Sarnat B. G. and Wexler M . R.: Postnatal growth of the nose and face after resection of septal cartilage in the rabbit. Oral Surg, Oral Med, Oral Path 26: 712, 1968. Sarnat B. G.: The face and jaws after surgical experimentation with the septovomeral region in growing and adult rabbits. Acta Oto-Laryng, Suppl 268,1970

77

Schmid E.: Die Annaherung der Kieferstumpfe bei Lippen-Kiefer-Gau­ menspalten ; ihre schadlichen Folgen und Vermeidung. Forts chr Kiefer-Gesichtschir 7: 37 , 1955. Skoog T.: The use of periosteal flaps in the repair of clefts of the p rima ry palate. Cleft Palate J 2: 332 , 1965. Skoog T. : Treatment of Patients with Clefts of Lip, Alveolus and Palate.

Second Hamburg International Symposium , 1964.

Ed. K. Schuchardt, Georg Thieme Verlag, Stuttgart, 1966, p 63.

Skoog T.: The use of periosteum and Surgicel® for bone restorati on in congenital clefts of the maxilla . Scand J Plast Reconstr Surg 7: 113,

1967. Skoog T.: Repair of unilateral cleft lip deformity: maxilla, nose and lip. Scand J Plast Reconstr Surg 3: 109, 1969. Skoog T. : Sk oog's methods of repair of unilateral and bilateral cleft lip. Cleft Lip and Palate, Chapter 19. Ed. W . C. Grabb, S. W. Rosenstein and K. R. Bzoch. Little, Brown and Company, Boston , 1971, p 288 . Skoog T. and Hellquist R.: Restoration of maxillary clefts by delayed periosteoplasty. To be published . Thilander B. and Stenstrom S.: Treatment of primary cleft lip and palate cases in the light of the results of an experimental animal study. European Orthodontic Society. Report of the Forty-Third Con­ gress, July, 1967, p 349. Tortil J. -M.: Interet du lambeau perioste dans la reparation primaire de la breche alveolair~procede de T. Skoog. U:E.R. Sciences Med/~ cales A et B, Universite de Nancy I, 7973.

78

I

Chapter III

Correction of the cleft nose - repositioning the alar cartilage and reconstructing the nasal floo r

General co nsiderations 82 I. Compl ete clefts Operative procedure 83 Preoperative condition Incisions and undermining Dissecting the alar cartilage Repositioning the alar cartilage Reconstructing the nasal floor Result II. Incomplete clefts Operative procedure 90 Preoperative condition Surgi cal technique Result

Comments 92 Healing Results Referen ces 93

80

The Cleft Nose

A technique for correction

General considerations

Nature goes her own way, and all that to us seem s an exception is really according to order Johann Wolfgan g Go eth e (18241

Congenital clefts of th e primary palate are asso ciated w ith a characteristic malfo rm ation of the nose. Whe rea s t he cleft of li p and maxilla is primary in origin , the nasal deformity m ay be regarded as a result of ab normal deve lopmental forc es, g en ­ erated by the discontinuity of the nostril circumference. M edi al­ ly, the alar cartilage is anatomically related to the septum an d shifts moderately with that stru cture. At the ala r base, di sp la ce­ ment of the cartilage is always greatest and correspond s di rect­ ly to the severity of the cleft This is slightly accentuate d by tra ction exerted by the nonunited orbiculari s muscle. In an attempt to explain the genes is of the deformed nostril , Burian (1967) stated that abnor m al con di t ions, present du rin g cartilage formation, influence the eventu a l shape of the alar cartilage; the medial crus shorten s and the late ral part flattens. Tange and Ohmori (1964) have shown, that th e inner and o uter surface of the nose are the same on the cleft as on the no ncleft side, which emphasizes that the necessary compone nts are p re ­ sent but are arranged in a distorted po sit ion. For surgical correction, it is importa nt to realize , that du e to downward and lateral tra ction, the relativ e po sition of th e alar ca rtilage in relation to the upper cartilage has chan ged . Inst ead of normally overlapping each othe r, these st ructures hav e ac­ quired a side-to-side relationship. Fu rthermore, the alar carti­ lage is shifted laterall y with respect t o the upper, mo re fixed, cartilage. These observations indi cate that the basic g u ideline for surgical correction should be to restore the topograp hic anatom y of the nostril by repOSitioning the alar cartilage (Skoog 1969)

82

I. Complete clefts

Operative Procedure

Preoperative condition

f I

1 In this frontal view, the flattened and ob­ liquel y rotated nose is prominently dis­ played . The alar cartilage is pulled out laterall y and droops down across the div ided lip . The asymmetric nos e form s a norma l tip on the noncleh side, but this ef­ fe ct is destroyed by the abnormal anatomy of th e leh side, where the dislocated and straight en ed alar ca rtilage has dev iated from its normal , ove rlapping positi o n on top of th e upper carti lage. Thi s distorted configuration leaves o nl y a d imple to mark the spot where a co ntou red nasal tip should rest .

2 Looking from below, up into the defect, the marked obliquity of the nose and the gross disparity of the nasal apertures are readily apparent. In addition to the S-shaped , flattened aspect of the cleh nostril , the bu ri ed alar base causes the top of the leh nar is to lie on a leve l with the nasal floor of the opposite side . This sa me distorting mechanism reduces th e heig ht of the co lumella on the cleh side by bend­ ing the su ppo rting co lumell ar carti lage into an elo ngated alar ca rtilage . Thi s g ives the nasal rim an abnormally long ap­ pea rance . In addit ion, the tip of the nose angles away from the v iew er in co ntra st to the normal nose w ith its protruding na sa l tip .

83

r

3 With the retractors pulling back on the lip and nose, the cutaneous Iining of the vestibulum is clearly seen to descend all th e way down to the lateral maxillary seg­ ment. Fi xed in thi s position, the alar base becomes everted.

4 This drawing demonstrates the dynam ­ ics of the nasal deformity. The lateral dis­ pla ce ment of the alar base carries the medi ­ al cru s of the ca rtilage with it. Simultaneous­ ly, the lateral forces place the cartilage under torsion about the axis of the alar rim .

84

1

The Cleft Nose

Incisions and undermining

5 After the severe dislocation of the nasal lining has been fully appreciated, the car­ tilaginous border is easily identified at its junction with the lip mucosa , and an incision is made along this line. This horizontal cut then angulates sharply up between the alar and upper cartilages .

6 The intercartilaginous incision is carried up to the nasal septum .

7 Using thin-bladed scissors, the skin is raised over the lateral cartilage. Undermin­ ing continues across the nasal tip to the normal carti lage of the opposite side .

85

Dissecting the alar ca rtilage 8 Beginning at the lateral attachment to the maxilla, the displaced alar cartilage is freed from its estranged position . Outer surface separation is carried out between the skin and cartilage, up to the nasal r o of. The scissors mark the lower extent of the dissection .

9 The alar cartilage is partially freed on the inner aspect as well, for a width of approximately 2 to 4 mm. Care must be ex ercised so as not to perforate this very thin lining. A blunt tipped pair of scissors, kept to the surface of the cartilage, is used for this purpose. There is no danger of penetrating the adherent perichondrium. Exposure is particularly important medially , where the alar cartil age mu st be well mobilized to permit positioning in an over­ lapping fashion on top of the upper cartilage. The lower portion of the cartilage maintain s its integu­ menta l attachments.

10 After mObilization, traction in a postero-Iateral direction , at the upper border of the ala r cartilage, accentuates the malformation.

86

11 Similar ly , without changing the hold of the fo r­ cep s, moving the cartilage in s upero-medial d irection recreates a contoured nasal tip. The medial arch of the cleft nostril is also refashioned by this maneuver, which simultaneou sly reform s the columell a to a nor­ mal height, curv es the nasal rim and raises the alar base .

Repositioning the alar cartilage 12 In o rder to mediall y ad­ va nce the al ar cartilage in ­ to its co rr ect position , on the top of th e upper cartI­ lage, a key stitch is passed th ro ugh t he nasal mucosa and upper ca rtilage and at­ tache d to a dist al alar seg­ m ent. As shown here, this sutu re is pl ace d close to th e septu m , about 4 mm away from the inci sed border.

I.

13 The alar cartilage lining is picked up about 7 mm laterally , and t he two borders are united with a mattress suture ; 4/0 Dexon is used.

14 Marked alar advancement is achieved with thi s key repositioning suture .

15 The alar cartilage now lies in a normal overlap­ ping position on top of the upper cartilage.

16 High up in the recreated dome of the nose, a temporary transfix­ ing suture has been placed thro ugh the con tralateral columel­ la ca rtil age . The interca rtilaginous incisi on has been cl osed without further correction, and the alar base is now ra ised to a normal level.

87

Reconstructing the nasal floor 17 The nasal floo r is not fully reconstructed unti l the lip segments have been incised and prepared for closure . In this case , flaps have been designed as described in the next chapter. In this photograph available lin ing for the lower vestibulum and the major portion of the nasal floor is exposed. The lower corner of this lining is marked by a forceps.

18 The dislocated lining with its attached cartilage is shifted 180' into the floor of the nose, where it is sutured to the muco· periosteal suture lin e, a result of the max­ illary repair desc ribed in the previous chap· ter. This maneuver recreates the vesti· bulum and the alar base sul cus. 19 The alar lining is sut ured into pla ce. Medially, the in cise d septal mu cos a stretches to add ample lin ing for the fl oor. Mobilization of the septal cartilage at the nasal spine aids in closure , In conjuncti on with lip repair, a cutaneous flap , ra'i sed from the upper portion of the lateral lip segment, interdigitates into a triangular opening prepared medially, in the co lumellar base. This further inverts the alar rim, accentuates the sulcus, and narroWS the floor (see Chapter IV, Fig. 30, p . 108).

88

Result

21}-25 Nasal symmetry has been achieved . The flattened alar car­ tilage has been curved to form a contoured nasal tip. The alar rim sweeps gently around to conform to the opposite side, and the sul­ cus at the alar base is naturally shaped without local surgical inter­ ference or the use of any deep sutures. The nasal floor is at correct level. The view from below demonstrates symmetrically equal nostrils. The left alar cartilage has been raised slightly higher than the nor­ mal side to compensate for eventual descent. The columella is straight and of a normal height. Freeing the upper border of the alar cartilage permits advancement of the entire lateral compartment. The shift will naturally be greatest in the dissected upper area, whereas the shorter rim restricts mobil­ ity. This has the desirable effect of reproducing an important fea­ ture of the normal nose, which is particularly apparent in the child , i.e. at the tip of the nose, the dorsal skin stretches over the edge of the cartilage into a horizontal plane, producing a flat triangular surface in front of the nostril. With the combined procedure of maxillary reconstruction by a periosteoplasty, and the described technique for nasal correction, the reconstructed airway reaches the anterior portion of the hard palate. It is of normal width and completely lined.

89

II. Incomplete clefts

O perative procedure

Preoperative condition 26 The nasal deformity associated w ith inco mpl ete cle fts o f th e lip bears a close similarity t o the more distorted an atom y o f com · plete defects . Thou gh the malformation is less severe in th e former instance, all the characteristic stigmata are present: th e al a is still pulled laterally, its base is recessed , the entire nose is o blique ly rotated , and there is a shortening of th e co lumella on the cl eft si de.

27 In view o f the unbroken circu mferen ce o f th e nares, the deform­ ing lateral traction is distributed evenly about the com plete nostril instead of being applied to the lateral segment alone . This broadens the entire columella and shifts the base of the columellar cartilage downwards into th e fl oo r of th e nostril.

90

Surgi cal technique 28-29 Th ',s va ri ant o f th e co m p lete anoma ly requires a mo di ficat ion of the prev iously described procedure. An incision is made laterally in the floor, and the tissues are freed medially to restore the base of the columella . The rest of the repair utilizes essentially the same tech­ niq ues as before, and the alar cartilage is mobilized from an intercartilaginous incision and repositioned.

Result

30 The nasa l floors rest at the sa m e leve l and the appe rtur es are sy m­ metrically equal and separa ted by a straight, normal appearing columella .

,

31 The alar cartilage has been raised to a slightly overcorrected position and the tip is balanced and rounded .

Late results of this procedure are shown in Chapter IV, pp. 777- 720. 91

Comments

Healing

The seemingly intricate pattern of closure utilized in reconstruct­ ing the nasal passage, particularly at the floor of the nose, might be expected to complicate healing or produce harmful scarring. This has not been the case. The flaps are all well vascularized and most of them fall into their natural position without tension. This permits primary healing and complete re­ constitution of the lining prevents scarring from secondary epi­ thel ial izatio n. The intercartilaginous approach is usually as harmless here as in adult rhinoplasty. If the incision has been carried on to the septum, or closure has been inexact laterally, the scar may, however, contract and form a stenosing fold. Since all of the lining within the vestibule has been preserved, correction can easily be accomplished with a Z-plasty. The interdigitating flaps which crisscross the floor of the nose effectively prevent sec­ ondary depression, which may otherwise occur, as conventional sagittal suture lines scar and contract. At the columella and within the entire alar compartment, dis­ section is limited and restricted to well defined anatomical planes. This results in minimal deep scarring, which does not stunt growth, or limit the possibilities for secondary corrections.

Results

The nasal deformity is mainly caused by dislocation and under­ development of the lateral maxillary segment. The permanence of correction, thus greatly depends on simultaneous restoration of the facial skeleton. Though a periosteoplasty builds up sup­ port at the alar base, in complete clefts, the primary maxillary operation is never sufficient to completely raise this corner stone of the nostril to its correct level. In addition, there is often persistent protrusion of the premaxilla. Consequently, some recurrence of the deformity can be expected. Overcorrection, and the use of transfixing sutures, compensate somewhat for this eventual development. Persistent separation of the lip muscles tends to pull the alar base laterally, bringing the entire cartilage with it. Special tech­ niques of primary repair have therefore been developed to re­ store muscle balance in the upper portion of the lip (see Chap­ ter IV). Following this repair, the reunited muscles should pro­ tect the reconstructed nose.

92

The Cleft Nose

The resiliance of the deformed cartilage and its tendency to re­ main in a straightened position is a third factor that may con­ tribute to a recurrence of the malformation. To counteract this obstinacy of the cartilage, in a small series of patients prolonged splinting with corrective acrylic moulds was tried. This cumber­ some treatment was discontinued after it became evident that the effect was minimal. With increased accuracy in diagnosis and following suitable dissection, it is possible in unilateral cleft deformities to fully restore nasal symmetry. The ideal primary result, however, in­ evitably deteriorates to some extent. Minor irregularities can be accepted, as appearance generally improves during the teenage period, when significant facial growth changes take place. Gross, persistent abnormalities should be treated surgically, applying the same principles as used in primary correction. The secondary repair can be carried out at any age; insignificant scarring, an undisturbed alar rim, normal anatomy of the alar base, and the availability of all original tissues permit reopera­ tion under favorable conditions. Additional procedures general­ ly prove more effective than primary treatment, since skeletal incongruence has been reduced and the muscle can be re­ approximated with little tension. Virgin conditions are present in those patients in whom nasal correction has never been attempted, regardless of age. The original deformity has then remained largely unchanged and the described method of surgical treatment can be utilized with only minor modifications.

References

Burian F.: The Plastic Surgery Atlas. Butterworths, London, 1967, vol 2, p 165. Skoog T.: Repair of unilateral cleft lip deformity: maxilla, nose and lip. Scand J Plast Reconstr Surg 3: 109, 1969.

Tange I. and Ohmori S.: Qualitative analysis of the configuration of the unilateral lip. Transact Internal Soc Plast Surg, Third Congress, Washington, 1963. Excerpta Med, Amsterdam, 1964, p 1150. (Read by title, abstract published in Congress papers.) 93

Chapter IV Cleft lip rep air-resto ring the functional anatomy by reconstructing the muscula r fra m ework and pro viding tissue by a d ouble flap design

General considerations 97 Operative procedure 99 Preopera ti ve co ndi t ion Plann ing the m ed ial side in lip repair Di ssecting the med i al si de M axi ll ary reco nstru ction Nasal correcti o n Pl a nning t he la te ral lip seg m ent Di ssect ing th e late ral sid e Mu co us mem b rane closure Reconstru ctin g th e mus cl e laye r Skin closu re Dressing Res ult Late result s 117 Comments 121 References 123

94

The Cleft Lip

A method of repair

in unilateral clefts

General considerations

Deviation from Nature is deviation from happiness.

Samuel Johnson: Rasse/as (7759)

In the cleft lip deformity there is a variable but absolute tissue shortage. To be effective and as anatomical as possible, recon­ struction must therefore preserve and utilize all available tissue.

The muscular deficit is more pronounced than the surface de­ ficiency, and the lack of underlying support is further exag­ gerated by retraction of the nonunited segments. This confused muscular anatomy was illustrated by Sanvenero-Rosselli (1934). Pennisi et al (1969) reviewed the most commonly used methods of lip repair and realized how each technique basically ignored the mal positioned orbicularis oris and failed to restore it to its normal horizontal axis. This is a fundamental err or, for recon­ stitution of the separated orbicularis muscle is a prerequisite to adequately restore the functional and aesthetic framework of the lip. As most methods merely app roximate the muscles at the border of the cleft and do not carry this tissue all the way to the midline, a muscular diastasis is a regular and p ers istent oc­ currence . This is evidenced by a broadening and flatte nin g of the cleft areas , as well as asymmetry of the philtrum and co m­ plete absence of a philtral ridge. The defect is further accentuated by lip movements. In order to restore the normal anatomy and achieve muscle balance it is necessary to unite the divided and retracted orbicularis muscle along the entire height of the lip. The origin and insertion of this circular lip muscle lies in the midportion of the philtrum. Consequently, the disjoined lateral segment must be advanced and sutured to its medial counter­ part at this level.

The method described in this chapter was first reported in 1958. In subsequent years special emphasis has been placed upon complete restoration of the muscular anatomy of the lip. Experi ­ ences with this technique were reported in 1969 (Skoog). Since that time, there has been an increased interest in the abnormal arrangement of the lip muscles. Fara (1971) studied the anoma­ ly in great detail by dissecting twenty-five stillborn children with various types of clefts. From his analysis, he devised a method in which he freed up the muscles at the edge of the piriform aperture bilaterally and restored the muscular sling with an end to end suture. The anatomical observations of Plenk and HoIl­ man (1973) and others may help to further refine operative tech ­ niques . Jackson (1973), aware of the importance of reconstruct­ ing the orbicularis oris muscle, devised an entirely new ty pe of Abbe flap based on this principle . 97

The described procedure also involves shifting tissue from the lateral segment to the medial side. In the upper portion of the lip, a skin flap is utilized to reconstruct the nasal floor . At the free border a full-thickness triangular flap is made to elongate and evert the lip. This idea was introduced by Tennison (1952). Millard (1964) used a small rectangular skin flap to form a white line across the bottom of the lip scar so that the red of the ver­ milion did not blend into the cutaneous scar. His concept is applied here by creating a triangular mini-flap at the vermilion border.

98

1

The Cleft Up

Operative procedure

Preoperative condition

!

1-2 The complete unilateral cleft in this three months old boy reveals all the characteristic features of the lip malformation . The unaffected side is of normal height and configuration with a naturally peaked philtral ridge . In contrast. the opposing philtral border has been pre­ empted by the cleft . The deformity is further exaggerated by retrac­ tion along the cleft edges. This superficial t issue shrinkage is similar to scar contracture following a traumatic or surgically split lip . Me­ dially, the cicatricing force tends to bring the free border of the lip up to the nost ril, obscuring t he definition and ful l ness of the Cupid's bow. Latera ll y, th e scar-l ike process alo ng th e edge has ma rk ed ly sho rt ened the lip.

99

Planning th e m edial side in lip repair

On the medial aspect the aim of recon­ struction is to restore the distorted philtrat lip segment. Us ing the un­ affected side as a model, planning involves: • reposition ing the center portion of the Cupid's bow; simultaneously, • revea ling the existing tissue deficit; and • preparing the medial side for an anatomical repair of the separated tip muscles .

d --~,

/

100

3--4 The philtral ridge on the normal side and the lip midline are identified . The latter is repre sented by a slight indentation at the ver­ milion border and a fine seam in the depth of the philtrum . Both lines are pulled towards the normal side by the uno_nrosed muscle but still serve as con v enient landmarks. The distance between them defines half the width of the central portion of the Cupid ' s bow. The other half can now be determined by measuring out the same distance from the midline along the vermilion border; the end­ point is designed as (a) . A line is drawn from (a) , perpendicular to the lip border, and where it intersects the midline is called point (b). A third reference point (d) is placed at the columellar base, where it joins the cleft, just inside the external naris . A curved line, run­ ning along the muco--cutaneous margin, con­ nects (d) with (a) . Lastly, on the vermilion border at (al, a minute triangle is marked out.

r

Dissecting the medial side

5-6 In these malformati o ns the frenu lu m is usually quite prominent and atta ched close to the free border of the alveo lar process. If leh in its abno rmal position , the persistent frenu lu m acts as a wedge to separate the medial incisors as they erupt. It shou ld be divided up to the level of the bu ccal su lcus . This is carried out before any lip incisions are made, as it will release the medial par t of the lip and giv e a fullnes to the centra l portion.

7 An incision is made along the line a-d, through the full thickness of the lip. The bordering rim of the cleh, where tissues are retracted and of a poorer quality, is dis· carded .

8 Starting in the center at the previously determined point (b), a through and through incision is made along the line a-b. A No . 11 bl ade is used.

101

9 The small vermilion border triangle at (a) is now excised in order to break the sutu re line at this site.

( ~,

10 The marginal tissue, freed by the inci ­ sion, is left attached in the red lip region and used to apply vertical traction to the lip while the repair is carried out. Another clamp has been placed on the cut end of the labial artery.

I I

I I I

I I I

I I

I

11 After these incisions are completed, the lip tissues are fully released and the vertical border retracts and everts. The center of the Cupid's bow falls easily into place in its proper horizontal position, while apart from the triangular fu ll-thickness defect created by incising the free border of the IiI" , the en­ tire lip segment acquires a normal con­ figuration. At (d), an additional incision has been made laterally in the columellar base to provide a recipient site for the nasal floor flap.

102

r

Th e Cleft U p

12-13 Th e thin muscle la ye r of th e medial lip segment is left attached to the ski n, but dis­ sected free from the mucosa and prema xilla along th e enti re ma rgi n of th e ve rtical in cis ion, as far as the middl e of th e philtrum , where th e heavie r orbicu lari s muscle of th e non cleft side in se rts .

103

•

Maxillary reconstruction Maxillary restoration and nasal correction should be completed before planning the repair of the lateral lip segment. Since the technique of periosteoplasty has been previously described in great detail, the brief pre­ sentation here is merely to demonstrate how maxillary reconstruction compliments the lip repair.

14 Medially, a mucoperiosteal flap has been

raised from the premaxilla and turned into the cleft.

15 A substantial mucoperiosteal flap has been advanced from the deep aspect of th e lateral seg­ ment and brought across the defect to meet the medial flap.

.

16 Th e two periosteal membranes are closely

approximated by a double row of sutures. Th ey bridg e the wide maxillary rift comp letely.

,

104 I

The Cleft Lip

17 An incision is made in the buccal sulcus , through mucosa and periosteum, to prepare the anterior lining for the periosteal repair.

18-19 Th e periosteum and cheek tissues are extensively raised, en bloc, and a periostea l flap is dissected off the cheek .

•

20 The flap is now sutu red over the cleft with its inner surface facing the defect.

105

Nasal correction The lip repair is closely integrated with nasal recons truction and it has proved quite effective to coordinate the two efforts. As th is technique has also been previously described, only a capsule view will be presented here. 21 The characteristics of the flared and flattened nostril be­ com e accentuated after peri­ osteop last y.

23 The inner aspect of the nasal floor is formed by repositioning the vestibular lining .

106

22 Repositioning the mobilized alar cartilage normalizes the shape of the nose and raises the alar base.

24 Symmetry ha s been larg ely restored and the alar bases li e level with each other. Thi s rai ses the lateral lip segment upward s and mediall y and thus fa cilitat es planning the final part o f lip r e­ construction.

Planning the lateral lip segment After comp letion of periosteoplasty and the es­ sential part of nasal correction, the design for the lateral segment is outlin ed. The purpose of recon­ struction here is fourfold, • the border is elonga ted to match the height of the other side; simultaneously, • a triangular flap is created to fill the tissue de­ ficit medially; • the edge of the orbicularis muscle is freed from its retracted position in preparation for midline union; and • the skin along the upper portion of the cleft is utilized as a flap to reconstruct the nasal floor,

d

c b

a

d, -

b,

c,

a,

25-26 Point (a , ) is fir st so ught. Thi s is w here th e full b ody o f th e lip m e rg es w ith the mu co us m embran e o f the cleft. It is difficult to use the vermili o n borde r as the so le determinant of thi s poi nt, as there is often an indist in ct and gradua l end to this line rather than a di stinct cut­ off, From point (a,). the flap a ,-b ,-c , is designed to fit the medial defect. Holdi ng the medial lip segment in its normal posi­ tion, the size of an adequate flap can be accurately estimated and the proper design made . The line a runs parallel to the muco-cutaneous junction and is of the same length as a-b, The flap a,-brc , corresponds to the a-b-c defect, with the length and angles being equa l , Adjust­ ment must be made to compensate for some slight unfold ing when the flap is released.

,-b,

This design adapts itself to the individual situation and th e position of the base of the triangular flap will change up to near­ ly 90", depending on the height of the lip . When little lengthening is required, the base li es in a ve rt ical position, but ap­ proa ches a h o ri zo ntal ax i s w h en co n ­ side rabl e e longa ti o n is needed , Th e impo rtance of h av ing the al ar bases aligned at th e proper level is demon­ strat ed by the relative ease in planning further reconstruction of the lateral lip seg m e nt. Idea ll y, point (d,) is placed o n a level w ith point (d). and the distance be­ tween (d,) and its alar base eq ual s th e di stan ce across th e fl oor o f th e unaffected nostril. Thu s, when point (d,) i s brought to (d). a n asa l floor is created with the same dimension s as the normal side. Th e lower down (d ,) is placed , the more the alar base will be raised when the flap is rotated into position , W ith correct planning , crd, equa l s c-d and thus this measurement can serve to check the accuracy of the design. A "m icroflap " i s crea ted at (a ,) to fit into the sma ll triangular defect at point (a),

107

Dissecting the lateral side

27-28 The skin markings are sup erficiall y incis ed with a N o. 15 blade, wh il e a No . 11 blade is used to make a sharp through and through incision along the margins of the triangu la r flap .

29 The mucocutaneous junction in the upper portion of the lip is incised with ou t di scarding any tissue.

108

30 The skin flap designed to reconstruct th e nasa l fl oor i s then undermined in a plane superficial to the underlying muscle.

31 The incisions have opened up the lateral segment, lengtheni ng it the correct amount. A hook passed throug h the nasal floor flap rotates it medially.

32 Further rotation of this flap to the side of the col umellar base just inside the nostril, completes the nasal vestibule, inverts the alar rim , and improves the conto ur of the sulcus at the base of the nostril. The lower triangular, full-thickness lip flap fits ac­ curately into the medial defect.

33 With the upper skin flap held aside, the orbicularis mu scl e is exposed . Its border is freed from the skin for a few mm by sharp dissection and also separated from the mu co us membra ne on its deep aspect. To avoid interfering with cheek musculature, care shou ld be taken not to mobilize the orbicularis beyond the alar base and th us distort muscle function . It should be pointed out that at this stage of repair, the lip muscles have al ready been detached from their ab­ normal insertions along the piriform aperture. This was effected by the periosteoplasty , when the perio­ steum was extensiv ely mobilized away from the lateral maxillary segment.

34 Th e border of the muscle form s a sub­ stantial mass and is held here by two foceps.

109

Mucous membrane clos u re

35 There is a three layer closure. The mucous mem ­ brane, muscle, and skin are all approximated separate­ ly. Starting laterall y, the in cised lip mucosa is sutured back to the alveolus, using 4/0 catg ut on an atraumatic reedle. Careful positioning is important so as not to dislocate the lateral lip segmen t and reproduce asym­ m etry. A key suture brings the flap to the medial seg­ ment at a level corresponding to the new philtral bor­ der . The lateral mucosa is thus advanced acrOss the maxillary cleft, but must not be carried as far as the midline.

Reconstructing the muscle layer 36 In reconstruction , the lateral orbicularis muscle is brought slightly beyond the midline to join its un­ affected counterpart. A 3/0 Dexon stitch , on a circular needle, is passed th rough the upper corner o f the lateral muscle .

110

The Cleft LIp

})'

~L-

37-38 The suture is sec ured media lly at a level just below the na sa l spine .

I

111

39 The initial muscle suture has been tied, effectively restoring the lip. Deviation of the co lum ella is also corrected . In this photograph the muscle union is rein­ forced further down with an additiona l Dexon stitch . A third suture may also be used .

40 The prolabial fl ap, comprised of skin and a thin muscle layer, is sutured on top of the advanced o rb i­ cu laris muscle .

112

41-43 M attress sutures of 3/0 plain catgut are u sed to app roximate the lower segments of the lip . The y can be accurately inserted, since the triangular flap and re cipient defect are prominent landmark s that facilitate suture placement. Deep bites of tissue are taken, through the mucous membrane and muscle . To take tension off the muscle closure , a wide retain­ ing catgut sutu re may be placed intraoral ly, in the up­ per po rtion of t he lip . In the free border of the lip the mucous membrane is closed with 6/ 0 ca tgut sutures .

113

Skin closure 44--45 Since union of the underlying muscle es­ sentia lly bring s th e cleft parts tog eth er, the skin is cl osed under minimal te nsio n ; 6/0 catgut' i s thu s used to accurately adjust the ski n edges . The microflap at the ve rmil ion borde r is too small to su ture but is held in pla ce with one stitch o n each side .

I Ophta lm ic 770 G on m icro-point cutting needle, Eth ico n, In c., Somm ervill e, N.J., U .S.A .

114

46 Behind the retracted nostril, the nasal floor

r

flap fits easily into the base of the columella. Its usefulness can now be fully appreciated .

47 By restoring the underlying muscular frame­ work, the general architecture of the lip has been effectively recreated . The philtrum now lies around a vertical axis and a natural Cupid ' s bow has been formed . In the immediate postoperative photo­ graphs , lip symmetry is slightly marred by the relative protrusion of the underlying premaxilla . 1

Dressing t

48 Surgical tape' is the only dressing used post­ operatively. It can be applied to protect the major portion of the suture line and reduces ten sion dur­ ing healings . The skin sutures are remov ed after four days .

;..

Steri-Slrip® Skin Closures, Minnesota Mining and Manu­ fa cturing Co . (3M). St. Paul, Minnesota, U.S.A.

2

11 5

Result 49-63 Twelve months after surgery scars are hard ly visible. The Cupi d' s bow and the philtrum are clearly defined . The anatom ic rep air o f the orbic ul aris mu scle offers normal mobil ity and help s to cr eate a natu ral appearance . The underlying bony framewor k h as been extensively restored and contributes significantly to th e result of the repair. At the site of the original maxillary d efect a solid base can be felt. The immediate result of nasal reconstructio n remains largely unchanged. The raised alar cart ilage shapes the tip. Laterally, it curves naturally toward s the alar base, which lies at the correct level and is bordered by a distin ct sulcus. Mid line position of the columella aid s in reproducing nostril symmetry .

116

Late Results

The described multifa cette d approach for the primary repa ir of clefts wa s ap­ plied in pati ents sh o wn in Figs. 54-70. Correction w as th us ach ieved by peri­ osteoplasty, reposition ing of the alar cartilage and an anatomic lip reconstru c­ tion. The follow-up p i ctures are chosen to demonstrate certain genera l features of the late results.

54--56 The preoperative photog raph demon­ strates a subtotal cleft of the lip , associated with a complete cleft of the alve o lar process . Reconstruction was carried out at the age of three months.

The result at two year s emphas izes the im­ portance of preserving all av ailable tissue in the initial repair so as to produce a wide , supple lip.

117

57-59 In this boy, born with a co mplete unilatera l cleft, the lip seg­ ments are widel y apa rt. Re storatio n of the orbicularis mu scle prod uces a distinct philtrum in the ce nter of the lip, and the full thickness tria n­ gular flap , transf erred from the lateral segmen t, aids in rep os itioning lip borders as well as in forming a symmet rical Cu pid ' s bow . At four yea rs of age, the alveo lar arch is in perfect al ig n ment and on ex­ posure, th e previous maxillary defect was found to be bridged by new bo ne.

11 8

60-65 Thi s three m on th s old girl presen t ed with a wide comple te cleft and max imu m nasal def o rm ity at th e prima ry recon str ucti on . W hen readmitted fo r pa la te repai r, eighteen m on th s later, bony restoratio n had occu rr ed . M inor seco ndary co rrectio ns of the lip and left n ost ril, acco rdin g to the principl es o f prima ry repair, were added later. The follow-up pi ctu re s show th e r esu lt s at four ye ars of age.

11 9

66-70 This co mplete cleft of the pri ­ mary palate has markedly affected the nose, lip and maxilla . In the primary repair, undertaken at three months of age , maxillary reconstruction was not included , and as a result the bony defect remained essentially unchanged. A periosteopla sty was thus p erformed as a delayed procedure, five year s later. The results at eight years are shown here; the bony defect is now almost nonexistent. Normal upper lip move­ ments are here demonstrated on whistling .

120

Comments

The staggered suture line effectively prevents distorting con­ tracture and secondary lip deformity. In addition, there is little tendency for the transverse scars to widen as the muscular forces pull in the direction of the scar. In time, the scars become relati ve ly inconspicuous. Those bordering the lower triangular flap are, in fa ct, often invisible, and since they are comparative­ ly short, there is no functional impairment. Midline mus cle union, prior to approximating the skin edges, markedly reduces surface tension and limits any tendency for broadening , while the layered closure, without overlapping suture lines, precludes massive scarring through the entire thickness of the lip.

•

Establishing muscle continuity across the midline restores sym­ metry and reproduces the sculptured anatomy of the normal lip with a raised philtrum, a natural central depression, and a peaked, well-defined philtral border . Laterally, the abnormal bulge that hallmarks the retracted orbicularis muscle flattens in­ to the slightly bevelled contour of the normal lip. Following restoration of the musclar framework, there is significant func ­ tional improvement; the cha-nge is most graphic in secondary lip repairs . One such patient reported that his ability to blow a trumpet was markedly improved. He experienced a sense of lip mobility, that he never imagined co uld exist. The lateral full thi ck ness flap effectively elongates the borders of the cleft and supplies bulk to the lower portion of the lip. Its triangular shape helps to evert and protrude the lip . Including the muscle la ye r in this flap has no adverse effects on future function. Most importantly, the design results in a wide and supple upper lip with a distinct Cupid's bow. An essential part of the procedure is the transfer of the nasal floor flap. Though the shaping, positioning and suturing may be regarded as te chn ically difficult, numerous advantages re commend its use: • it furnishes the necessary lining to comp lete reconstruction of the nostril; • the floor of the nose is formed by a transve rse flap, which will not have a tendency to contra ct or become depressed; • tissue is provided to compensate for a defi ciency at the columellar base, thereby increasing the width of this structure and restoring symmetry;

12 1

• rotating the nasal floor flap upwards and shifting it medially contours the ala and a more distinct su lcus is created at the base, without the need of additional dissection or the aid of deep sutures . Breaking the sutu re line at the ve rmili o n border refines the repair. Despite the minute size of the flap , it effectively camou­ flages the scar as it crosse s the mucocutaneous junction. Following surgery the greatest ten sion will be exe rted in the upper portion of the united lip . At this leve l, the resulting pres­ sure effectively repositions the protruding premaxilla. Thi s force reproduces the normal molding action of the lip without result­ ing in tightness of the lower portion that would only distort the growing maxilla . These dynamics are particularly well demon­ strated in bilateral clefts (see Chapter V) .

122

References

Fara M .: The im portance of folding down mu scle stumps in the opera­ tion of unilateral clefts of the lip . Acta Chir Plast 73: 162, 1971 . Jackson I.T. : The im portance of o rbicularis oris in cleft lip repa ir. Abstr ac ts 2nd Internat Cong': Cleft Palate, Copenhagen, August 26--3 1, 1973, P 180. Millard D. R. Jr.: Refinements in rotation-ad va ncem ent cleft lip tech­ nique. Plast Reconstr Surg 33: 26, 1964. Pennisi V . R. and Shadish W . R. : Orbiculari s oris mu scle in the cleft lip repa ir. Cleft Palate J 6. 141 , 1969. Plenk Jr. H. and Hollmann K.: Hi sto logical observations in exc ision s of in co mpl ete cleft lips. Abstracts 2nd Int ern at Congr Cleft Palate, Copen­ hag en, August 26--3 1, 1973, P 179. Sanvenero-Rosselli G.: La divislone congenita dellabbro e del palato. Luigi Pozzi, Roma, 1934. Skoog T.: A design for the repair of unilateral cleft lips. Am J Surg 95: 223, 1958. Skoog T. : Repair of unilateral cleft lip deformity: maxilla , nose and lip . Scand J Plast Reconstr Surg 3: 109, 1969 . Skoog T. : Skoog's methods of repair of unilateral and bilateral cleft lip. Cleft Lip and Pala te, Ed . W. C. Grabb, S. W. Rosenstein and K. R. Bzoch. Little, Brown and Company, Boston , 1971 , p 288. Tennison C. W .: Repair of unilateral cl eft lip by ste ncil method . Plast Reconstr Surg 9: 115, 1952.

123

Chapter V

Repair of bilateral clefts-reconstructing the anatomy in stages

Introduction 127 Surgical correction, general consi derations 128 Maxilla

Nose

Lip

Timing the repair 129 Primary stages of repair 130 Operative procedure Periosteoplasty and alar co rrection Supplementary reconstru ction of the colume lla Lip repair Repair of the second side Secondary lip reconstruction 134 Original deformity Operative procedure

Preoperat ive condition

V to Y plasty

Muscle repair

W ound closure

Result of primary perio st eoplasty

Early result

Late result

Comments 141 Referen ces 142 124

Bilateral Clefts

Methods of reconstruction

Introduction

The entity "cleft lip" describes a spectrum of possible mal­ formations, ranging from the relatively innocuous maxillary depression to the gaping bilateral deformity. The latter is mere­ ly an extended and exaggerated consequence of the same pathophysiologic mechanisms responsible for the more benign lesions. Thus , an understanding of the basic biologic defect which produces all clefts can be used in planning therapy for the many variations of the aberration, including the extreme disfigurement associated with complete bilateral clefts.

1--2 This three month old child demonstrates the classical findings of bilateral cleft lip. The marked protrusion of the prema x illary seg­ ment is most obvious. The deformity is accentuated by retarded de­ velopment of the lateral segments. He ld forward on the elongated vomero-premaxillary stem, the alveolar part of the premaxilla is at­ tached to the nasal septum and is freely movable with these struc­ tu res.

Concentric retraction of the prolabium has occurred . This small "cap " of tissue rests on the elevated and displaced premaxilla. Another conspicious feature of bilateral clefts is the absence of a columella. Even in incomplete deformities this structure is markedly shortened with a distinct tissue deficit. The flared and flattened nostrils on each side of the cleft add to the difficulty in reconstruc­ tion .

•

127

•

Surgical correction, general

considerations

In contrast to the unilateral m alf ormation, there is no no rmal side to use as a model, an d the repair must thus be g u id ed almost exclusively by th e p rinciples mentioned ear lier in t he chapters on unilateral clefts. The recommended techni q ues f or soft tissue repair in the primary management of bil ate ral clefts were first reported in 1965 (Skoog).

Maxilla

Wide dislocation of the maxillary segments is gradually over­ come by the constant guiding pressure of the repaire d lip . T hi s physiologic molding is relatively atraumatic to vomerine an d maxillary growth centers. Staged repairs, closing one cleft at a time, are performed so as to minimize ten sion. A surgi cal set ­ back of the premaxilla should definite ly no t be carried o ut; t he late results are disastrous with marked retardation in m axi ll ary growth and subsequent deformity. Pr eo per ative orthope di c ad ­ justment fails to confront the entire pr ob lem of the protru d ing premaxilla and is less effective, length y an d costl y . O nly wh e n the lateral segments are collapsed is o rtho pedic ex pan si o n car­ ried out priorto surgery. The "floating" premaxilla is a most disabling characteristic of bilateral clefts. With the addition of periosteoplasty on each side, a stabilized and shaped alveolus is fo rm ed.

Nose

As in the unilateral cleft, the principle nasal deformity i s due to lateral pull and displacement at the alar base. In t he b ila teral defect, these unopposed forces spread and flatt en th e nares to such an extent that they totally shift the colu'mell a Into the nostril rim. At the same time, the wide clefts separa te th e car­ tilages so that an unsupported nasal tip results. Bilateral al ar dislocation makes reconstruction particularly difficult, an d m ere medial adjustment of the cartilages is rarely sufficient. Restora­ tion is aided by prolabial flaps, which are used to help elongate the columella. Because of the severity of the nasal deformity, secondary nasal correction almost invariably is required.

lip

As with cleft repairs in general, but particularly true in the bilateral defect, all tissues should be preserved. in this respect, the prolabium is an essential component in restoring normal

128

Bilateral Clefts

width and co ntour to the lip. Even in cases where it may at first seem to be too tiny and too far removed to be of mu ch use in reconstruction, it has been found to be of great value. The prolabium comprises the philtrum and the central portion of the Cupid's bow, and though the tissue is deprived of muscle. the primary repair permits a fuller r econstruction to be carried out later. An important purpose of this closure is to mold the dislocated premaxilla into a normal position . When the final stage is completed, the retracted orbicularis muscle is brought to the midline and the prolabial mu cosa and subcutaneous tissue s are shifted to form the lip tubercle. This restores the muscular framework and general appearance of the lip (Skoog 1973).

Timing the repair Plasti c surgery has four dimensions, the last being time . Recon­ struction thus mu st be carefull y gauged at critical intervals to provide the most physiologic sequence of repair . This principle is particularly valid in bilateral clefts.

•

For purposes of correction, each side can be regarded as a separate defect with the first operation being carried out at about the age of three months. Thi s allows for gradual and less for cefu l molding than would otherwise result from co mplete re­ construction attempted at one time. Barring complications, the other side is repaired three months later. Nasal reco nstruction and maxillary restoration are included in the two primary opera ­ tions. I n asymmetri ca l conditions the most seve rely affe cted side is corrected first. Most bilateral clefts must be secondarily cor rected to recon­ stitute the separated orbicularis muscle. Me chani ca l factors make primary union difficult if not impossible. The secondary operation is performed before the age of five, as soon as the maxillary segments are properly aligned, the tension ha s been reduced and the tissues are pliable. Due to the severity of sec­ ondary deformities, complete restoration is often not possible. Additional corrections may. however, be attempted over the entire growth period and even after full maturity has been rea ched. 129

Primary stages of repair

Operative procedure Periosteoplasty and alar correction 3 The preoperative condition of this patient with bilateral clefts is show, in Figs. 1-2. When this photograph was taken during surgery, periosteoplasty and nasal re co nstru c­ tion had already been co mpleted on the left side, as an initia l step in the repair . The result is an improved nasal contour with elevated alar base and lengthened columella on that side. This elongation remains, however, insufficient.

Supplementa ry reconstruction of the columella

4 In continuing the reconstruction , a triangular flap is designed to further improve the columella, It is comprised of tis sue from the lateral portion of the prolabium . The tip of the flap is placed so that the central portion of the pro­ labium, destined to form the philtrum , will be of normal shape and have a vermilion border wide enough for a Cupid ' s bow, In practice, this means that the medial border of the flap will lie in a vertical position ; laterall y the bor- ' der is placed close to the mucocutaneous j unction ,

130

5 An incision has been made transversely across the base of the columella, where the jun ction between the nose and the lip is indicated by a furrow, and extended along the borders of the flap outlined on the prolabium . The flap is elevated and further mobilized by underm ining the ti ssues proximal to its base on the septum. In this way the tip of the nose is freed , and when brought forward the amount of columellar deficiency is demonstrated.

(

6--7 The prolabial flap is sutured into the columellar defect with 6/0 plain catgut. A marked elongation of the columella on the left side ha s thus been obtained , and there is a good relationship with the raised alar base.

131

•

Lip repair 8 The lip repair is performed as in the unilateral case, see Chapter IV . On the lateral segment, the base of the lower trian ­ gular flap is placed at a right angle to the upper incision line, all three line s are of equal length . Standardized planning facilitates the later repair of the second side. It may also be helpful to tatoo a few symmetrical key points with a fine needle, when the first side is designed.

9-11 It is important at this time to shift the lateral lip segment medially to a higher lev el, so that the alar base is brought for­ ward to rest on the superior aspect of the premaxilla. Pre ssure exerted by the united lip will then effectively mold the protrud­ ing premaxilla into its normal position .

12 This diagram illustrates the functional dynamics of the repaired lip . There is no pressure across the lower portion of the premaxilla and its border is left free.

132

Repair of the second side The second side is treated with a similar procedure and the same standard pattern. This stage is more difficult for several reasons. The cleft has widened; the premaxilla has swung to the opposite side in such a way that its medial edge juts outwards and the prolabial tissues, previously soft and pliable, are now scarred, inelastic, and displaced to the repaired side.

'.

\

13 When the patient is readmitted at the age of six months for reconstruction of the other side, the immediate operative result of the pre v ious repair appears basically unchanged. The scar lines are marked out in blue.

14 Pri or to beginning reconstruction, the operated left maxillary defect is reexposed . As a result of periosteoplasty, bony con ­ tinuity has been achieved across this gap. An additional deposit of bone was needed to com pletely stabilize the segments, and merel y elevating the periosteu m from the new bone was suf ­ ficient to produce the required amount in this particular case, though in less favorable instances subperiosteal implantation of Surgicel is recommended. 15 In this drawing , appositional bone formation to the lateral segment is visualized by comparing with the original , identi ca l defect of th e nonoperated side. The new bone forms a nasal floor at the co rrect level , and the width of the piriform aperture is reduced .

133

Secondary lip reconstruction

Original deformity 16 Thi s asy mmetri c bil ateral c left was r ep aired in the usual fashion . Simu ltane ou sly, perios t eo­ pla sty wa s performed bil aterally.

Operative procedure

Preoperati ve condition 17- 18 At four years of age the patient demon­ strates characteristic residual defects. The lateral lip seg m ents are retracted , separated by the widened prolab iu m and there is marked defi­ cien cy of tissue at the center of th e lip border. The "whi stle deformity" is due not on ly to a defect in mus cle co ntinuity, but also t o displaced prolabia l ti ssues.

) ./

134

V to Y p/asty 19 Additional mu cosa and fullness at the lip border is furni shed by a V to Y plasty. All the soft ti ssue struc­ tures o f th e original prolabium are included in the flap , w hi ch is dissected free down to the mucocuta­ neous junction . The V-flap thus has as its base the mucocutaneous border of the philtrum.

Muscle repair 20 The retra cted muscle borders in the lateral lip ele­ ments are freed from the skin and mu co us mem­ brane. This dissection must be carried past the area scarred by previous surgery . Since muscular adhe­ sions to the maxilla may extend far laterally into the cleft regions, extensive deep dissection is required to permit proper reconstructi on .

•

21--22 The mobilized muscles are united in the midline w ith 4 /0 Dexon s utures. This closure should not exte nd below the up­ per two thirds of the lip . 135

23-24 In the lower portion of the lip the muscles are sutu red to the repositioned subcutaneous tissues of the prolabial flap . If the muscles are united for the full height of the lip, an unnatu ral puckered appear­ an ce will result.

Wound closure 25--26 After muscle approximation it is frequently found that the lip mucosa is still fixed in an abnormal position by scar tis ­ sue over the cleft area . This prevents the complete transfer of the lateral lip ele­ ments to the midline and maintains an asymmetry at the lip border. A supple­ mentary incision in the buccal sulcus, ex­ tending from the midline to the premolar region, gives good exposure during divi­ sion of these fibrous adhesions. The mucosa can then be readjusted and ad­ vanced medially to its normal position, using 4/ 0 catgu ': sutures for closure. Following restoration of the vestibular lin­ ing, the prolabial triangular flap easily ad­ justs itself to its new position . This com­ p let es the V to Y transfer.

136

Result of primary periosteoplasty 27 In con junction with secondary lip reconstructi on, the left maxillary cleft is re-exposed. The periosteum is raised and regenerated bone can be clearl y seen ; it has stabilized the premaxilla completely.

Case report with an early result

28 The bilateral cleft deformity in this

29 Three months later, the previously minute prolabium

girl was treated according to the described procedures. The subtotal cleft on the right was repaired at the age of three mon ths .

is now of normal hei ght and the alar base is at the correct level. An identical c losure was then performed on the op­ posite side.

137

30 By the age of four years, the prolabium has widened beyond normal dimensions due to th e pul­ ling force of the separated muscle. Displacement of the prolabial mucosa ruins the border line of the li p.

31-32 Secondary lip rec onstruction has been per­ formed by restoration of the muscular framework and repositioning of prolabial tissues to the free border As a result, the lip appears normal in its cutaneous portion and a full Cupid's bow has been formed .

Case report with a late result 33 This girl had her first primary cleft re­ pair at the age of three months . She demon­ strates all the stigmata of a complete bilat­ eral cleft.

34 Three months postoperatively the pa­ tient retu rns for repair of the other side. Scarring fr om the original procedure is in­ significant and the premaxilla has swung to­ wards the latera: segment. Lengthening of the columella is obvious, as is the relati ve ly normal position of the alar base. Periosteo­ pia sty had not been devised at this time.

138

•

35 At four yea rs of age the patient was readmitted for delayed periosteoplasty. The premaxilla had considerable mobility and persistent maxillary clefts were present bilaterally. It was possible to line them completely w ith periosteu m, and Sur­ gicel was thus implanted within the created cav­ ities.

The picture demonstrates the relatively normal length and configuration of the columella supplied by the prolabial flaps . The orbicularis mu scle in the lateral segments of the lip remains clearly separated and at the free border of the lip, there is a central thinning . Secondary correction was per ­ formed at age eight, with repair of the separated muscle seg ments and reconstruction at the free border. This was done as described prev iously.

36-37 In conjunction with secondary lip reco n­ struction, both maxillary clefts were reexamined. New bone was found to have been deposited bilat­ erally, fully restoring the anatomy. X- rays revealed tooth buds within the newly formed bone.

139

-

)

38-42 The result at age ten, when the patient returned for routine follow -up. Dental occlusion is good and maxillary development has been normal. This girl is musically talented and ca n play the flute .

140

•

Comments

The primary lip repair might be simplified to reduce visible scar­ ring by freshening the edges and making a straight line closure, often termed "lip adhesion". Lip elongation would then be in­ cluded in a secondary stage. On the other hand, the method presented here provides more physiologic molding. There are, however, some technical difficulties because of the minute flaps and the relatively great tension encountered in closing the sec­ ond side .

Lip

Bringing the muscle layer of lateral lip segments to the midline marks a major advancement in the treatment of bilateral cleft. It restores function, improves the general sculptural appearance of the lip, narrows the widened prolabial tissues and changes the prolabium into a philtrum-like structure . It also eliminates tension on the scar lines, which thereby become less visible. In the upper portion of the I ip, it may be difficult to completely advance the separated muscle to the midline through an intra­ oral approach, and external exposure is thus required. For this purpose, an incision is made in the scars at the base of the columella and extended a few mm downwards in the lip scar. The muscles of the lateral lip segments should then be well mobilized, so that they can be easily sutured to the nasal spine and united in the midline. This maneuver, performed bilaterally, contours the upper portion of the philtrum . Reconstruction of the lip tubercle also requires extensive dis­ section to allow complete repositioning of prolabial tissues, which should be freed down to a thin base at the vermilion border.

Nose

•

Lip correction reduces the width of the broadened nose by shifting the alar bases medially. Repeated advancement of the alar cartilages to improve cO'ntour at the tip of the nose may also be performed at this stage. The length and shape of the columella is directly related to the dimensions of the cleft. Be­ ing totally absent in complete clefts , prolabial flaps are useful in reconstruction and apparently do not deprive the prolabium of any essential tissue . 141

Maxilla

Much is gained by reconstructing the cleft maxilla. The primary goal is to establish a normal anatomical framework, thus stabi­ lizing the maxillary segments and thereby restoring function; simultaneously a foundation for the concomitant soft tissue repair is created . The problem of the disjointed maxilla is par­ ticularly acute in bilateral clefts, where the floating premaxillary segment requires definitive treatment to counteract gross func­ tional impairment. Restoration of the alveolar arch in these cases will generally require repeated periosteoplasties, and only when both sides have been treated can complete stabilization of the premaxilla be expected.

Orthodontics

From an orthodontic viewpoint, maxillary reconstruction re­ duces the tendency for collapse of the alveolar arch, though jaw orthopedic treatment will probably still be required . When nor­ mal configuration of the dental arch is attained, the properly aligned jaws can be placed in precise occlusion. Another ad­ vantage of bone regeneration is that teeth are then able to migrate into the cleft area, thus further aiding dental rehabilita­ tion.

References

Skoog T.: The management of the bilateral cleft of the primary palate (lip and alveolus). Part I. General considerations and soft tissue repair.

Plast Reconstr Surg 35: 34, 1965.

Skoog T.: The management of the bilateral cleft of the primary palate

(lip and alveolus). Part II. Bone grafting. Plast Reconstr Surg 35: 140,

1965.

Skoog T.: Skoog's methods of repair of unilateral and bilateral cleft

lip. Cleft Lip and Palate, Ed . W. C. Grabb, S. W. Rosenstein and

K. R. Bzoch. Little, Brown and Company, Boston, 1971, p 299. Skoog T.: Early management of bilateral cleft lip and palate. Read at the 2nd Internat Congress on Cleft Palate, Copenhagen, Denmark,

August 28, 1973.

142

l- _ _

,

Chapter VI

Repair of lateral facial clefts anatomy

reconstructing the muscular

Introduction 746 Operative Iprocedure 748 Preoperative markings Dissection of the muscle layers Repair of the muscles Skin closure Result Comments 754 References 754

Title page: The drawing illu strates a slight right­

sided transverse facial cleft and th e associated wide disruption of oral and bu ccal mu sc ulature.

144

Lateral Clefts

./

Method of repair

Introduction

The lateral fa cial cleft (macrostomia) results from a defective union between the developing mandibular and maxillary pro­ cesses. The lesion invades the complete depth of the cheek and separates the upper and lower lips as it pierces the corner of the mouth. The anatomy of the disjoined lips is otherwise un­ disturbed. The incidence of this conge nital malformation is rare, as atypical clefts represent only 1.5 per cent of all cleft lip and palate deformities. Corrective procedures in the past, fell far short of an ideal restoration and as described, were all similar to tarsorraphy . In the technique recommended by Barsky et al. 1964, the lateral limits of the cleft were determined and skin and mucosa l fla p s utilized in reconstructing a new commissure, whereas the de ­ ficient muscle layer was totally neglected . W ang and Macom ber (1964) recognized the specific mu scular action of this region and united the orbicularis oris m uscle to ade q uately rec onstruct th is defe ct. The present operation is base d on this prin ci p le of repa ir ing the underlying m uscu lar f ramework, incl ud ing the cleft bu ccal muscle, as w ell as clo sing the superficia l cleft.

.

,

146

I

Lateral Clefts

I

t

I

,

1-2 Ev en a minimal lateral facial cleh is associated with a gap in the sup ­ porting musculature. The sling effect th a t these muscles offer to the corner of the mouth is absent, and cau ses the affected side to droop . The deformity becomes more obvious w hen t he mouth is opened, and the separated muscles contract indep endently. This patient has an obvious right-sided cleh, which partially obscures a smaller defect on the leh side. The presence of preauricular tags is characteri stic of congenital mal­ formations involving the first and second branch ia l arches. Accord ing to Grabb (1965), a distinctiv e tag located Ju st anterior to the jun ction of the tragus and antitragus, is almost al ways associated wi th m acro­ stom ia.

147

Operative procedure

Preoperative markings 3-4 The lateral extension of the normal red lip can bee seen on the upper and lower sides of the cleft due to the color contrast be­ tween the mucosa of the lip and the cleft. This difference is ac­ centuated by the presence of a mass of o rbi cularis oris muscle on the lip side, caused by a retracti on of the muscle . The transi­ ti onal zone is u sually found more medially than anticipated. The false co mmissure is marked at the mucocutaneous junction . It curves to the inside of both the uppe r and lower lips and an­ gulat es across the free borders o f the lips, along the ma rgins of normal lip tissue . On the upper lip, thi s line of incision is ex­ tended a few mm into the vermilion border.

5 Even the moderate external deformity of this case inv olve d com plete discontinuity of the or­ biculari s muscle, and a wedged separation with­ in the buccal muscle layer extending into the cheek .

148

Lateral Clefts

t

­ Dissection of the muscle layers

\

6 At the true lip margi n, the dis­ section reveals a retra cted mass of orbicularis o ri s muscle, which ca n be ex posed after extracting it from the surrounding tissue .

8 Th e dissection o f th e m u scle layer lining the cle ft, is con­ t inue d alo ng the upper and lower borders.

I

7 An incisio n alo ng the muco­ cutan eous border o f the cleft ex p oses the ti ssu e defect. Lateral to the cleft, the muscle layer is ret ra cted and incom­ plet ely separated . Subcuta­ neou s di ssectio n is therefore required to en sure that the buccina to r is fully freed and ca n be reco nstituted.

149

Repair of the muscles

9--11 When the dissection is completed, the true magni­ tude of the defect is seen . The margins of the bor­ dering musc les are distinctl y displayed and a sub­ stantial depth of ti ssue is found between the sub­ cutaneous layer and the ora l mucosa . Simp le ap­ proximation of th ese displaced structures will re­ store the norma l anatomical integrity. The closure is p erformed in two layers. It begi n s in the bottom of the cleft, where the muscles and mucosa are brought together in one layer with a rOw of inter­ rupt ed 4/0 catgut ma tt ress sutures, tied on the oral side.

150

I

12-14 The freed ends of the orbicularis form a discrete bulge. This muscle is repaired as a separate entity with a few bu ried 4/0 Dexon sutu res, thereby re­ storing the sling effect to the corner of the mouth .

.'

·t

151

15 The buccin ator repair is supplemented with a few

5/0 catgut sutures on its external surface. A fter the m uscles have been approximated, the th ick subcuta ­ neous fat laye r fits into accura te apPosition atop the muscles. A few fine catgut sutures may be needed in this la ye r to obliterate any dead space and improve the contour.

Skin closure 16--18 As in ot her congenital c left deformities, there is never an excess of tissue. Thi s principle applies to the skin as well, and only minimal tri mming along the borders of the original cleft is required before suturing . The suture line at the angle of the mouth should then be broken to counteract the stra igh t line effect. The superficia l incision at the v ermilion border of the upper lip was used for that purpose. Skin edges can be approximated without tension, using 5/0 non-absorbable material on atrau matic needle.

152

Result 19-20 Two months after surgery, symmetry of the mouth and cheeks is clearly seen. 21 After one yea r, there is a complete re sto ra­ tion of fun ction .

153

Comments

Macrostomia should be recognized as a malformati on in vo lvi ng several tissue layers. The external defect is always combined with a more extensive separation of the deep tissues of meso­ dermal origin, i.e . the oral and buccal musculature. In this respect, lateral facial c lefts show great similarity to congenital cleft lip deformities. Any procedure that is confined to surface anatomy only hides the deep division with a thin tissue cover­ ing. An effective repair requires full exposure of the disturbed anatomy in order that the deficit can be bridged with a solid matri x of muscle. Reconstruction of a commissure then does not present a great problem. The results of this procedure have been gratifying in terms of both function and ap pearance .

References

Barsky A. J., Kahn S. and Simon B. E.: Principles and Practice of Plastic Surgery. Second Ed. , McGraw-Hili Book Comp, New York, 1964, p 419. Grabb W. C. : The first and second branchial arch syndrome. Plast

Reconstr Surg 36: 485, 1965. Wang M. K. H. and Macomber W. B.: Median clefts of the lips; lateral and oblique clefts of the fa ce. Reconstructive Plastic Surgery. Ed. J . M. Converse, W. B. Saunders, Philadelphia, 1964, vol III, p 1533. 154

Chapter VII

The significance of the periosteum in regenerating resected portions of the maxilla; the effects of early bone grafting on facial development; the tissue response to subperiosteal Surgicel ® implantation, and; the results of removing the periosteum fro m membranous bones. Studies in growing rabbits and guinea-pigs

Introduction 158 Osteogenic potential of maxillary periosteum

Cleft anatomy and periosteal activity

Periosteal repair versus bon e grafting- a d ifference in

the qual ity of bone

Environment and periosteal bon e regeneration

Surgi cel @and bone formation

Th e effects of periosteal res ection

Conclusions 172 References 173

156

Regeneration of Facial Periosteum and Bone

Experimental research

Introduction

At its inception, an air of mysticism surrounded the use of periosteal membranes to form new bone. The scientific basis for this procedure was unclear and the technique of "bone­ less" bone grafting provoked a series of stimulating questions. • Does normal maxillary periosteum possess an osteogenic cap acity, which coul d account for the dramati c results obtained through periosteoplasty?

I

• In the original proposal of this procedure it was postulated , that the periosteal lining bordering the ma x illary cleft was cap­ able of forming new bone. If this, in fa ct, was the case, why then, within the congenital defect, did the unmanipulated perio­ steum remain largely inactive? • Is there a qualitative difference between bone produced from local periosteum and bone resulting from autogenous bone grafts? • Is there an environmental influence on the bone-forming capacity of freed periosteum? • What are the effects of Surgicel ® when placed in a p eriosteal lined cavity? • How does the remova l of perioste um from the outer aspect of facial bones affect their future development?

•

In the relati ve ly uncontrollable clinical setting , with the many factors influencing surgical results , the great number of cases required for a proper assessment, and the long time needed for final evaluation, a true analysis cou ld not be made. These in­ quiries were thus taken to the research laboratory, where ex­ tensive experiments were carried out to probe the problems and to better understand the nature of max illary periosteum . In a series comp rised of more than 300 rabbits, aged 2-3 weeks, Engdahl (1972) performed unilateral maxillary resection which included the premaxillo-maxillary suture (Figs. 1- 3). He varied the position of the periosteal lining and the material used to fill the defect. Bone regeneration and maxillary growth were studied by gross examination and by triple fluoro ch rome latel­ ling .

158

f

, This depicts the standard, right -sided, maxillary resection used in Engdahl's experi ments on 3 weeks old rabbits.

2--J These two craniums, the larger from an adult and the smal ler from a young rabbit at the time of resection, are presented to show the considerable maxi llary growth that occurs in this species .

In another investigation, in more than 100 growing rabbits and guinea-pigs, Hellquist (1972) studied the effect of removing the periosteum from the facial bones. Periosteal r.egeneration was fOllowed by consequetive histologic surveys. The growth of the denuded bone, as well as the development of the entire sku ll , was examined gross ly and by using osteometric and radiographic methods. Some of the results of this informative work will be presented here. By courtesy of Dr. Engdahl and Dr. Hellquist, their original illustration s are used in these summarie s. 159

4 This drawing illustrates the tec hnique of early, subperiosteal ma xillary resec­ tion . The periostea l lin ed cavity has been left to fill spontaneously with blood.

Osteogenic potential of maxillary periosteum

In growing rabbits, subje cted to standardized unilateral maxil­ lary resection, the periosteum proved to be essential for maxil­ lary regeneration. The more periosteum preserved at surgery, the earlier and more complete was the restoration of the normal anatomy. .When the periosteum covering the lateral surface of the maxilla was resected together with its bone, and only the medial wall of mucoperiosteum was left in place, bone formation dimin­ ished. Yel, even a single-layered periosteal membrane was capable of forming new bone across a substantial maxillary defect. When the resection included the periosteum on both the lateral and the medial aspects, there was minimal new bone formation at the borders and the defect persisted throughout the entire growth period. Unilateral maxillary bone resection with its covering periosteal lining did not markedly influence the growth and development of the facial skeleton , despite the inclusion of the premaxillo- _ maxillary suture in the resected segment. When subperiosteal maxillary bone resection was carried out and the resulting , periosteal lined cavity was left to fill sponta­ neously with blood and/or serum, bony reconstruction took place at an extremly rapid rate. Regeneration was visible at the end of the first postoperativ e week , and normal anatomy was largely restored in two to three weeks. In some cases suture-like growth sites were obse'rved within the regenerated bone. The new bone grew in harmony with the facial skeleton and only minimal maxillary deformity consequently developed. (Figs. 5-8)

160

5-6 There is complete regeneration of the right maxillary wall . which has a sl ightl y roughened bony surface. Unimpaired skel etal growth is evidenced by the evenly grounded fa cets of the incisors-this is characteristic of a normal bite.

7 This microphotograph . taken in ultraviolet light. demon strate s the sequentia l regeneration of new bone. The animal was sacrificed 23 days after surgery . Fluoroch rome injections were given 15 (yellow). 18 (red) and 21 days (g reen) postoperatively. The dark zone. separating the fluoroscently active areas. represents suture formation within the newly formed bone. Longitudinal g rowth at this site is evident by the distinctly co lored zones along its posterior bony border.

-

Although the enclosing perio steum does not stain with this tech ­ nique. the section demonstrates that the mass of new bone originates from the periosteum . Along the lower border in this illustration. the most recently formed bone (green ) is found on the surface. adjacent to the black periosteum. whereas the red and yellow stained bone. formed a few days earlier, has a more central locati on. The distinct chronologic labelling indicates growth byapposition. S In this transverse section through a rabbit skull. a standard bone resection had been performed and bone marrow aspirate has been used to fill the periosteal cavity. The animal was sacrificed 15 days after surg ery. The normal anatomy is largel y rest o red and a suture ­ like growth site has formed in the po sterior portion of the regenerat ­ ing maxilla. Labelling was carried out 3 (yellow), 9 (red) and 12 (green) days postoperatively. In this study the rate and quantity of bone formation differed insig­ nificantly from the results obtained when a blood matrix was used.

161

Th is series of experiments shows that the maxillary periosteum possesses an osteogeni c capacity capable of completely regenerating bone. It confirms the conclusion s based on random clinical observations of spontaneous maxillary reforma­ tion and also provides a reasonable explanation for the favor­ able results obtained w hen periosteoplasty wa s performed across a cleft. In animal studies, the thin, transparent mucoperi ost eum on th e medial aspect of the maxilla was found to have a less vigorous osteogenic po tential than the thicker and better-vascularized periosteum covering the outer bone surface. In children, the reverse seems to be true. The mu co periosteum on the deep aspe ct of the lateral maxillary segment forms a substantial tis ­ sue la ye r. When this den se periosteal membrane is freed, it proves to be more acti ve in forming bone than the perioste um raised on the outer aspe ct of the maxilla. Similarly, the thin mucoperiosteum of the premax illa demonstrates little bone forming capacity. 80th results, in animal experiments and clini­ cal observations, indicate a direct relationship between mor­ phologic appearance and osteogenic pote ntial.

Cleft anatomy and periosteal activity

One experiment was designed to study the oste ogenic activity of normal periosteum when placed in an anatomical framework that resem bled a congenital cleft. Following maxillary resection mucoperiosteal flaps were wrapped about the ra w bone sur­ fa ces. Under these conditions the periosteum acted in an identi ­ cal manner t o the periosteal lining of tru e clefts, and no bone developed. (Figs. 9-12.) This experiment supports the initial assumption, that in con­ genital clefts the topographic anatomy of the periosteum alone inhibits bone regeneration . The defect might then be expected to enlarge during growth, but clini cally this does not occur, as there is a gradual compensatory collapse of the maxillary seg­ ments, produced by the tight and scarred tissues of the co n­ comitant lip repair . In the ani ma l experiments , this readjust­ ment was preve nted by a rigid bony frame wo rk, which apart from the' created defect, was intact. Furthermore, the soft tis­ sues we re pliable and under no tension .

162

Regeneration of Perio steum and Bon e

9 Resection performed in such a way that the bony borders could be com­ ple tel y lined with mucoperiosteum. On the lateral aspect, the covering periosteum was removed together with the maxillary bon e; media ll y, the mucoper iost eum was split and two flaps were obtained, which were then sutured over the exposed edges.

1 \

10-11 This is the result of early maxillary resec­ tion, where the periosteal membranes were placed in a position that simu lated a congenita l cleft. In this experimental model , alm ost no bone regeneration took place and the defect widened as the maxilla grew forward. No sig­ nificant snout deviation occurred .

12 In anoth er animal o f this experimental group , labelled 15 (y ellow). 18 (red) and 21 (green) days after surgery, the original defect has widened rather impressively with th e gen ­ eral growth of the maxil la. Th e rounded , inactive edges of the bOMY cavity are well demon ­ strated . Note the thick and tortuous prema x illo­ maxillary bone sutu re on the control side.

163

Thus, the periosteum-bone relationship determines the fate of bone regeneration. The location of the new bone, when formed, will be decided by the position of the periosteal lining. This supports the concept of freeing the periosteum and placing these membranes where bone is needed. The results of the animal experiments are in complete accord with clinical ex­ perience in maxillary clefts.

Periosteal repair versus bone grafting - a difference in the quality of bone

In the 1960's, it became readily apparent that bone grafting cleft deformities in early childhood could impair maxillary growth . This alarming observation led to a critical reassessment of the obtained results and at the First International Cleft Palate Con­ gress in 1968, early advocates of this mode of therapy advised against primary bone grafting. The method is, however, still being used in some centers. The discouraging clinical experience with bone grafting cleft deformities makes it particularly pertinent to establish, whether bone produced by bone grafting is of different nature than that formed from local periosteum and blood. Uniform experimental results of autogenous bone grafts, show the rapid and massive formation of a block of bone . The animals, however, soon de­ veloped pronounced deviation of the snout and severe maloc­ clusion . The explanation for these striking deformities was the limited growth within the grafted segment. The new bone se­ emed to inextricably lock the premaxilla and maxilla together , causing deviation as well as underdevelopment of the growing maxilla (Figs. 13-14.) In bone formed in this manner, un­ resorbed kernals of bone grafts could be recognized in the new­ ly mineralized bone. No distinct suture-like growth centers were observed.

•

164

When prior to bone grafting, the lateral periosteal lining was resected with the bone, rapid resorption of the autogenous bone grafts occurred. New bone formation followed, however, although this process was somewhat retarded. The subsequent new bone was thinner than when the cavity had been lined completely with periosteum.

•

13-14 This is the result of early, subperiosteal maxillary rese ction and bone grahing. The animal was sacrificed at maturity.

There ha s been es sen tiall y no growth w ithin the bone grahed seg­ ment, resulting in di stortion and deviation of the snout to w ards the operated side. Severe inversion of the frontal bite has occurred w ith unopposed growth of the in ciso rs. The developmental arrest of the right side of the maxilla impedes th e maturation of the contralateral side and results in a seve rely deformed and stunted maxilla. For comparison . the normal skull of Fig. 6 on p. 161 is sh own again on the leh. In this animal an identical maxillary resection was made at an early stage; bone regenerati o n fr om the preserved periosteum is com plete and growth unimpaired.

This investigation clearly demonstrates, that with in a stand­ ardized maxillary defe ct, the bone produced by bone grafting behaves quite differently during growth than the bone wh ich regenerates from a perio steal lined cavity that has been filled with b lood These observations may well explain the unfortu­ nate results of primary bone gra fting in infant clefts.

Environment and periosteal bone regeneration

Engdahl also studied the influen ce of bone marrow on new bone formation. Following ma xi llary bone resection , w hen the periosteal lined cavity was filled with autogenous bone marrow aspirate, the results were similar to those obtained from bl ood filling , though bone marrow seemed to act as an additional source for bone formation. By remo ving the lateral periosteal wall together with the bone, it was possible to demonstrate that the osteogenic ca pacity of the periosteum overshadowed that of the bone marrow. Local infe ction in the resection area was found to disturb maxil­ lary growth and cause deviation of the snout. This compli cation occurred in a small number of animals.

165

Surgicel®

and bone formation

The tissue response to subperiosteal Surgicel implantation wa s also studied in young rabbits (Skoog 1967). A su bperi osteal pocket was created over the fronto-nasal bones and loo sely packed with Surgicel soaked in blood. On histologic examina­ tion the tissue rea ction was characterized by massive prolifera­ tion of osteoblasts and fine vessels. The ce llular growth orig ­ inated from both the bone surface and the osteogenic layer of the elevated periosteum. At fourteen days, most of the original fabri c had been absorbed. Thickening and hyperemia of the periosteum was then most pronoun ce d. Bony trabeculae formed at an early stage and later there were signs of bone resorption. (Figs. 15-18.)

The conclusions derived from these experiments were that Sur­ gicel m ay be used safely for subperiosteal implantation. Such a procedure, will result in bone formation within the mass, where the fabric itself will be completely absorbed. When Surgicel was implanted into the periosteal lined cavity used in Engdahl 's experiments, it was found that the forma­ tion of new bone wa s delayed within a standard time . The anatomy was not as well restored as in the prev io us series, where the cavity had been filled with blood alone . These ob­ servations reinforce the opinion that Surgicel itself should not be regarded as having osteogenic qualities, but when used as a scaffold to support a periosteal membrane in a desired position, the incorporated blood clot will effectively permit bone forma­ tion within the mass. Surgicel can thus be utilized for recon­ structive purposes to regulate volume, shape and position of the newly formed bone (Skoog 1969). In Engdahl's experiments, the depth of the resected cavity was only about 2 mm . The fabric thus occupied a comparativ ely large portion of the spa ce, which might explain the quantitative results obtained. In addi­ tion, the tissue response of Surgicel, whi ch in clinical experi­ ence some times seems to be a stimulus to periosteal bone formation , may act adversely in the young rabbit, w here the perio steal membrane is quite delicate and possibly acutely sensitive to the foreign material.

166

•

.­ "'

••

.t

15 In growing rabbits, Surgicel , soaked in blood ,

was loosely packed into a subperiosteal pocket over the fronto-na sal bones.

16 In this section, made 8 days later , a layer of undifferentiated cells (osteoblasts) covers the bony surface and is seen to invade the implant. Fi ve vessels and fibril s have al so formed. 17 After 14 days , there is evidence of cancellous

bone formation , ma inly within th e periphery of the implant. Some clearly defined trabeculae ha ve also formed with a surface layer of os teo­ cyt es .

18 Besides evid ence of new bone formation ,

there are also signs of resorption with multi ­

nuclear o steoclasts present along the ed ge of

the bone.

167

19 Thi s se ction through a rabbi t nasal bone w as mad e 7 da ys after the cover ­ ing periosteum had been completel y removed . A thin la yer of perio steum has started to reform over th e denuded bone . (Hematoxylin and eo sin , x 40 .)

, ...'" ,

20 Eighteen days after resec­ tion marked periosteal regen­ erati o n has occurred . The thick­ ne ss of the new tis sue con­ siderably ex ce ed s that of nor­ mal perio steum . There is a richl y cellular inner layer, which lies immediately above the new ly forming bone . (Hematoxylin and eosin , x 50. )

21 This section of the nonoperated side is

presented fo r comparison .

Th e e f fects of per iosteal resection

Observ ations made on more than 150 patients with m ax il lary clefts, treated b y periosteoplasty, indicate that on the ou t er aspe ct of the lateral ma x illary segment, where the periosteum is rai sed and shifted, complete periosteal regeneration took pla ce without impairing ma x illary growth. In fact, an appo s i­ tional la y er of new bone wa s f o und to form beneath the re­ generated periosteum . In Hellquist' s in v estigation in growing rabbits and guinea -pigs, unilateral periosteal resecti o n was ca rried out on the outer aspe ct offacial bones . The extent of resection varied among four ex perimental g roups, the most extensive excision compri s­ ing an area over the nasal bone, the anteri o r portion of the

168

Regeneration of Periosteum and Bone

frontal bone, the premaxilla and maxilla . Within ten days, a new periosteal layer started to form over the denuded bone surface. The regenerated periosteum soon became hypertrophic, de­ monstrating a considerable increase in thickness, when com­ pared to the control side . This was present both in the inner cambial layer and the outer capsular zone . After six months, there was a regression of this hypertrophied periosteum and a normal thickness eventually returned. (Figs. 19-21 .)

22-23 These transverse sections are of rabbit nasal bones, 29 days after unilat­ eral periosteal resec­ tion. A distinct in­ crease in thickness of the entire nasal bone can be seen on the operated side (upper microphotograph) compared with the control shown below. (Hematoxylin and eo­ sin, x 50. )

Osteocyte necrosis is normally found in growing bone tissue. A slight and temporary increase in the number of necrotic osteo­ cytes was noted in the outer cortex of the denuded bones, but the bone tissue itself never became necrotic. Instead, ten days after periosteal resection, when a regenerated periosteal layer was already present, an appositional layer of cancellous bone started to form subperiosteally. This new bone formation was of considerable magnitude, causing a total increase in thickness of the related bones. The two layers of bone were subsequent­ ly integrated , and after six months an increased bone thickness remained. The fine cancellous structure of the new bone was gradually converted into compact bone, but some communica­ tions to the inner diploe persisted. The increase in bone forma­ tion under the regenerated periosteum i s most likel y related to periosteal hypertrophy and associated hypervascularity. (Figs . 22-23) In rabbits, osteometric and roentgenographic studies showed that removal of the periosteum in growing indivudals had little influence on the growth of the facial skeleton, provided that the resection did not include the surface of the maxillary body. When the periosteum was removed from this area , growth changes took place in several animals, causing vary ing degrees of snout deviation . In contrast to changes observed in rabbits after periosteal maxillary resection, growth disturbances were negligible in guinea-pigs, despite the fact that they had been operated upon in an identical fashion and at the same age. Neither did deviation of the snout nor downward tipping of the nasal bones develop in these animals . (Figs. 24-26. ) These different results may well be explained by differences in the skeletal and va scular anatomy in the two species. In the rabbit, the anatomy of the outer, lateral aspect of the maxilla is cribriform and richly vascularized, with a number of thin-walled vessels passing into and through the perforated bone. In the guinea-pig, the corresponding area is purely cortical with a 169

24--26 These pictures of an adult guinea-pig demon­ strate normal bone growth and cranial development after unilateral periosteal resectio n of the facial bones. Th e sur­ gery was performed when the animal s were six days old . 27 The ext ent of the periosteal resec ti on i s shown in this drawing . It comprises the outer aspect of the nasal bone, the anterior part of the frontal bo ne, the prema xil la and the maxilla. In the guinea-pig the bon y surfaces of all these bones are similar ; smooth and cortical. Th e results were the sa me for the entire ex perimental group, ir re­ spective of the exte nt to which the periosteum had been rem ove d.

28-29 Th e craniu m of this adult rabbit shows no im­ pairment of growth, despite exten sive unilateral remo val of its peri osteum at ten days of age . In several anima ls in the rabbit seri es damage to per­ forating maxillary vessels re sulted in deviation of the snout towards the operated side. However, w hen the periosteu m covering the nasal and frontal bones w as removed with the premax­ illary p eriosteu m , but the vascular plexus of the cribri­ form maxillary body was left undisturbed, growth was never significantly imparied .

170

Regeneration of Periosteum and Bone

bone surface similar to that of the premaxilla and the nasal bone. Since the vascular architecture in the maxillary region of the rabbit varies, it is not possible to state accurately the injury caused by the operation in each animal. The experience in these experiments clearly indicates, however, that in rabbits, inter­ ference with the periosteum of the cribriform portion of the maxillary bone seriously affecs major vessels . This vascular damage is likely to impair the nutrition of the entire maxilla. Variations in the vascular anatomy would influence the degree of surgical trauma to the operated animals , and could thus satisfactorily explain the differences in maxillary growth dis­ turbances observed within the rabbit group. Interestingly enough, the moderately reduced dimensions of the rabbit maxilla were compensated for by an overgrowth of the frontal premaxillary process, despite this process also being deprived of its periosteum. This observation demonstrates that the mere removal of periosteum will not disturb the growth capacity of the underlying bone (Figs. 28-29). Furthermore, in all the rabbit experiments, periosteal resection resulted in an in­ crease in width of the nasal bone. Where the resection was limited to the premaxilla and anterior portion of the nasal bone, new bone was laid down on the adjacent portion of the maxilla, even though this area was not included in the periosteal resec­ tion. These findings coincide with observations of other in­ vestigators that the proliferative response to trauma extends to involve the adjoining and intact periosteum .

,

.

,

171

Conclusions

Morphologically, periosteum and bone are well defined struc­ tures. Histologicall y, the two tissues are less clearly separated as the periosteal layer of osteocytes on the bone surface is completely integrated with the syncytial network of osteocytes within the organized bone. From a biological point of view, the distinction between periosteum and bone is in many respects artificial. Thus, periosteum will regenerate as such, but under ce rtain conditions, it will also la y down new bone. Similarly, bone is capable of forming more bone, which will also develop a covering periosteal layer. Regenerated periosteum and bone can be used independently or together. The periosteum, being the more cellular tissue, can reasonably be expected to be the more active component. The utilization of this tissue in the repair of maxillary clefts is but one application of this fascinat­ ing discovery. The effectiveness of free periosteal grafts ha s been demonstrated by Ritsila, Alhopuro and Rintala (1972). This further expands the wide possibilities and the potential use of the periosteum .

172

References

Engdahl E. : Bone regeneration in maxillary defects. An experimental investigat ion on the significance of the periosteum and various media (blood, Surgicel, bone marrow and bone grafts) on bone formation and maxillary growth. Scand J Plast Reconstr Surg, Suppl 8, 1972. Hellquist R.: Facial skeleton growth after periosteal re section. An osteometric, roentgenographic and histologic study in the rabbit and guinea-pig. Scand J Plast Reconstr Surg, Suppl 10, 1972 . Ritsila V ., Alhopuro S. and Rintala A .: Bone formati o n w ith free periosteum. Scand J Plast Reconstr Surg 6: 51, 1972. Skoog T.: The use of perio steum and Surgicel . for bone restoration in co ngenital clefts of the maxilla . Sca nd J Plast Reconstr Surg 1: 113, 1967.

,

Skoog T .: Repair of unilateral cleft lip deformity: ma x illa , nose and lip. Scand J Plast Reconstr Surg 3 : 109, 1969.

173

C hapter VIII

Cleft palate repair-restoring the muscular anatomy and reconstructing the anterior portion of the soft palate

Introdu ction 176 Principles of repair 178 General surgical considerations 178 Age for repair 179 Anesthesia 179 Operative procedure 180 Preoperative condition Infiltration of the operative site Freeing the palatal mu cope riosteum and mobilizing the soft palate Repair of the soft palate muscle layer Reconstruction of the anterior portion of the soft palate Closure of secondary defects Result Bloodloss and replacement Tympanotomy

Comments on operative procedure 192 Comments on results 196 References 197

Title page: This drawing depicts pal ­ ate anatomy in cleft and normal co n­ ditions. Note the anteriorly displaced muscular attachments on the cleft side. Th is pathologic arrangem ent is largely responsible for disturbing muscle function and shortening the palate. A related feature of this ab­ normality is the absence of the aponeu rotic portion of the soft palate. Re constru ctive efforts should focus on these two aspects of the deformity. This illustration has been adapted from von Luschka' s "Der Schlundkopf des Menschen" (1868).

174

Cleft Palate 1

r--­ \

(

\ j) .....

f

• - ­ Palatme aponeurosis

M .levator veIJ palaltni

. M palatopharyngeus

/ -

M palatogloss us

A te:cJlnique o.f pt'-itnal'-y=¥efll · · fai~=-

.1

Introduction

"Es gibt somit meiner Ansicht nach zwei ver­ shiedene Arlen des Gaumenverschlusses,· di e eine dieM der Sprache und ist vorzugsweise zu Stan de gebracht durch die Thiitigkeit der Gaumenheber und des oberen Schlund­

schnurers . .. " Gustav Passavant (1863) Though Passavant clearly visualized the essential function of the levator and "upper pharyngeal constrictor" in forming speech, it has taken surgery a century to develop techniques which satisfactorily restore this lost mechanism for ve l o­ pharyngeal closure to cleft palate patients.

1 This drawing illustrates the normal functions of the levator palati and the palata-pharyngea l muscles. The blue arrows indicate the direction of their pull. These two muscles are most important in velo­ pharyngeal closure, moving the soft palate upwards and ba ckwards to meet the posterior pharyngeal wall. The broad blue and black arrow represents the vector of the muscular forces. The upper portion of the palata-pharyngeal muscle narrowS the pharyngeal diameter.

In the nineteenth century random methods for closure of palatal clefts coalesced and evolved into the procedure known as von Langenbeck's operation (1861). Through long , lateral incisions, von Langenbeck mobilized the palatal mucoperiosteum, de­ tached the nasal mucosa from the posterior margins of the hard palate, and then sutured together the paired margins of the cleft. With minor modifications, this method is sti ll in use today. The works of Victor Veau, published in "D ivision Palatine" (1931), mark the beginning of a new era in cleft pa late surgery. Based on accurate observations and a brilliant analysis of th e 176

Cleft Palate 1

cleft palate malformation, Veau introduced principles which led to a more anatomic repair. He pointed out the functional im­ portance of the abnormal muscular anatomy in these condi­ tions, and paid particular attention to restoring the muscle layer of the soft palate. By preserving the greater palatine vessels, he also found that he could divide the mucoperiosteal flaps anteriorly, thereby elongating the palate.

,

In 1964, Ruding gave a detailed account of the anatomy and function of palatal muscles, in cleft and normal conditions . He emphasized their abnormal immobile insertions into the rim of the hard palate and recommended that all tensor insertions be severed and that the tensor-levator system be luxated from the hamular grooves. He also described a technique for detaching the musculature anteriorly and constructing a levator palati loop. To ensure optimal function of the naso-pharyngeal sphincter, Braithwaite (1964,1968) suggested extensive mobili­ zation and coaptation of the palatal muscles. To this end the lateral pharyngeal space of Ernst was widely dissected, back to the posterior pharyngeal wall and packed to narrow the sphinc­ ter. The superior constrictor was freed from the pterygoid plate, and the hamulus was broken off, allowing medial displacement of this muscle. Most importantly, the muscular palate was com­ pletely freed from the posterior border of the hard palate before . midline approximation was carried out. The functional results obtained with this procedure proved excellent. Based on an anatomic study and review of the comple x muscular inter­ actions of the normal velum as compared with the cleft soft palate, Kriens (1969) advised detachment of the cleft palate muscles from the mucoperiosteum and palatal bone. However, no separation was made near the nasal layer, as severing the muscular insertion at that point was felt to invite a mucosal slough. Kriens approach was made through von Langenbeck­ Ernst incisions which, undoubtedly, hindered extensive and ac­ curate dissection. In :his technique the muscles were ap­ proximated anteriorly, but the palate was not lengthened.

177

Principles of repair

The principle of freeing the palatal muscles from their abnormal attachment to the bony palate and transferring them as a mov­ able muscular sling to a posterior level marks an important and logical development in cleft palate surgery. In the procedure to be described, the aims of the repair are : 1) to reestablish the normal anatomy of palatal muscles, and 2) to elongate the pal­ ate by reconstructing the anterior portion of the soft palate, the zone of the palatine aponeurosis . In clefts, palatal muscles develop with an attachment to the hard palate instead of a mid line affixation at a posterior level (see front page) . The muscular portion of the palate is thus brought forward , producing the characteristic, abnormally short cleft velum. As a result of this displaced insertion, the function of these muscles is seriously hampered and partly re­ versed. When the anterior portion of the soft pa late is exposed at surgery, it becomes evident that there is a marked deficiency of intervening palatine aponeurosis . In the normal palate , this tissue layer is rather substantial. Reconstruction of the apo­ neurotic section seems to be an appropriate way of lengthening the palate . This procedure also serve s to prevent the severed muscles from reattaching anteriorly, and at the same time it counteracts any tendency towards late contracture with con­ comitant forward displa cement of the soft palate . As the pala­ tine aponeurosis is relativel y fixed , mucoperiosteal flaps are ideally suited for this reconstruction.

General surgical considerations In cleft palate reconstruction, care must be taken not to surgical­ ly induce secondary deformities. At bi rth, in median clefts of the palate, the alveolar arch is essentially normal , whereas com­ plete clefts demonstrate character istic ma xillary malformations which remain basically unchanged throughout life, if not surgi­ cally altered. The severe maxillary defo rmities frequentl y en­ countered in adult cleft palate patients have an essentially dif­ ferent character and are the end products of surgical interfer­ ence with growth centers, mucoperiosteum, and vascular supply. Infection and scar formation are additional contributing factors. Improved surgical techniques and control of infection

178

Cleft Palate 1

have reduced these hazards, but though diminished, they still warrant careful attention. For these reasons , surgery on the oral aspect of the hard palate should be as limited as possible. Mucoperiosteal flaps used for elongation of the velum , for ex­ ample, should be made short. This reasoning can also be ap­ plied to complete clefts, where a co mparatively narrow opening remains within the hard palate after closure of the primary pal­ ate. This defe ct is closed separately in one layer, with a flap raised from the nasal septum. To a varying degree all procedures leave the palatal bone ex­ posed . Under the conditions present in the oral cavity, healing by secondary intention inevitably results in so me damage to the regenerating periosteum , with subsequent impairment of local maxillary growth. Scar contracture further complicates the situation by causing a late " buckling " deformity of the adjacent section of the alveo lar arch. Within the hard palate, remaining raw areas should therefore be reduced to a minimum.

Age of repair Preferably, the cleft palate should be repaired before a set pat­ tern of speech develops. In our series , the operation has been performed at about 18 months of age. Recurrent middle ear in­ fection was the only factor that prompted earlier surgery.

Anesthesia The operation is carried out under general anesthesia . In addi­ tion, the operative field is infiltrated with lidocaine solution (Xyl ocaine®) with epinephrine. The supplementary use of a local anesthetic with a vasoconstrictive agent is a definite ad­ vantage in palate surgery. The subperiosteal injection aids dis­ section , and the infiltration facilitates handling the delicate tis­ sues as well as minimizing oozing. Clinical studies by Dingman et al. (1949). Rintala (1965 ). and others prove that the total blood loss is considerably redu ce d by this measure. During surgery, the local anesthetic also permits a higher level of general an­ esthesia to be maintained. 179

O perative procedure Preoperative condition 2 The Dingman mouth gag is used for exposure. The patient's head is hyper ­ extended and supported by a padded ring, while the fa ce is draped with ad­ hesive plastic sheets.' As is comm o n in Eu rope, I prefer to sit at the head of the table. The operativ e drawings are made from this perspectiv e, but for clarity, ali illustrations are here reproduced in a frontal view. In this 18 months old boy the cleft ex­ tends to the middle of the hard palate. The palate is characteristically shorter than normal and the width of the pharynx is increased. The adenoids are visible be­ tween the two halv es of the div ided pal­ ate. t Sleri . Drape®, 3M Co mpany. St. Paul , M innesota, U .S .A.

((J)

All the drawing s present the operative field in a true perspective instead of closely fo llowing exact dimensi ons and keep ing with fixe d proportions as is com­ monly done. Consequently, the hard pal­ ate occupies a smaller ar ea than it does in actuality. Therefore, though the flaps appear to lie in an anterior position, they are in fact localized posteriorly in the hard pa late.

Infiltration of the operative site 3 The operati ve site is injected with 0.5 per cent Xylocaine® with epinephrine. In the hard palate the needle is kept in con ­ tact with the bone until the surrounding tissues blanch. The soft palate, including the uvula, is infiltrated to obtain an even degree of enlargement. Along the border of the cleft , tissues are distended two to three times normal size. 180

Freeing the palatal mucoperiosteum and mobilizing the soft palate

II

4 In the hard palate, mucoperiosteal flaps are designed to lengthen and re- . construct the anterior portion of the soft palate. They are quite short, since the de­ gree of elongation is not dependant upon the length of the flap , but rather on the change in position of its base. In this method one flap has become stand ­ ardized as a small ro tati on flap , and is here shown on the patient's left side. Its anterior border is curved to meet the re­ quirements, when it is rotated into the soft palate . Medially, this anterior incision starts abo ut 2 mm anterior to the cleft posterior spine. The flap from the op­ posite side is planned to cover the full length of the cleft, when rotated into po­ sition. In practice this means that the an­ terior incision is made just in front of, or at the apex of the cleft. Velar incisions are made with a No . 11 sca lpel blade on the oral aspect at the junction of oral and nasal mu co sa , and carried deep enough to expose the muscles.

•

•

181

1

5 The righ t mucoperiosteal flap is raised, ex posing the periosteal attachments of the muscles at the posterior border of the hard palate. The major p alatine vessels enter th e fl ap laterally.

7 Laterall y, th e mobiliza­ tion of nasa! mucosa is ex­ tend ed by blunt dis secti o n in th e loose connective tis­ sue layer along the medial pterygoid plate, t owa rds the nasop haryn x. Freeing the soft tissue na rrows the nasa l co mp artm ent and re­ leases th e soft pa late. The m edi al and posterior mobil­ ity of the palatal flap is still restricted by the neuro­ vasc ul ar bundle at the pos­ terior palatine foramen .

182

6 At the margin of th e cleft, a dental elevator is inserted under the bony edge of the palatal shelf. Th is fr ees the nasal m ucoperiosteu m. Separation is easi ly ac­ complished by kee ping th e instrument close to th e bone while passing it pos­ teriorly around the posterior nasal spine and proceeding latera lly along the pos­ terior margin of the bone. Th is dissection should wide­ ly mobilize nasal m u co ­ periosteum and allow mid­ lin e closure.

8 Through a lateral incision, the hamular process is ex ­ posed behind the maxillary tubero si ty. The wh ite ten sor tendon is clearly de­ m ons trated as it traverses the process . The hamu lus is commonly fractured , but rarely does th is widely ac­ ce pted maneuv er add sign i­ ficantly to relaxation. Alter­ ing th e fun cti o n of th e t ens o r palati muscle may even disturb th e opening mechanism of the Eusta­ ch ian tu b e. The hamular proce ss was not fra ctured in t his case. After mobilizing the so ft palate by free ing th e lateral lin ing of the nasal co mpartment, there is little need for wide dissec­ tion into the pa rap haryngeal space .

9 An oral mucoperiosteal flap is elevated and held aside by a hook. The nasal mucoperiosteum has also been stripped from the bony palate. The forceps illustrate how medial ad­ vancement stretches the mucoperiosteum and shihs the en­ tire soft palate posteriorly. This is all possible, since the muscl es are readil y detached en bloc with the periosteum . Mobilization of the soft palate is restri cted by the greater palatine artery and nerve which, in clehs, emerge m o re an ­ teriorly than normally. The release of these structures per­ mits backwards displacement of the soft palate. For that purpose the postero-medial wa ll of the palatine canal is re ­ moved. A fine osteotome is pla ced at the bony edge border­ ing the palatine foramen . While the neurovascular bundle is protected by a shielding instrument, a small triangular piece of wall is chi sell ed out. Thi s bony fragment is either re ­ moved or turned back on itself by rotating the osteotome laterally. The le sser palatine nerves, emerging close to the resected segment of bone, should not be injured in this maneuver. These sensory nerves supply the soft palate and the tonsillar region. If the greater palatine vessels are divided at the bony fora­ mina, the utilized mucoperiosteal flaps are unlikely to have their blood supply seri ousl y impaired. These vessels are preserved, howeve r, as merely freeing them affords suf­ ficient mobilization of the soh palate, while still maintaining a relatively fixed base . The sensory innervation of the flaps through the greater palatine nerve is also mainta ined .

183

Repair of the soft palate muscle layer 10 Closure of the nasal lining is completed ba ck to the tip of the uvula, using fine interrupted sutures of 4/0 chromic ca tgut on an atraumatic needle.' The knots are placed on the deep surface to obviate bury­ ing suture material.

The palatal muscles sti ll maintain their anterior at­ tachments to the nasal mucoperiosteum. This mem­ brane has been freed extensively which allows the soft palate to be positioned posteriorly by about five mm .

, Ethicon , Inc., Sommervi lle, N. J., U.S.A.

184

11 The muscles have been sectioned at their peri­ osteal insertions anteriorly and are here being dis­ sected away from their attachments to the nasal mucosa for a distance of at least five mm. Thi s is the most delicate feature of the operation, as the muscle fibers insert directly into the thin mucous mem­ brane and, unlike the oral lining , there is no sub­ mucous layer of fatty or glandular tissue beneath the nasal epithelium to buffer and support the dissection . Adequate mobilization is best achieved by in cisi ng the muscles just above the membrane and ge ntl y teasing them backwards with a sca lpel , No. 15 blade. Suffi­ cient rela xation is thus obtained , which normalizes the position of the palatal muscles and permits them to be swung medially and united at a posterior lev el.

12 Once the fibers are div ided the y contract and form a substantial muscle mass . In this picture, these clear­ ly defined structures are marked by two pairs of for­ ceps.

The excellent vascularity of the exposed nasal mem­ brane is demonstrated .at surgery by the presence of fine vessels and multiple superficial hemorrhages. Unlike the mucoperiosteum within the hard palate, the nasal mucosa of the soft palate will stretch. If additional length is needed, an anterior Z-plasty of the nasal mucoperiosteum, a vomer flap (see Fig. 30), or an inverted flap of oral mucosa may be utilized . These procedures produce a staggered closure of the nasal mucosa and reduce the likelihood of future scar contracture.

,

185

13 Mattress sutures are used to unite the

palatal muscles. Th ey m ust embrac e the full

thickness of the muscle layer, as there is a

tendency for the muscle s to retra ct away

from th e wound edge. Wide "tension"

sutures are not needed .

14-16 Closure of the muscular portion of th e so ft palate h as been com pleted by ap­ p roxi m ating the tissue layer co mpris ed of oral mucosa and muscle. Th ree or fo ur verti­ ca l mattress sutures of 3/0 chromic ca tgut on an atraumatic needle are used. Dexon' may also be in terspersed between the ca t­ gut for prolonged support ; 4 /0 plain or ch romic ca tgut is sufficient f o r suturing th e uvular seg ments.

The anterior portions of the freed palatal muscles are united across th e midline, over­ lapping each other in such a way that they form a muscular sling. Since this is ac­ compli shed und er no t ensio n, a few 5/ 0 pla in catg ut sutures ca n be used. 1

Polyglycoli c acid, Davis

186

+ Geck,

Cya namid In ternationa l.

Cleft Pa late 1

Reconstruction of the anterior portion of the soft palate

17-1 8 The leh mucoperiosteal flap is rotated about 90°. It is designed to recon­ struct the anterior portion of the soft pal­ ate and swings easily into place, without undue folding . Its slightly curved an­ terior border reaches across the midline to join the retracted oral mucosa of the opposite side and provide abundant tis ­ sue, where a shortage usuall y exists. In a standard " push-back" procedure, latera l displacement of the borders of the oral mucosa makes midline closure difficult. With the aid of a rotation flap, oral ap­ proximation is easily accomplished. The right mucoperiosteal flap extends across the midline when its anterior border is rotated and sutured to the op­ posite oral mucosa, along the edge of the cleft.

187

19 The mucoperi osteal flaps are sutured togeth er in the area between the musc ular palate and th e h ard palate . To eliminate dead space, some o f th ese sutu res are anc hored to th e nas al m u cosa. The sutures are placed to th e side of the nasa l c losure, to avoid superimposed suture lines .

20-21 W hen closu re is com pleted, bilatera l gaps persist ant eriorly .

188

+­ I

22--24 Flaps of buccal mucosa are used t o partially cove r these raw surfaces. This promotes more rapid healing and reduces pterygoid and palatal scar formation. Cheek donor sites are closed directly and no packs or dental plates are used. The principle of this procedure was rec omme nded by Blair (1912) for repair of palatal defects.

25 In this repair, the cleft is closed without tension. This provides excellent healing co nditions and ex­ cludes the possibility of fistu lization. The soft palate is markedly elongated and the mass and general elastic­ ity of the muscular portion is equally impress ive. All these factors con tribute to the desired end result, a normal speech mech an ism .

189

Result •

26 Nine months after surgery, this follow­ up examination reveals that the palate is well united and appears to be of normal length .

28 There is insignificant scar formation in the hard palate and no evidence o f co n­ tra cture in the reconstructed anterior por­ tion of the so ft palate. The bu ccal flap has effectively prevented any scar from forming a band behind the maxillary tuberosity. 27 Excellent levator function is demon­ strated in thi s picture. On into nation , the po sterior border of the soft palate arches and narrows in a normal fashion , its wide excursions extend to the posterior pha­ ryngeal wall .

190

The ch ild started to talk soon after surgery. No nasality or other signs of velopharyngeal incompetence are now present.

Cleft Pa late 7

•

Blood loss and repl a cement

Although blood loss is reduced during palatal surg ery by pre­ operative infiltration of vaso-constrictive solutions, blood trans ­ fusions are given routinely. In view of the highly labile vascular response of these infants, and in light of early experiences of postoperative shock, we do not hesitate to give blood at the slightest indication. In addition to full replacement o f o bserved blood loss, these children are often given an additional 50 to 100 ml during surgery, or in the re cove ry period .

Tympanotomy

Mo st patients with congenital cleft palates suffer fr o m Eusta­ chian tube dysfunction . Markedly vi scous middl e ea r fluid is an almost constant finding in untreated cases . The ENT se rv ice routinely performs tympanotomy and evacu­ ates the secretion within the middle ear cavity in connection with cleft palate surgery . Th is is done in the anesthetized pa­ tient, when the repair of the palate has been com pl eted . In cases with tenacious secretions (glue ear) a teflon drainage tube is inserted through the tympanic membrane and left to drain ex­ ternally for as long as necessary.

191

Comments on operative procedure

Ali methods for cleft palate repair result in an initial elongat io n of the velum. Since most techniques require extensive dissec­ tion and advancement of tissue layers, there is, however, a high risk of eventual scarring and contracture. There is also a marked tendency for the tissues to return to their original position. It has , in fact, been shown by Palmer et al . (1969) in a compara­ tive study, that using a "push -back" procedure may result in a palate , which is shorter than that obtained with a simple closure , without employing spe cial lengthening measures. Today , the major problems in cleft palate surgery are still those of ade­ quately elongating the palate and devising techniques to fore­ stall postoperative shortening. Following the described operation, the soft palate generally ap­ pears to attain a normal length, with its posterior border moved back about fifteen mm. Several factors account for this effect. The preoperative shortness of the soft palate, which is mainly the result of abnormal muscular anatomy, is accentuated by superficial contraction along the cleft margins. This feature , which is also characteristic of the cleft lip deformity, is treated by releasing the tissue layers bordering the cleft. Midline clo­ sure is then sufficient to produce elongation, as the resulting suture line is longer than the longitudinal diameter of the orig­ inal , oval-shaped defect. Since this is a posteri o rly directed lengthening, it involves a backward rotation of the soft palate segments. Wide undermining on the nasal aspect of the hard palate per­ mits medial advancement of the mu coperiosteum and further backward rotation of the velum. When the dissection is ex­ tended laterall y, along the sides of the soft palate, the freeing also results in a backward shift-" push-back"-of the palatal segments. On the oral aspect, any restriction in palatal elongation is elim­ inated by severing the mucoperiosteum over the hard palate and detaching it from the posterior border of the bony plate. Freeing the neurovascular bundle at the posterior palatine fora­ men serves the same purpose . Sectioning the abnormal an­ terior insertions of palatal muscles and dissecting them off the nasal mucosa furthe r releases the soft palate. In addition, in re­ constructing the anterior portion of the soft palate, the oral mucoperiosteal flaps are sutured to the nasal mucosa in such a way, that they tend to push the velum backwards .

192

Preoperative condition

29 This three-month-old child demonstrates a complete unilateral cleft with wide separation of the palatal segments. The primary palate (al­ veolar process and anterior part of the hard pal­ ate) was closed by periosteoplasty in conjunc­ tion with a lip repair as described in Chapter II.

30 Eighteen months later the maxillary segments have spontaneously adjusted themselves, producing a symmetrical alveolar arch. Massive new bone formation was then found within the cleft, effectively pre­ venting maxillary collapse. The originally wide bony defect is reduced to a narrow fissure, and the outer surface of the lateral segment bears a near normal relationship to the premaxilla. The topographic anatomy is accurately depicted in this illustration, based on original photographs and plaster impressions. At this stage, the remaining cleft of the hard palate was repaired with a single layer of mucosa, raised as a septal flap. It was tucked under the margin of the palatal mucoperiosteum on the opposite side, and the exposed raw surface waS left to heal by secondary intention. A small triangular flap of septal mucosa was raised posteriorly to provide extra nasal lining for the soft palate. With th is exception, re­ construction was carried out as previously described, with short muco­ periosteal flaps. Thus, the major portion of the palatal mucoperiosteum remained undisturbed during the entire procedure,

194

Clef t Pal ate 1

Result

•

31-32 After four ye ars, the palate is well healed with insignificant scarring, and an almost normal appearance . The dental arch has a normal configuration and occlusion is good . Minimal c rossbite of the ca nine tooth is mainly due to in co mplete dentition at the cleft, where the lateral incisor is missing .

195

Comments on results

Wound healing has always been uneventful and is complete within eight days, at the time of catgut suture dissolution . As buccal flaps are used for secondary wound cover, the only open surfaces remaining are insignificant and overlie bone. At dis­ charge after one week, the length and mobility of the pa l ate is impressive. In our experience, the functional results of this procedure are superior to those obtained by the Veau-Wardill technique. The effect of reinserting the levator and palate-pharyngeal muscles into the middle third of the soft palate is particularly noticeable by the remarkable degree of palatal elevation possible after surgery . Reestablishing sphincteral mechanism of the palatal muscles also acts to promote closure of the pharyngeal isthmus by constriction.

A late tendency of the soft palate to be carried forward by con ­ tracting scar tissue seems to be moderate. This is partially ex­ plained by the restored function of the palatal muscles, but most likely, the degree of contra cture has been reduced by the limited tissue trauma of the anatomic repair and by reconstruct­ ing the anterior portion of the soft palate with firm tissues that are resistant to shrinkage. The presence of calcifications within these tissues at a later stage has been noted in a few cases and probably originates from transferred palatal periosteum . It is a common experience that an increased incidence of mid­ dle ear infection in children with cleft palates can effectively be reduced by palate repair. This relationship was experimentally demonstrated by Schultz (1964) , who produced clefts of the rab ­ bit palate to study the effect of this defect on the Eustachian tube and middle ear. Seventy-fiv e per cent of the animals dis­ played evidence of chronic otitis media. The factor essentially responsible for these infections seemed to be the loss of palatal muscle function. Kriens (1969) analyzed the paradoxical effect of cleft palate muscles on Eustachian tube function, and pos­ tulated that they would perform their normal action if their at­ tachments to the hard palate had been freed. This assumption is likely to be valid, though not proven by clinical evidence . Our present routine of evacuating middle ear secretions in con­ junction with palate repair has not yet been subjected to a fol ­ low-up study and critical analysis.

196

References

Blair V. P.: Surgery and Diseases of the Mouth and Jaws. C. V. Mosby Comp, St. Louis, 1912, p 192. Braithwaite F.: Cleft Palate Repair. Modern Trends in Plastic Surgery. Butterworths, London, 1964, p 30 . Braithwaite F.: The importance of the levator pa lati muscle in cleft palate closure. Brit J Plast Surg 21: 60, 1968. Dingman R. 0 ., Ricker O. L. and lob V .: Bloo d loss in infant cleft lip and cl eft palate surgery . Plast Reconstr Su rg 4. 333, 1949. Kriens O. B. : An ana tomic al approach to veloplasty. Plas t Reconstr Surg 43: 29 , 1969. v . Langenbeck B. R. C.: Operation der angeborenen totalen Spaltung des harten Gaumens nach einer neuen Methode. Deutsche Klinik 73: 231,1861 . v. Luschka H.: Der Schlundkopf des Menschen. Laupp, Tubingen, 1868. Palmer C. R., Hamlen M ., Ross R. B. and Lindsay W . K. : Cleft pa late repair : Comparison of the result s of two su rgical techniques. Canad J Surg 12: 32, 1969. Passavant G.: Ueber die Verschliessung des Schlundes b eim Sprechen. Frankfurt, 1863. Qu oted : Arch path Anat Physio l, klin Med 46: 1, 1869. Rintala A.: Blood loss in cleft palate surgery. Acta Ch ir Scand 129: 288, 1965. Ruding R.: Cl eft Palate. Anatomic and surg ica l conside rations. Plast Reconstr. Surg 33: 132, 1964. Schultz R. C.: Surg icall y produced cleft palates in rabbits. Plast Re­ constr Surg 33: 120,1964. Veau V .: Divisi on Pa latin e. Masson et Cie Ed ., Paris, 1931.

197

Chapter IX

Correction of velopharyngea/ incomp etence by palato-pharyn goplasty -reconstructing the soft palate, and utilizing pharyngeal flap s to provide additional tissue and to p revent secondary deformity Introduction 200 Indications for palato-pharyngoplasty 201 Palatopharyngeal recon struction ve rsus prosthetic devices 202 Pre- and postoperative evaluation 202 Speech Velopharyngeal function Pathology Surgical considerations 204 General considerations The palate The pharyngeal flap Anesthesia O peratiVe procedure 207 The pharyngeal flaps The palato-pharyngoplasty Result Postoperative therapy 212 Results 212

Title page: In this patient, born with a complete unilateral cleft lip and pal­ ate, repair at childhood resulted in velopharyngeal incompetence; the con tra cted soft palate was about five mm short of reaching the post­ erior pharyngeal wall as demon­ strated by cineradiographic examina­ tion, Definitive corrective surgery was performed at age nine, according to the method described in this chapter. The pictures illu strating the operative procedure were actually taken at surgery of this patient.

Anatomy Speech Hearing and nasal function Conclusions 215

Repair of large palatal defects Subtotal reconstruction of the soft palate 217 Reconstruction within th e hard palate 219 References 221

198

Roentgenograms, one year following palato-pharyngoplasty, show the soft palate at rest (A) and elevated on in­ tonation (8). A superiorly based pharyngeal flap is utilized and its base, behind the soft palate, has re­ mained unchanged. Th e position of th e palate is maintained without sig­ nificantly restricting mobility. The raised velum makes broad , high co n­ tact with the posterior pharyngeal wall in a normal fashion and speech is without impairment.

Cleft Palate 2

A

~_ _

~--

Pharyngeal flap

Sofl palale

~-- UvlJla

B

•

Techniques for secondary re p a ir and subtotal reconstructi o n

Introduction

Ismail is something of a conundrum in this seml' barbaric world, ... a most intelligent young man, in manners extremely courteous, and by nature generous and kindly. This de­ scription hardly squares w ith his behaviour on the campaign, when he conducted h im­ self more like Genghls Khan than a civilized human being . .. his cleft palate, his high, rapid, almost unintelligible voice, may have been disadvantages that he tried to overcome by an outward show of grandeur.

Alan Moo rehead: The Blue Nile (1962)

In 1865, Passavant described a method of correcting palato­ pharyngeal incompetence resulting from an ineffective repair of a cleft palate. He incised transversely through the full thick­ ness of the soft palate, turned the separated posterior portion of the palate back on itself so that its upper surface faced down­ wards and the raw wound surface backwards. This wound edge was then sutured to the posterior pharyngeal wall, where a cor­ responding square of mucous membrane had been excised. The palatal defect resulting from the original incision was left to close spontaneously. Schoenborn (1876, 1886) considered Passavant' s technique dif­ ficult and on the advice of Trendelenburg, he introduced a modified procedure-the pharyngeal flap operation . This opera­ tion has been used intermittently since that time, but not until recent years has it gained widespread recognition as a valuable aid in improving the speech of patients with palatopharyngeal insufficiency. In his first publication, Shoenborn described a flap which was based inferiorly and mobilized from the naso­ pharynx. Insertion of the flap into the unrepaired soft palate cleft was combined with a von Langenbeck palate closure. In a later publication he advocated the use of a flap with a superior base and popularized a two-stage procedure . Rosenthal (1924) reintroduced Schoenborn's first method. Numerous papers have since been published on the use of these procedures, both in primary and secondary repairs (Padgett 1936, Conway 1951, Dunn 1951 , Moran 1951, Burian 1954, 1963, Skoog 1954, 1965, Sanvenero-Rosselli 1955, Petit et al. 1956, Stark and DeHaan 1960, Honig 1963, and others). Owsley et al. (1966) and Orti­ cochea (1968) have reported excellent results with using mod­ ified procedures in pharyngeal flap surgery. Since 1951, more than 200 palato-pharyngoplasties have been

performed at the Plastic Surgery Department in Uppsala . An

improved quality of speech was sought in a variety of velo­

pharyngeal deficiencies. Different techniques were employed

and several surgeons performed the operations.

200

Indications for palato-pharyngoplasty

Although the primary goal in the corrective surgery of velo­ pharyngeal incompetence should be the restoration of palatal anatomy, in most patients there are also definite indications for a simultaneous pharyngeal flap transfer . This additional proce­ dure further improves results and in spme cases it is the sole determinant of a successful operation. Based on the experience gained from our large series of patients, in reconstructing the speech apparatus with the aid of a pharyngeal flap, the follow­ ing indications have been adopted.

•

(1) Unrepaired clefts of the palate in patients older than

five years.

In our series of previously unoperated adults, closure of the pal­ ate alone always resulted in velopharyngeal incompetence, de­ spite having adequately positioned the palate at the time of sur­ gery. This occurred because the soft palate had to traverse too great a distance to reach the posterior pharyngeal wall. It has therefore become our routine in these cases to combine palate closure with pharyngoplasty, rather than to attach a pharyngeal flap at a later stage. (2) Submucous clefts of the palate. Indications for operation given under (1) also apply to sut­ mucous clefts which have been neglected for more than five years. (3) Incompetent palatopharyngeal function despite previous cleft palate surgery. This group presents a great many anatomical and functional variations, ranging from muscular, well-united but short palates, to scarred, atrophic palates with little mobility and a varying deg ree of tissue deficiency. (4) Tissue defects requiring reconstruction. The procedure described on p. 218 illustrates the principle of utilizing large pharyngeal and buccal flaps to repair an extensive soft palate defect. (5) Velopharyngeal incompetence due to paresis. In patients suffering from neurological disturbances affecting the velopharyngeal muscles, this operation has proven to be of great value. Marked functional improvement is obtained with a flap supported velum. It enhances the effectiveness of the weakened muscles, e.g . less power will be needed to elevate a soft palate that has been attached at a higher level. In this group, there is obviously no need for surgical elongation of the palate. 201

I

j

Palatopharyngeal reconstruction versus prosthetic devices At present, the merits of using a pharyngeal flap as opposed to a prosthesis provide little controversy. There is basic agreement with Boyle's statement in 1957 that, "if acceptable speech ap­ paratus can be provided by some form of surgery, including the posterior pharyngeal flap, it should by all means be preferred , and the prosthesis reserved for cases where surgery cannot succeed" . In this Department, it has always been possible t o offer surgery to patients with defective speech as an alternative to a pros­ thesis, the patient's general health not withstanding . In patients seeking relief from the in convenience of wearing an obturator, it is my experience that following adequate reconstruction of the palate combined with a pharyngeal flap transfer, speech results are comparable or superior to those obtained with mechanical aids.

Pre- and postoperative evaluation The degree of velopharyngeal incompetence is evaluated by an assessment of speech, ve lopharyngeal closure and palato­ pharyngeal anatomy. For this judgement the close cooperation of the entire Cleft Palate Team is required .

Speech

202

A variety of diagnosti c techniques provide essential information to aid the speech pathologist in making the final diagnosis. Nasality, resulting from nasal emission of air during pronouncia­ tion of consonants, can be measured by special equipment and is of particular interest in the preoperative evaluation of these cases. Test sentences are recorded preoperatively as a base­ line from which to measure speech improvement.

Cleft Pala te 2

Velopharyng eal fu nction

Cineradiography is of great value in obtaining an accurate pre­ operative diagnosis. This technique was introduced in 1955 (Skoog and Nylen) and further studied and developed at this Department by Bjork (1961) and Nylen (1961). With minor spee ch faults , cineradiographic te chnique permits differentia­ tion between those patients, who are lacking the anatomi cal requirements for normal speech and would benefit from a pharyngoplasty, and those who could be expected to retrain a dysfun ctioning velopharyngeal mechanism by means of speech therapy. Following a pharyngeal flap operation , speech depends on the abnormal anatomy of the velopharyngeal region. Movements of the pharyngeal flap itself and other re­ lated speech structures become even more diffi cult to assess, though they may be demonstrated in various speech articulatory positions by cineradiography . In a number of our patients, cineradiography and sound spectro­ graphy were synchronized for a detailed speech analysis (Nylen 1961) . This technique offered valuable information on "cleft pal­ ate speech" in general, but was not found to be a great diag­ nosti c aid in treating particular individuals.

Pathology

Intraoral examination is essential to confirm the diagnosis of velopharyngeal incompetence. The anatomy should correlate reasonably well recorded function. For the surgeon, the identifi­ cation and lo calization of scar tissue and fistulas , the verifica­ tion of palatal tissue deficiency, the appearance of adenoids, the evaluation of the configuration of the nasopharynx, and ob­ servations of palate at rest and during phonation will influence his choice of method and decide his overall management of the problem . The information obtained by visual inspection is also valuable in predicting the probable result of palato-pharyngo­ plasty. The preoperative anatomy has a decisive influence on the final outcome.

203

Surgical considerations

Late stage repair of cleft palates and secondary correction of palatal insufficiency and defects have three main objectives: • The soft palate must be reconstructed and placed posteriorly to restore muscle function and to give sufficient palatal length . • A pharyngeal flap is utilized to maintain this position. • The transferred flap should also furnish additional palatal tissue when needed. Though a pharyngeal flap alone will usually improve the quality of speech, to achieve the best possible result, effective recon­ struction relies primarily on the restoration of the normal pal­ atal anatomy.

General considerations

As adult pharyngoplasty is a major procedure, elective opera­ tions on the palate should only be performed on patients in good general health. Surgical interference with scarred tissues in secondary cleft deformities causes considerable bleeding. Re­ placement of blood interoperatively must therefore be con­ sidered in planning surgery. In addition, localized inflammatory reaction due to the continued use of intraoral appliances should be allowed to subside, by eliminating irritating devices for a few days prior to surgery.

The palate

Unrepaired cleft palates, requiring the combined procedure of a palato-pharyngoplasty, are treated according to the principles of primary repair advocated in the previous chapter. In sub­ mu cou s clefts, the deficient tissue in the midline should be ex­ cised to expose the muscular layer on both sides. Short mu co ­ periosteal flaps are raised from the hard palate as in complete clefts to allow the soft palate to be freed and positioned poste­ riorly. The same principles of treatment also apply to cases where pre­ vious surgery has resulted in velopharyngeal incompetence. These patients most commonly present with a well-united soft palate which, due to scar formation and contracture, is found to be inadequate, both in length and mobility . For exposure, the soft palate is split in the midline, and short mucoperiosteal flaps are raised from the hard palate. The soft palate is disengaged

204

Cleft Palate 2

from its dislocated position by sharp dissection at the posterior borders of the hard palate. This can usually be done without sectioning the nasal lining. Lateral mobilization is carried out subperiosteally along the pterygoid plate. The dissection of scar tissue is mandatory for the restoration of palatal movements. Therefore, all abnormal attachments must be divided and the dissection should be carried close to the nasal lining for length sufficient to allow the muscular portion of the palate to be positioned at a posterior level. In most instances it becomes evident that a sufficient amount of palatal tissue is available, though this might not have been appreciated preoperatively. The presence of scar tissue does not permit a clear identifica­ tion of distinct tissue layers, thus an anatomic repair as in primary operations is not possible . Instead, the palatal seg­ ments must be handled "en bloc", which to some extent facili­ tates closure. A gain in palate length on the oral aspect is ob­ tained by suturing the mucoperiosteal flaps in a rotated posi­ tion.

•

When scarred tissues heal, the tendency for contracture to re­ develop is obviously great. The attachment of a properly de­ signed pharyngeal flap will hold the palate in position during healing and th roughout the critical postoperative period. It will also counteract the tendency towards contracture in minor raw surfaces left on the nasal aspect of the reconstructed palate ; major defects are covered by the flap. At a later stage when tis­ sues have softened, the surrounding tissues should have be­ come sufficiently slack to permit mobility, particularly allowing elevation of the soft palate . In cases with a true deficiency of tissue, the surgical release of whatever remains of a functioning palate is particularly im­ portant. The addition of a pharyngeal flap will mainly provide mechanical closure of the velopharynx.

The pharyngeal flap

In the most common procedures the pharyngeal flap is based inferiorly. In many cases, however, the presence of an excessive amount of adenoid tissue in the nasopharynx makes it an un­ suitable donor site for a flap. In other cases, a larger flap is needed than can readily be obtained. It is then always possible to elevate a superiorly based pharyngeal flap of sufficient length and width to meet any demands. In recent years, I have

205

used this flap almost exclusively, partly because the operation is performed w ith increasing frequency in young patients with nasopha ryngeal adenoids, but mainly be cause the results using a modified technique have been most gratifying.

1 At age nineteen, this pa­ tient underwent palato­ pharyngoplasty fo r velo­ pharyngeal incompeten ce. A superiorly based flap was employed in the pro­ cedure. This pictu re demonstrates an unfortunate late com­ plication of this tech­ nique, w hen performed in the usual fashion: a thick scar band ha s formed at the base of the flap and co ntinued down the mid­ line of the donor site, pul­ ling the entire palate downwa rds and back­ wards, seriously restrict­

The raw area left at the base of the pharyngeal flap will sca r and eventually co ntract, causing late displacement of the flap . In the inferiorly based flap this scarr ing tends to move the pal­ ate upward s and backwards, which may aid the action of the palate in speech. When contra cture develops below a superiorly based pharyngeal flap, a thick band may form which displaces the soft palate downwards and backwards, restricting its move­ ments (Fig. 1). Such late displacement with impaired fun ctio n occurred in al­ most ten per ce nt of our early series. In several cas es sub­ sequent surgery had to be performed. The scar tissue was then excised and the base of the flap shifted upwards. Closure of the wound was obtained by advancing mucous membrane flaps from the sides . To avoid this co mplication of a superiorly based pha ry ngeal flap, an operative procedure was designed in which two supplementary flaps are used to create a lining across the posterior pharyngeal wall , beneath the base of the pharyngeal flap proper (Skoog 1965). The procedure, as presently e m­ ployed , will be described in this chapter .

ing its move ments.

Pharyngoplasties whi ch do not involve the transfer of a phar­ yngeal flap have rarely proved to be worth-while and will not be discussed here .

Anesthesia

The operation is performed under general endotracheal anes­ thesia . Lidocaine (Xylocaine®l, 0.5 per ce nt, with epinephrine , is inje cted into the areas to be incised in the palate and pharyn x. This reduces bleeding co nsiderably and facilitates the surgical procedure .

20 6

Operative procedu re

2 This nine year old boy was born with a unilateral, complete cleft. The lip deformity was corrected at the age of 3 months; the palate was repaired 15 months later, using a Veau-Wardill procedure. As a result of a midline contracture that developed post­ operatively, the soft palate shortened, causing velophary ngeal in competen ce. It was then de cided to reposition the palate and transfer a pharyngeal flap. The patient is under endotracheal anes­ thesia . Exposure by a Dingman mouth gag demonstrates the velum to be abnormally short, though well united .

The pharyngeal flaps 3 The soft palate has been split to expose the pharynx. The cut surlaces are scarred and thin. They measure only about 1 em in length. The scar formation and anterior dislocation of the soft palate ex plains re­ stricted levator function. The presence of adenoids in the epi­ pharynx makes this area unsuitable as a donor site for a pharyngeal flap. It must be raised farther down on the pharyngeal wall , and be superiorly based. This maneuvre is perlormed prior to mobilizing the soft palate so as not to obscure the phar yngeal field with blood from above.

207

4 The flap to be transferred is planned and lifted from the posterior pharyngeal wall, with its base at th e level of the Eustachian cushions. It includes almost the entire width of the posterior wall. Separation is carried out in a plane Over­ lying the prevertebral fascia. Adjacent and parallel to this centra l flap , two similar but smaller flaps are raised , one on each side, their bases being just below the Eustachian orifices and extending downwards onto the lateral phar­ yngeal walls. These flaps are approximately 1 cm in width and 2 cm in length.

5 The two lateral flaps are rotated m ed ially and sutured to each other and to the preve rtebral fascia to form a bridge of mucous membrane, just bel ow the base of the trans­ ferred central flap. One of the two lateral flaps may also be used for lining the base of the central flap, while the other one is placed aCross the posterior pharyngeal wall; 3/ 0 chromic catgut on an atraumatic needle is u sed for suturing . No attempt is made to close the donor areas for the phar­ yngea l flaps .

208

Th e palato-pharyngoplasty 6 Before the central pharyngeal fla p i s transfer red, the soft palate must be completely freed ante ri orly and pu sh ed back into a normal position. In previously operated palates, this necessitates radical dissection through scar tissue along the posterior border of the hard palate. On the nasal as pect, the lining is mobilized from the palatal shelves and late r ally, as described in the primary repair of the cleft palate. In attaching the pharyngea l flap to the nasal aspect of the soft palate it is not necessary, or useful, to create a reci pi en t surface fo r the flap by raising the mucous m emb ra n e at that site. In secondary repairs of the palate, the tissues are gen­ erall y scarred and tightl y bound. Thus, in dividing the soft palate in the midline and freeing it, consider ab le retraction will occur. Under this condition the pharyng eal na p ha s worked well by providing additional tissue, pa rt ic ularly nasal lining . The flap generally falls within th e posterior two thirds of the soft palate. It can be sutured in place without t en s ion and under good exposure. A few mattress sutures and simple adjustment sutures of 4/0 chromic catgut are used in this closure. Posteri o rl y, the nasal lining of the soft palate is used to cover the remaining raw su rface at the base of the phar­ y ngeal flap. Small muco us m embrane flaps are raised and reflected for this purpose, as shown here . If the soft palate itself is sutured to the base of the phary ngeal flap ov er­ corre ction may occur, resulting in restricted mobility and partial obstruction of the air passage.

7 In secondary repairs, the mucoperiosteal flaps, raised from the hard palate bilaterally, are designed short. After the soft palate has been fully released from its scarred at­ tachments and positioned posteriorly, these flaps will shift and rotate medially. They thereby provide an oral lining to elongate the palate, which is so essential to restore function . The anteri or borders of the mucoperiosteal flaps may be united in the midline with little tension. Approximation is accomplished by mattress sutures as described for the primary cleft palate repair, using 3/ 0 chr omic catgut and Dex on . Over the area of the pha ryngeal flap , the needle is passed superfi cially through its mu scular lay er to prevent dead space.

209

Eusta ch ian orifrces

"\ 8 This drawing is oriented so that the viewer is effectively seated in the epipharynx looking downwards. He thus has a backside, lateral view of the pharyngoplasty. The uvula is not used for lining , but sutured independently in front of the pharyngoplasty. A small section on the under­ surface of the central pharyngeal flap may be left without a mucosal covering ; this free portion of the flap will tube itself during the healing process.

9 Palate closure is completed without ten­ sion . The elongation is considerable, meas­ uring more than 1 cm . In this case the raw surfaces over the hard palate were left to heal by secondary intention.

,,'

10 In this picture two instruments raise the posterior border of the palate to expose the lateral pharyngeal flaps , which have been placed across the posterior pharyngeal wall . Following the operation healing was un­ eventful and the patient was discharged from the hospital after 7 days.

210

Cleft Palate 2

Result Pictures taken three months after surgery

" The soft palate is in a relaxed position . Its posterior border remains attached to the pharyngeal wall at the original level where it was fixed surgically. The lateral phar­ yngeal flaps have effectively prevented any postoperative downward dislocation.

•

12 The mobility of the soft palate is shown on intonation; the function of the levator muscles is excellent. In elevating the post­ erior border of the soft palate, the phar­ yngeal flaps on the posterior pharyngeal wall become partly visible. Th ere is no scar­ band formation across or below these flaps. The large raw surface, left inferiorly on th e posterior pharyngeal wall, is comp letely reepithelialized with a slightly paler su rface th an the no rma l mucous membrane of the flaps. Characteristically there is no reducti on in the dimensions of the phar ynx, as at this si te, co ntracture will not OCCur in a tra ns­ verse direction. Speech is now considered to be normal. On the title page of th is chapter, the results of palato-pharyngoplasty is demonstrated in roe ntgenogram s of this patient.

211

Postoperative therapy

Intensive speech therapy is started two months after surgery and continued until maximum improvement is achieved. The patients have then been admitted to a convalescent home for cleft lip and palate patients , where they are trained according to a system recently reported by Lindholm (1971) One basic principle has been to treat the patients individually for periods usually ranging from two to four weeks, and repeat this treat­ ment when indicated. Mothers are often asked to stay with their children and to attend some of the lessons. This permits treat­ ment to continue at home. In many respects the facilities of­ fered at this institute have proved invaluable in the rehabilita ­ tion of cleft palate patients. Following operation, patients are examined regularly at the Cleft Palate Clinic. An y remaining speech impairment caused by other anatomic defects is treated surgically, whenever possible. Thus, in many patients collapse of the maxilla has been cor­ rected by dental orthopaedi c expansion; palatal fistulas have been closed; scar-bands and adhesions in the premaxillary region have been released to allow free movements of the up­ per lip ; and tightness of the lip has been corrected by an Est­ lander-Abbe flap. In cases showing irregularities and defects of the dental arch , extensiv e orthodontic and prosthodontic treat­ ment has been carried out.

Results

The early results were published in 1965 (Skoog). In separate articles, Aschan (1965) reported on hearing and nasal function in more detail, and Lindholm (1971) made a phoniatric evalua­ tion of various speech qualities . The observ ations made in these initial follow-up studies have since been confirmed in a considerabl y larger group of patients .

212

•

Cleft Pala te 2

Anatomy

The technique described for utilizing a superiorly based phar­ yngeal flap has been successfully employed in more than 80 patients, mostly adults. Healing was in all cases uneventful. The base of the pharyngeal flap, which was attached to the soft pal­ ate, remained at a high level, without a scar-band developing below the flap . Though no downward retraction of the palate occurred, a decreased ability to lift the soft palate was a com­ mon finding. This seemed to result from its being bound post­ eriorly to the pharyngeal flap. Although some restriction of movement was present, the patients were all able to actively raise their palates . In a few instances the levator action was forceful enough to move the astricted portion of the pharyngeal wall along with the soft palate. This was demonstrated in cine­ fluorographic films. When the soft palate was elevated , the two lateral pharyngeal flaps shifted into the upper portion of the posterior pharyngeal wall, became visible. Their reddish color differed distinctly from the whitish, scarred epithelium below. Though these flaps car­ ried a muscular layer, they never demonstrated contractility or a tendency for ridge formation; they had flattened and become distended from the pull of the adjacent scar surface. There is, however, a possibility for a functional sphincter mechanism to be generated at the base of these flaps . This has not ye; been in­ vestigated . Surprisingly enough, healing of the large wound surfaces on the posterior and lateral pharyngeal walls by secondary inten­ tion, never resulted in scar contracture or obvious narrowing of the pharyngeal space. Epithelialization added a smooth surface. The postoperative topographic anatomy of the velopharyngeal region was dissimilar in almost all cases, and movements char­ acteristic of normal velopharyngeal function were rarely pre­ sent. This was in part due to the original condition , but was also influenced by surgical treatment. Motion of the lateral pharyngeal walls appeared quite powerful in many cases, par­ ticularly when other parts of the velopharyngeal system were less mobile. In some instances the posterior faucial pillars moved medially like curtains, contributing to velopharyngeal closure. Other abnormal movements were often present.

•

Speech

Locution was best following operation at an early age. Patients treated before they were ten years old , all attained normal or 213

almost normal speech; of those with refractive impediments, 90 per cent were operated upon past the age of twenty. Im­ provement was however, generally marked even in these cases , including eleven patients over fifty, the oldest being 68 years old. Only one per cent of the patients considered their speech not to be improved by the palato-pharyngoplasty. When comparisons were made between movements of artic­ ulatory structures and audibility, no uniform relationships could be demonstrated. This reflects the complex nature of phonetics and manifests a need for further study of compensatory mech­ anisms in abnormal velopharyngeal function . In 20 patients, treated according to the described procedure, the anatomical requirements for surgical correction were particular­ ly favorable . The patients were mentally alert, had good hear­ ing, and could be operated upon at an early age , ranging f rom 6 to 11 years . This group included three children with sub­ mucous clefts of the palate. In the other patients the soft palate had undergone considerable retraction following primary re­ pair, but after scar excision and separation from the hard palate, tissues were found to be adequate to form a substantial soft palate. Prior to surgery all these patients demonstrated marked velopharyngeal incompetence, resistant to speech therapy. Postoperatively, this treatment was successfully con­ tinued for residual difficulties in articulation. Speech , as judged by specialists at least one year postoperatively , was graded as normal in seventeen cases, 85 per cent, and greatly improved in the remaining three patients.

Hearing and Nasal Function

214

In the postoperative oto-rhinological examination hearing was much better than could be ex pected from the aural pathology. Palato-pharyngoplasty emended hearing. An objective rhino­ metric examination, combined with the rhinoscopic findings, demonstrated that both hearing and nasal function are essential factors for articulation . Intelligibility was found to be most de­ pendant on nasal function . It is of great interest, that the width of the nasal airways influenced the size and shape of the aper­ tures on each side of the pharyngeal flap. In asymmetrical con­ ditions, the opening was larger behind the wider nasal passage. This provides a functional explanation for the asymmetry of the velopharyngeal region, which in some cases gave the false im­ pression of an incompletely disrupted palato-pharyngoplasty .

Cleft Palace 2

Criticism of the pharyngeal flap operation for not being a phys ­ iologic procedure may be justified in cases of overcorrection , where the soft palate has been broadly and tightlY attached to the posterior pharyngeal wall, occluding the pharyngeal space to such an extent that nasal breathing is impaired. Speech then has the characteristic closed nasality, and patients have dif­ ficulty in freeing the nasopharynx of mucus.

Conclusions

The predetermining influence of the preoperative condition on the final result makes a meaningful evaluation of this recon­ structive procedure particularly difficult. Yet, in spite of this limi­ tation, some general conclusions can be drawn. • The pharyngeal flap operation has proved to be a most va luable supplementary procedure in late primary repairs of cleft palates and in most secondary corrections of velop har­ yngeal incompeten ce. Following adequate palate repair com­ bined with a pharyngeal flap transfer, postsurgical speech is comparable or superior to mechanically aided articulation . • Normal , or near normal speech may be obtained by a phar­ yngeal flap operation, only when good muscular fun ctio n of the soft palate is present. A suffi cient amount of tissue must also be available to make repositioning effective. The pharyngeal flap will then maintain this new position and compensate for any minor incompetence in velopharyngeal closure. The flap should be made loose enough to allow the soft palate, on elevation, to co ntact the posterior pharyngeal wall. In the superiorly ba sed flap, late displacement by scar formation can be prevented by special surgical techniques. As long as the base of the pharyn­ geal flap does not restrict motion of the soft palate to any sig­ nificant deg ree, there is no difference in basing the flap superi­ orly or inferiorly. There are, however, technical indications and contraindications for the use of each type of flap. • In the superiorly based pharyngeal flap , the technique de­ scribed for creating a mucous membrane bridge across the posterior pharyngeal wall has proved to be effective in prevent­

21 5

ing late scar formation and conco mitant d istortion of the palate. The functional results following this procedure have been most g ratifyi ng. • In cases in which there is poor muscular fun ctio n or a sub ­ stantial deficiency of tissue, a pharyngeal flap will not fu lly sub­ stitute for soft palate tissue. Even in these cas es, howeve r, it can be used to re constru ct a palatal membrane w h ich w il l re­ duce the nasal escape of air, thereby ameliorating a most un­ desirable facet of cleft palate speech. With such an immobile palate, however, certain qualities in sound formation , cha r­ acteristic of normal speech , can not be reproduced. • Speech results will be better if pharyngopl asty is performed early, preferably before the age of ten. The assumption that an early pharyngeal flap operation might later prove inadequate, in the face of pharyngeal enlargement, h as not been substan­ tiated by our series. • Intensive speech therapy is needed to help patients acquire control of their new speech mechanisms and to eliminate secondary speech deficiencies. The apparent variation in the pattern of movements following velopharyngoplasty can be at­ tributed to a difference in the postoperative anatomy an d th e functional capacity of various articulatory structures. Speech therapy, and other facets of treatment, work by reinforced feed­ back. Cinestetic, auditive and visual feed-back links are built up, that may not have existed before . • The abnormal anatomy resulting from pharyngeal flap sur­ gery will have no adverse effects on middle ear fun ction. On the contrary, our observations indicate that an existing hearing loss may be improved by this procedure . • The patient demand for this type of treatment will not diminish significantly with increasing age. Patients over fifty are as anxious as younger people to undergo surgery, even if they have worn a well-functioning obturator and their speech, though nasal, has been quite acceptable. The magnitude of the operation at their age, and the inconvenience of a lengthy post­ operative treatment does not deter them, as these individuals desperately wish to be relieved of their disability. Sometimes they request an operation so as to appear normal to their grand-children , which vividly demonstrates the deep seated psyc hological consequences of a congenital defect. 216

•

Repair of large palatal defects The vast majority of cleft palate patients needing additional re­ constructive procedures present little or no tissue deficit. Cor­ rection according to the described principles of palato-phar­ yngoplasty are then adequate to provide a well functioning speech mechanism. Patients, who have suffered a definite tis­ sue loss of the velum or hard palate as a consequence of the original or subsequent surgery, will also benefit from similar procedures, though speech may not always be completely nor­ mal. Repair of even extensive palatal defects can be accom­ plished through the use of available buccal and pharyngeal lin­ ing and thus does not require extraoral tissues, as evidenced by the following case reports.

Subtotal reconstruction of the soft palate A method for reconstruction of the soft palate, utilizing buccal and pharyngeal flaps, was developed in a patient, in whom the major portion of the soft palate was absent (Skoog 1965).

Preoperative condition 13 This thirty-five year old

patient had suffered a sub­ total loss of the soft palate in conjunction with prima ry re­ pair of a cleft, at the age of three. His speech was poor, despite the use of an ob­ turator. A small remnant of soft palate tissue is seen at the right. 217

Reconstruction

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, surgical drapes, Mi nnesota Mining and Manufacturing Comp., St. Paul. Minn .,

U.S.A.

227

Anesthesia

3 Starting at the tip of the nose, the operative field is anes­ thetised with approx imately 8 ml of 1 percent Xylocaine ® (lidocaine) containing epine­ phrine 1: 100000. Infiltration is continued subcutaneously along the dorsum to the glabella and over the sides of the nasal pyram id.

5 Through a separate puncture site the needle is inserted into the region of the alar base, and this area is completely anes­ thetized down to the nasal floor and piriform aperture. From this point the injection is extended along the line of the planned lateral osteotomy, up to the level of the medial canthus.

228

4 The membranous septu m, in­ cluding the columellar base and anterior nasal spine, are simi·

larlyanesthetized.

6 Both sides of the nose are stuffed with conon batten soaked in 10 per cent cocaine and an equal amount of 0.1 per cent epinephrine. The packing is left in p lace for ten minutes. The posterior nasopharynx is then loosely packed with gauze to absorb blood and prevent it from dripping down the back of' the throat during operation.

Reduction o f

the nasal tip 7 The alar carti lage is exposed through a rim incision placed 1 or 2 mm above th e inferior bor­ der of the cartilage. Through this incision , the nasal mucosa is dis­ sected off the carti lage over an area correspo nding to the boundaries of the estimated re section.

8 The resection begins by in­ cising the alar carti lage about 2 mm above it s low er border.

9 The ca rtil age is sepa rated from its cutaneou s attachments with a pair of Stille' s blunt-tipped , thin-bladed scissors.

10 The alar cartilage is sectioned medially, and is delivered from the incision to be resected lateral­ ly .

229

Undermining the dorsal skin 11 An intercarti laginous

incision is made be­ tween the lateral and alar cartilages and ex­ tended onto the septal mucosa, curving down­ wards between the colu mella and the in­ ferior m argin of the septa l cartilage . It is im­ portant that no part of thi s incision joins the original rim incision in order to avoid creating a flap o f nasa l lining which may result in problems of reposition­ ing and blood supply.

12 A pair of blunt ­ tipped scissors is in­ trodu ced th rough the incision and the skin is dissected free fr om the dorsum of the nose above the periosteum. The undermining is ca r­ ried as far proximally as necessary and may ex­ tend into the glabellar regi o n.

230

Reduction of the hump 13 The nasal sk in is elevated w ith an Aufricht retractor to expose the lateral ca r­ tilages . A pair of straight-b laded iris sci s­ sors is introduced , and each of the lateral ca rtilages is divided in turn at the previous­ ly determined level of resection , up to th e margin s of the nasal bones .

14 The septal cartilage is then sectioned at the same leve l.

15 A spec ial, straight, thin­ blad ed osteotome is used for cUlling through the bon y com­ ponent of th e hump (se e p. 246).

231

16 The osteotome is inserted horizontally into the inci sions made in the carti­ laginous part of the dorsum, and its edge is advanced until it meets the bony por­ tion. While the ope rat or co ntro ls the course of the in­ stru ment. th e as­ si stant uses a hammer to drive the chi sel through the bone to the g label la. Th is completely frees the hump, and it can then be removed with a straight hemostat.

17 If the hump re­ section is co nfined to the area of the bridg e alo ne, the described procedure will be suffi cien t. In most cases, howe ver , the bony resection shou ld be extended into the glabellar region . A specia lly designed curved osteotome is m ost useful fo r this part of the procedure.

•

18 The straight osteotome is remo ved

and the curved one in serted in its pl ace. Thi s is facilitated by ha ving prev iously elevated the handle of th e stra ight in stru ­ ment slightly t o widen the track with o ut causing a fra cture . When the curved osteo­ tome is driven th rough the bone, it creates a smooth glabellar notch.

232

•

The Large Nose

19 The removed section is larg e, and characteristi­ cally widest at the junction of the bony and ca rtilagi­ nous elements .

20 The excised hump is wrapped in saline-soaked gauze and preserved for later trimming and re­ placement as a graft .

•

21 Hump resecti on has been comp leted with a minimum of tissue under­ mining.

22 The striking width of the re sultin g de­ fect in the bridge are a is now evident, and the lateral wall s of the nasal pyramid must be moved medially to narrow the open dorsum.

233

I

Na rrowing the nasal pyramid

23 A special , narrow, thin-blade osteotome is used for the lateral osteotomy.

24 A stab wound is made in the lateral part of the floor of the nose, over the margin of the piriform aperture. The osteotome is introduced through this incision with the guarding knob under the skin. No undermining is done prior to this osteotomy.

25 It is important to co nfine the sectioning of the lateral nasal wall to its base. The instrument should therefore be kept flush with the maxilla, not allowing the edge to run up into the lateral wall of the nose itself. The osteotome is advanced with gentle taps of the hammer for about two thirds of the distan ce to the medial canthus. At this point, there is a sudden drop in resistance and the osteotome takes a slight medial roll. Thi s marks the development of a greenstick frac­ ture, occurring obliquely across the upper portion of the nasal bone. Hinged at the fracture site, a few more taps of the hammer will shift the nasal wall medial­ ly. The wall is now in the desired position and there is no requirement for in- or out-fracturing as in other rhinoplasty operations. When the nasal pyramid has been narrowed in this fashion, the walls remain fixed in their new position . The fracture line fall s well away from the lacrimal system .

234

Trimming and shortening the cartilaginous septum 26 The cartilaginous septum usually requires further trimming to plane it to the level of the bony res ection . This may also be true for the lateral cartilages. Slight over-correcti o n at both sites is desirable to prevent bulbing above the nasal tip . Sparing the mucous mem­ brane, fine adjustment is made with straight scissors.

,

27 Shortening and /o r tilting the nose is often a part of the procedure. This is accomplished by excising an appropriate amount of septal car­ tilage from its inferior border. In order to preserve some excess lin­ ing, the mucous membrane covering this section is separated from the cartilage prior to removing the cartilagino us segment. When it has been necessary to shorten the septal cartilage consider­ ably, the lateral walls of the nose mu st be shortened as well. This is done by resecting the lower borders of the lateral cartilages including their covering mucous membrane.

235

Shaping the resected hump

28 All of the attached mu cosa is stripped off th e underside of the hump. This exposes the bone and cartilage of the nasal vaults on !!ach side of the septum.

29 The lateral walls of the specimen are trimmed using a straight rongeur for the bone and scissors for the cartilage .

30 The septa l section of the hump acts as a strut f or the nasa l roof and ma intains the angulat ion of the hu mp. Removal of this com ponent invariab ly all ows the graft to straighten out.

236

The Large Nose

31 After trimming, the dorsal surface is generally perfectly straight. Should some bony prominence remain, this is rongeured down to the level of the car ­ tilage.

32 The width of the bony segment is maintained. The cartilaginous portion is narrowed considerably by removing the major part of the lateral cartilages, leav­ ing the central section intact. The perios­ teum and perichondrium are not dis­ turbed.

237

Replacement of the hump as a graft

33 The graft has been shortened and trimmed and now confo rms to the pre· pared base.

t

I

34 When the skin of the dorsum is elevated, the osteocartilaginous graft ca n be accurately positioned under direct v ision.

35 The graft readily fits into place and is in broad conta ct w ith the margins of resection, particularly in the bony area where it is firmly supported by the septum and the nasal bones. The nasal profile is normal and flows naturally into the glabellar notch.

238

36 On ly minor adj ustments are necessary to align th e edges of the graft with th e margins of the lateral walls. In spite of the nar­ rowed nasal pyramid, the normal width of the dor­ sum has been maintained and its bevelled contou r is natu rally rounded.

37 In th e majority of cases the graft w ill remai n firm ly in place w ithout fixa ti o n . If it displays any tendency towards mobility, a 4/0 catgut sutu re may be used to fix the tip of the graft to the septu m. Should the hump be inadvertently fractu red du ri ng removal or shap ing , it can be held together with a periosteal catgut suture prior t o re in­ se rti o n.

I

• 38 At the completion of the proced ure , stru ctural anatomy is re sto red. The round ed contou r of th e grafted dorsum contrasts marked ly w ith the sharp edges o f bone and car­ tilage fo ll ow ing the u sua l meth o d s of redu cti o n rhino­ plasty .

•

239

Closure of the wounds

39 No wound surfaces are left exposed . The alar rim incision is accurately

closed with a few inter­ rupted 4/ 0 catgut sutures .

40 The anterior portion of the intercartilagi­ nous incision and its columellar extension

are closed in a simi lar manner by merely approximating the mucosal edges. Laterally, this incision will adjust itself spontaneously, and is left open for drainage .

Dressing with tape 41 Strips of microporous tape' are applied over the dorsum of the nose, gently com­ pressing the skin over the graft and there­ by prev enti ng the accumulation of fluid . I

Steri -Strip@ sk.i n closures . 3 M Comp ., 51. Paul , Minn. ,

U.S.A.

240

42 The tape is also important t o mold the nose, particularly in the supratip area where compression is necessary and difficult to obtain by any othe r form of splinting .

Splinting with plaster

43 As it is easily molded to fit accurately , plaster of Paris is the preferred materia l for sp linting. Two layers of 10 cm wid e plaste r bandag e are cu t int0 a " T" -shape, with the ba se of th e T being broad enough to cover th e entire nos e.

44 T he p laster is m ol d ed t o fit th e nose. It is rein ­ forced over the glabella and a sma ll sling of pla ster is added just below the ti p to p rev ent spread ing . The sp lin t is held in p lace wi th a strip of microporous tape p lace d across the forehead . A str ip o f elasti c t ape, anc hored to each cheek, prevents th e nose from being dislodged. Th e pos terior nasopha ryngeal pa cks a re remo ve d and the nose is not packed postoperative ly .

Postoperative care Almost all patien ts are treated on an out-pa tient basis. Pain and discomfort are moderate and can be readily con trolled with oral analg esics. Post­ operative oozing is minimal and s ubsides in one or two days. There may be some accumula tion of dried bloo d w ithin the nostrils, wh ich the pa­ tients are instruc te d to re move gently, thereby ensuring a patent airway and greatly enhancing comfort. ProphYlactic antibiotics are no t used. The original plaster dressing is removed after one week. At th is time alm os t all swelling has abated and a new well-molded plas ter splin t is applied and le ft in place for another week or ten days to afford added support to the healing gra ft. When the nostrils are cleaned, any remaining ca tgut sutu res are re m oved with th e crust. 241

Result 45-50 Five months postoperatively, the nasal configuratio n has been markedly altered from the preop erative appearance. In profile, the nose is shorter and the naso -Iabial angle has been improved. The bridge is straight and the glabellar notch significantly deepened. A frontal view highlights the narrowed nasal pyramid. The bulbous tip has also been reduced proportionally, and the nostrils are rou nded and symmetrical. In semi-profile the overall reduction is apparent, as is the un­ di sturbed rounded co ntour of the dorsum.

242

---

--~-"-----'-------------------

Further examples

I

,

t 51-54 This result illustrates the wide range of possibilities for shaping and reducing the nose. Utilizing the dorsal hump as a free graft, the surgeo n has greater flexibility in determining the shape , size, and contour of the new nose . The gently rounded dors um appears natural , and the nasa l prominence, so evident in the preoperative photographs, has now been co rrected .

•

243

-..

55-58 Similar techniques can be applied in les s ex­ tensive ci rcum stances. Thi s patient request ed correc­ ti o n of her humped profile w ith lowering of the bridge and mo re definition given to the nasal tip . The proce­ dure involved ra dical removal of the dorsal frame­ work, includi ng the glabellar notCh, narr owi ng of the bo ny pyramid and replacement of th e trimmed speci­ men as a composite graft. Only minor adju stment s w ere made to th e tip an d alar ca rtilag es . The end re sult is a n atural cO ntoured dorsum w ith an even su rfa ce.

244

•

59--00 In this patient a rhinoplasty was performed in an identical fashion to the preceding case. How­ ever, resection and trimming of the hump was slight­ ly altered to produce a straight profile.

245

-

59-60 In this patient a rhinoplasty was performed in an identical fashion to the preceding case. How­ ever, resection and trimming of the hump was slight­ ly altered to produce a straight profile.

245

61 Thin -b lad ed nasal osteo tom es designed for the de­ scribed pro cedure are manufa ctured by AB Stille -Werner, Stockholm , Sweden .

The handle offe rs the operator a firm grip , while the flat­ tened head aids in judging the position of the instrument during th e osteotomy. The double -guarded instru ments are used f o r the hump resect ion, the curved one for the glabell ar region, and the single-guarded chisel is employed for the latera l osteotom y. The numbers indicate th e width of the edge in mm. The illustr ated sizes are the most co m­ monly u sed , although other widths are avai lable.

246

Comments

Use of the nasal dorsum as a composite graft

After removal and recontouring, the nasal dorsum is replaced as a free graft. This represents a new principle in reduction rhinoplasty. Impaired healing and infection might be expected to occur, as the procedure in vo lves the introduction of a com­ posite graft of bone and carti lage to a bed that communicates with the nasal cavity. These complications, however, do not arise. After hump redu ction, narrowing the nasal pyramid ef­ fectively makes the graft bed a closed space. The mucous mem­ brane that line s the lateral wa ll s comes in contact with the septal membrane throughout the length of the dorsum , thereby sea ling off the nasal cavity from the graft . Thus , in over one hundred and fifty operations of this kind , there ha s been no evidence of either infection or delayed healing. During the same period, a number of iliac bone grafts were used to correct post­ traumatic deformities of the nose. Some of these implants be­ came infected and the grafts were l ost , despite being inserted into a bed which did not communicate with the na sa l passages. Regrafting the hump therefore appears to be a safer procedure.

There are a number of very obvious advantages of thi s tech ­ nique :

•

The composite graft consists of original tis sues from the area.

• It can be shaped to render a natural dorsal co ntour, with a rounded and fairly broad bony section accentuated at the osteo­ chondral junction, and with the cartilaginous portion tapering to­ wards the tip. •

The straight graft provides continuity to the entire profile.

• Despite the fact that the dorsal support extends from the glabella to the tip of the nose, flexibi lity is still maintained, as below the bony pyramid the graft is composed of cartilage. • When the graft is replaced after proper trimming, it will mask irregularities and asymmetry. • It rests li ke a roof over the lateral walls and eventually unites with them to form a so lid bond, which prevents spread ing of the nasal pyramid.

247

• The lack of significant complications associated with graft­ ing, and • the superior esthetic results merit its use as a standard pro­ cedure. In this technique, hump resection involves removal of a large intact segment of dorsum. This can only be performed properly with thin-bladed osteotomes such as those demonstrated . The thicker-bladed instruments, commonly used in rhinoplasty, are likely to fracture either the hump or the lateral walls. A proper execution of the lateral osteotomy is essential to nar­ row the base adequately and to provide a stable foundation for the graft. This technique also requires a thin-bladed osteotome and is effected without undermining . On the dorsum , under­ mining is limited to a relatively small area . The possibility of hematoma formation and postoperative swelling are thereby greatly reduced.

Nasal tip reduction

In describing this method of reduction rhinoplasty, the tech­ niques of hump removal and adjustment of the nasal pyramid have been highlighted. Though other facets of the operation have not received as much emphasis, recontouring the tip of the nose or altering the size and shape of the nostrils are ob ­ viously integral components of the operation . The nasal tip reduction is performed at the beginning of the procedure when the nose is firmly positioned and there is little troublesome bleeding. The resection is usually fairly radical, but a rim of alar cartilage is always retained to maintain a natural contour and avoid the creation of an amorphous tip without cartilaginous definition. The remaining arch of cartilage also prevents alar collapse and anterior angulation of the nostril. The final shaping of the tip is delayed until the hump has been removed and the dorsal graft is positioned . Then, if the tip is still considered too prominent, this can be corrected by alar base resection and/or by reducing the height of the columella.

Late results

248

The long-term results of this procedure have been gratifying. Union of the graft has occurred in all cases. There is some degree of resorption of the bony portion , but this has not been to such a degree as to seriously affect the result. Since the car­

The Large Nose

ti lag e reta i ns its orig ina I size and sh a pe, this part of th e graft may appear slightly prominent in cases in whi ch bone resorp­ tion has been most marked. To avo id this unwanted possibility, it is wise to slightly ove rcorrect when trimming the dorsal part of the septal ca r1 ilage. Th is will also prevent any minor skin redundancy in the supratip area from disturbing the fi nal resu lt. The amount of mucosa removed corresponds t o the degree of nasal reduction. All wounds are closed accurately, which results in early hea lin g and insigni fi cant scar formation . Late co ntra c­ tion with subsequent distor1ion has not been obse rved . Th is also app li es to the rim inci sion, which has never been a source of postoperative inconvenience.

References

Cottle M . H.: Nasa l roof repair and hump removal. Arch Otolaryng 60 .' 408, 1954. Joseph J .: Nasenpiastik und sonstige Gesichtsplastik. Kabitzsch , Leipzig, 1931 , p 88. Sheen J .: Secondary rhinop lasty. Presented at the Seventh Annual Symposium on Cosmetic Surgery. Miami, Flo rida, February 10th, 1973. (Not pub li shed .) Skoog T.: A method of hump reduction in rhinopla sty. Arch Otolaryng 83: 283, 1966.

249

Chapter XI

I. Correction of protruding ears by conchal resection Introduction 253 Anesthesia 254 Operative procedure 255 Preparing and draping Plannin'g and resection An esthesia Conchal resection Closure of the wound Dressing Result

Comments 262

II. Reconstructing the anthelix by perich on drioplasty Introduction 264 Operative procedure 265 Preoperative condition Preparing the perichondrial flaps Reconstructing the anthelix Wound closure Immediate result After four weeks After supplementary conchal resection Perichondrial cartilage regenerati on Final result

Variations in operative technique 272 Comments 276

III. Perichondrial otoplasty in an irregular deformity of the ear Preoperative condition 277 Operative procedure 277 Incisions Unfolding the cartila ge Perichondrioplasty, utilizing flaps and a free graft Skin closure by a flap transfer Immediate result Final result

References 283

Title page : Accen tu ated by his closely cropped hair thi s bust of Augustus Caesar ex hib its a pair of clearly pro­ truding ears This familial trait can be seen in statues of many of the Roman Emperors. Courtesy of Direzione Generale dei Monumenti Musei e Gallerie Pon tifi­ cie, Citta del Vati cano.

250

I

Chapter XI

I. Correction of protruding ears by conchal resection Introduction 2 53 Anesthesia 254 Operative procedure 255 Preparing and draping Plannin·g and resection Anesthesi a Con chal resection Closure of the wound Dressing Result Comments 2 62

II. Reconstructing the anthelix by perichondrioplasty Introduction 2 64 Operative procedure 265 Preoperative condition Pr ep aring the perichondrial flap s Reconstructing the antheli x Wound clos ure Immediate result After fo ur weeks Aft er su pple mentary con chal res ect i on Perichondrial ca rtilage regeneration Fi n al result Variations in operative technique 2 72 Comments 2 76

III. Perichondrial otoplasty in an irregular deformity of the ear Preoperative condition 277 Operative procedure 2 77 In cisions Un folding t h e cartilage Pe richondriop lasty , utilizing f la p s and a fr ee graft Skin clo sure by a flap t ran sfer Immed iate result Fin al resul t References 283

250

Title page: Accen tu at ed by his closely cropped ha ir th is bust of Aug ustus Caesa r exhi bits a pair of clea rl y pro­ tru ding ea rs. Th is fami lia l trai t ca n be seen in statues of many of the Roman Em perors. Courtesy of Direzione Ge nerale dei Monum enti Mu sei e Ga ll eri e Pontifi ­

cie, Citt!! del Vati ca no.

Helix -_~

~--1-----';----Crus posterior of anthelix

\-- --'-- -

Tnangu lar fo ssa

--,=~---'-"----- Crus anterior 01 anthelIx

AnthelIx

-_~

- - ----,r7'- - - - Co ncha 01 auricle 0-;-­

. . .-

Tragus

- -- - Anlllragus

--

252

1 In this moderately protruding ear the greenshaded area defines the position of the aural cartilage. The anthelix is less devel o ped than nor­ mally.

I. Correction ofprotruding ears by conchal resection

Introduction

•

The ba sic anatomical defe ct of protruding ears is a localized abnormality of the aural cartilage . Its dorsal folding i s incom­ plete at the lateral border of the co ncha , and this congenital deformity presents as underdev elopment or absence of the antheli x. With this principle at last realized, attempts at correc­ tion became more purposeful, and a number of new tech­ niques were introduced to r econ struct the anthelix (Lu ckett 1910, McEvitt 1974, Cloutier 1961 , Sten st rom 1963, Baruch 1970, Muhlbauer 1972, and others). Significant improvement in the general configuration of the ear can now be made. Approximately seventy -fi v e per ce nt of cases of protruding ears require reconstruction of the anthelix. In the remaining twenty­ five per ce nt, with only limited protrusion , a fairly well develop ed anthelix is present, and the m ost striking feature of the mal ­ formation is an oversized concha. With th is type of disfigure­ ment, it is more advantageous to redu ce the concha than to re shape the anthelix. An elliptical co nchal resection has thus been devised and has, in these selected ca ses , produced most sati sfa ctory resu Its (Skoog 1958). Th is te ch n iq ue u til izes th e ex ­ cept ionally ri ch vasc ular suppl y of the ear which time and again, both in the literature and in personal exp erien ce, ha s enabled the la cerated ear t o survi ve, even on the narrowe st pedicle,

253

Anesthesia

With few exceptions, local anesthesia is used in corrective sur­ gery for protruding ears. Most of bur patients are treated when they are about five years old. At this age, children can gen­ erally be persuaded to submit to the temporary discomfort of the injections, when assured that the entire procedure will then be completely painless . Confidence is gained when they ex­ perience immediate anesthesia, and this encourages good pa­ tient cooperation. Lidocaine (Xylocaine®) has marked sedative effects and occasionally the young patients may fall asleep dur­ ing the operation. When the anesthetic subsides, analgesics are usually required.

254

Operative procedure

Preparing and draping

2 The patient is placed in a supine position, with the head raised slightly, and the face , neck and ears are prepared with antiseptic solutions. No hair is removed, as it is retracted away from the surgical area with tape. Both ears are then draped with an aperture adhesive sheet.' This effectively partitions off the operative field, yet, it permits the surgeon to keep under constant sur­ veillance the relationship of the ear to surrounding structures . The drape remains secure and does not dislodge during the procedure.

Planning the resection

3 This ear is moderately protruding due to an enlarged concha, while a distinct anthelix is present. An estimate of the exce ss co ncha is made, and an ellipse is marked out for resection. Its greatest width , usually about five mm, is generally opposite the tragus. The excision is planned for the deepest and most posterior part of the conchal cavity, as indicated. Superiorly it follows a curve under the anterior crus of the anthelix, while inferiorly, it angulates behind the antitragus. The four sinuous lines of the diagram represent the convolutions of the ear surface . If the lines of resection are placed correctly, when the edges are reappro x i­ mated they will fit snuggly together.

1 Steri-Drape'3l , Small aperture drape 16"x 16 ". 3M Comp., St. Paul , Minn., U .S .A.

255

I

Anesthesia

4 Approximately 5 cc of 1.0 per cent Xy locaine ® (lidocaine) with epine­ phrine are injected subcutaneously into the previous ly designed ellipse. The cartilage is then pierced by the needle and a sim ilar amount of an esthetic is deposited in the posterior subcutaneous layer. A circular periauricular nerve block will also produce satisfactory an esthesi a. Adjacent to the auditory canal , the se nsory nerve supply of the co ncha is to a varying extent derived from the auricular branch of the vagus. Separate su bcutaneous infiltration of this area with 1 to 2 cc anesthetic so luti on is therefore required. With this technique the injection of about 10 cc, 0.5 per cent Xylocaine ® with epinephrine, will o rdinarily be sufficient.

...

~-

Concha! resection 5 Starting at the medial margin of the marked area, a through­ and-thro ugh incision is made with a No . 11 blade .

6 The knife passes perpendic­ ular through the back o f the ear as it foll ows the outline along the anterior surface .

256

j

7 An elliptical segment, comprised of the full thick­ ness of the ear, is excised. The skin, now has a tend­ ency to retract away from the cut edges, revealing the protruding carti lage. This protuberance is most evident on the medial side, where some trimming may be required . 8 The edges of the wound can now be readily ap­ proximated . Resistance may still be encountered at either the upper or lower poles . This is overcome by breaking the spring of the cartilage 'with a subcutan­ eous incision at the end of the ellipse.

9 A slight discrepancy may exist between the two sides of the ellipse, which can be corrected by remov­ ing one or two small wedges of cartilage from the lateral edge.

257

11 Suturing the cut car1ilage edges to­ gether, as shown in this drawing, folds the ear backwards and ac­ centuates the anterior anthelical crus.

Nonabsorbable suture material (4/0 Supramid,' white) is used. 10 The elliptical excision corrects the height of the concha, but may not rectify a prominence of the upper pole. This protrusion is due essentially to an insufficient folding of the anterior crus of the anthelix and can be simply cor­ rected by excising a small wedge of car1ilage from this area.

I

Societe Steril Catgut (SSe) , Neuhausen am Rhelnfall , SW itzerland.

258

,.

I

Closure of the wound 12 Wound closure begins in the middle of the ear with a double vertical mattress suture of 4/0 plain catg ut.

1

,

1

13 The suture is tied on the posterior surface. Four

such sutures are usually required .

•

(

14 The skin edges come together easi ly as the suture line falls behind the ant helix .

I

15 This drawing diagrammatically depicts the vertical mattress suture used in closure . All layers are closely approximated.

259

16 On the anterio r surface, a few 6/0 catgut skin sutures supplement the closu re. Posterio rly, a few additional sutures of 4/0 catgut are used to ensure adequate hemostases.

17 At the end of the procedure the r elatio nship of the ear to the head is normal. The reduction in con­ chal depth has tucked the ear backwards, allowing the original anthelical fold to lie in a normal plane.

Dress ing Th is type of operation does not invo lve recon­ touring the cartilage, a procedure which requires splinting during healing to prevent recurrence of the deformity. Therefore, a simple protective dressing is all that is needed and it is left in place for ten days . At that time the catgut sutures can be washed away with the crust. This suture material leaves no undue markings and is of ob­ vious advantage in pediatric practice.

260

Result

18-19 These preoperativ e pictures rev eal ob v ious protrusion of the ear. This effect is generated by an enlarged concha, while the anthelical fold is reason­ ably well dev eloped .

20-21 Six months after correction the patient demon­ strates a normally appearing ear, and the position has remained unchanged since the last sutures were placed, see Fig. 17. The wounds are well healed and the conchal scars are virtually invisible . They are partially hidden behind the anthelix and antitragus.

261

Comments

The conchal resection does not impair blood supply to the ex­ ternal ear, either at the time of, or subsequent to surgery . Heal­ ing has always been by primary intention and is complete in about one week. The resulting scars show no tendency to de­ teriorate, which is particularly important in the visible anterior portion. This excellent appearance probably reflects the ten­ sion-less skin closure . The cartilage has also been approx­ imated without tension , thus permitting the ear to remain in its new position. No serious complication has occurred in a series of 150 cases , and there has been no loss of sensation along the helical border. This type of resection preserves the original curve of the ant­ helix and simply readjusts this important structure to a normal position . In closure , the resected margins are aligned edge to edge and thus heal without forming a step or other irregular­ ity. Although the width of the resected ellipse is at most only about five mm, it radically improves the appearance of the ear. The effect is ensured by careful selection of the site of resec­ tion . The procedure not only lowers the concha but also per­ mits the ear lateral to the excision, to rotate into a plane closer to the head . Ear protrusion may, in some cases, be limited to specific areas due to localized enlargement of the concha . In these instances, the site and size of the resection are adjusted accordingly. In conclusion, this method should be employed only in cases with an acceptable anthelical fold , and where the major part of the deformity is due to an excessively large concha . Then the aesthetic results should be excellent.

262

II. Reconstructing the anthelix by perichondrioplasty

r

Introduction

•

Approximately seventy-five percent of patients with protruding ears require anthelical reconstruction. The smooth , rounded curve of the naturally shaped anthelix is, however, difficult to duplicate. Surgical attempts to reconstruct the anthelix usually violate the natural framework, replacing this peaceful arrange ­ ment with sharp edges ; and then the cartilage , which is re­ silient to molding and intractable to shaping , tries to regain its original position. Sutures often produce ex cessive folding and a pinched look, or they flatten part of the ear and cup the remain­ ing portion, resulting in an " hour glass deformity". The delicate balance between concav ities and con v exities is thus destroyed. A new method of corre ction ha s therefore been dev ised, which reshapes the antheli x but does not result in a conspicuous, un­ natural contour. The underlying principle for this procedure is to use the mobilized peri chondrium to generate cartilage, thereby maintaining the folded ear in the desired position . The clinical work is an application of ex perimental studies on aural perichondrium by Skoog , Ohlsen and Sohn , reported in depth in Chapter XII.

•

I

264

Operative pro cedure l

Preoperative condition 22-23 This protruding ear, in an eight year old boy, demonstrates the characteristic absence of a distinct anthelix . The flattened appearance reflects the in­ completely folded crus posterior.

24 Lightly pressing on the outer margin giv es the ant­ helix a more pronounced , softly-curved contour and puts the upper portion of the ear in a natural relation­ ship with the side of the head. This effect is reproduced when a perichondrioplasty is pertormed.

25 The patient is seen here on the operating table, draped and prepared for surgery. Periaural infiltration with 0.5 per cent Xylocaine® (lidocaineL con t aining epineph rine, is usually em­ p loyed, but in this instance special indications dic­ tated the use of general anesthesia,

I ThiS technique was first rep o rted at th e Fourth Biennial Meet ing of the lord Skoog Society in Valencia, Sp ain , May, 1973.

265

Preparing the perichondrial flaps

26 The posterior surface of the aural cartilage , corresponding to the anthelix, has been exposed .

27 The distinct groove of the crus anterior is easily identified and an incision is being made along this furrow, through the perichondri um .

28 The perichondrium is ele­ vated off the cartilage laterally, as far as the region of the posterior crus.

266

29 A similar dissection is ca rried out m edially, ove r the co ncha .

30 This maneuver is fa cilitated by the use of sma ll , sharp-edged elevators, whi ch strip o ff the ad­ here nt perichondrium . A knife may also be used , but it is then difficult to avoid damaging the cartilage. No cartilage should be left on the raised perichondrium; neither shou ld any peri­ chondrium remain in place, still adherent to the aural cartilage.

Reconstructing the anthelix •

31-33 In reconstructio n. the mobilized per ichondrial flap s are used for recontouring the ear cartilage, and the sutures are adjusted to give the desired fold to the anthelix. Two nonabsorbable (S upra mid) sutures sec urely an chor the perichondrium in position . The fibrou s nature of human perichondrium permits thi s method of reco nstruc­ tion.

267

34 A tightl y sea led sub peric hond rial pocket has been produ ced by using a supplementary, co ntinuous 5/0 Dexon suture along th e borders of the peri­ chondrial flaps. Bl ood drawn fro m the patient is being added to this created cav ity to act as a medium for ca rtilage growth .

Wound closure

35 The wound edges are accurately approximated with a running mattress suture of 4/0 plain catgut. Thi s suture effectively stops oozing from the edges and will have dissolved, when the patient returns for his first d ressing in ten days. No permanent marks are left by this suture material.

Immediate result

36-37 The upper portion of the ear ha s been com ­ pletely repositioned and normal anthelical crura have been formed. The immediate operative result em pha­ sizes the relatively large concha that remains to be corrected. In this case a secondary procedure was per­ formed, as shown on the next page, though total re­ constr uction can be made in one stage. A light, well-fitted co mpress ive dressing is used to protect the ear postoperative ly.

268

After four weeks 38--39 Four weeks postoperatively, the configuration of the ear is essentially un changed . This demonstrates the stability of perichondrial reconstruction, since in this case the molding force on the cartilage apparently had to be considerable. As a secondary procedure , a conchal resect ion was now performed. An elliptical, full thi ckness ear section was excised in the depth of the conc ha , co rrespond­ ing to the greatest conchal width. The technique for this procedure was described earlier in this chapter.

After supplementary conchal resection

40--41 The immediate results show the limits of the

resection. The ear has now attained a completely nor­ mal shape.

269

Perichondrial cartilage regeneration

42 In conjunction with the second stage of the procedu re, the perichondrioplasty was un­ covered. A thin, transverse section of the gen­ erated cartilag e has here been removed for histological examination . A black Supra mid sutu re, that had been left in place in the peri ­ c hondrium, can be seen at the upper resection border. 43 The shape and thickne ss of the newly formed cartilage can be better assessed in this drawing.

44 The newly formed cartilage, shown in the upper two thirds of this microphotog raph, differs from the normal ear cartilage at the bottom of the picture in that it possesses less regular stru ctures and an increased cellularity .

I

.. 270

45 Th e outer area of the new ca rtilage is shown in this picture. The richly ce llular zone at the sur­ face indicates that re generation o ri ginates from the perichondrium . (Hematoxy lin-eosin , x50.)

Final result 46-48 The results, six months after surgery, show the ear remaining in its immediate post­ surg ical shape and position.

•

271

Variations in operative technique

Case 1. Preoperative condition 49-50 In this five yea r old boy, the complete anthelix is poorly de­ veloped and is in fact effectively absent along the entire rim. As a result, the ear stands out at right angles to the head . In the upper portion of the ear, reconstruction was carried out with the use of perichondrioplasty along the po ste ri o r surface, as de ­ scribed in the previous case. In the mid-portion of th e ear, the en­ larged concha was reduced subcutaneously by removing an elliptical segment of cartilage.

I Result 51-52 The shape and relative position of the ear is corrected . The rounded , normal con figurat ion of the anthelical fold has been recap­ tured , branching out superiorly into the thin shelf of th e crus anterior, and gradually disappearing into the soft curve of the crus posterior. A slight thickening of the ca rtilage could be palpated at the site of the perich ondrioplasty. During follow-up over 6 months, no changes oc­ curred .

272

Protruding Ears

The above patients, used for demonstrating the surgical proce­ dures in perichondrioplasty, have both presented marked en­ largement of the aural concha, which required excision. Since perichondrioplasty is a technique that offers great possibilities for remolding the ear cartilage, it is a matter of personal pre­ feren ce in any particular case, as to what extent this method should be combined with a conchal reduction. The following example demonstrates correction of prominent ears by peri­ chondrioplastyalone.

Case 2. Preoperative condition

53-54 This fi ve yea r old boy presented with markedly protruding ears. The auricle lacks a natural contour and , in particular, the anthelical fold appears flatt ened .

273

Preoperative markings

55 Exerting gentle pressure on the rim reshapes the ear and forms a normal anthelix. The re­ Quired degree of fold ing is indi­ cated by the area ou tlined in blue, with the solid central line highlighting the created ridge. A perichondrioplasty WilS per­ f o rmed, which co rrected the ear according to the dotted pattern.

274

..

56 To secure orientiltion for the perichondrial dissection, the an­ terior markings are trilnsferred to the posterior surface in the fo l­ low ing mil nner. A fine need le is used t o pierce the ear. When the point shows through the skin, the tip is sta ined with methylene blue and the needle is then with­ drawn . Thi s leaves a blue imprint on the posterior surface of the cartilage in the desired spot.

Immediate result 57- 58 Reconstructing the anthelix has given shape to the ear as well as restoring the normal relationship of the ear to the side of the head . In a f rontal view the helical rim is seen to over­ ride the less prominent anthelix in a norma l fashion . Compa r e Figs. 53-54.

Final result

59--61 Th ree months after surgery, the immediate operative re­ sult has remained unchanged. T he anthelical ridge sweeps naturally into the graded prominence of the curved posterior crus and the fold of crus anterior. The se structures shape and define the triang ular fossa.

275

Comments

If free spanning sutures or nonspecific connective tissues are used to fold the cartilage back on itself, they will eventually be­ come lax and the ear will return to its original position . In ele­ vating the perichondrium, and suturing the layers together in a pocket above the old cartilage, new cartilage soon forms within the cavity . This reinforces the suture line and the cartilage sur­ faces become adherent to each other in a sculptured and per­ manent relationship . The cartilaginous proliferation is limited by the perichondrial membrane and new cartilage fills the roofed connection much as clay is deposited in a mold, up to the top and no more. The procedure uses a posterior approach, which leaves an inconspicuous scar and the newly formed tis­ sue is recognized on palpation as only a slight thickening of the ear cartilage. To achieve a pleasing result, the position of the ears must be symmetrically corrected and the harmonious balance between the curved and flattened areas restored. With a perichondrio­ plasty the cartilage is gently folded , not cut or crinkled Though experience undoubtedly is necessary to decide exactly what is needed in each particular case, using the perichondrioplasty technique facilitates anthelical reconstruction and provides an effective method of molding the ear into a natural shape. The regenerative potential of perichondrium is probably most pronounced in the growing individual. The tissue reaction in­ duced by perichondrioplasty is, however, repairative and should thus be present even in older patients . This view has been confirmed by the successful results obtained with adults and has also been demonstrated in animal experiments.

I 276

III. Perichondrial otoplasty in an irregular

deformity of the ear

Preop erative condition 62--03 Thi s striking ear deformi ty arises fro m an ab­ normal transverse foldin g o f th e ca rtila ge, ext ending from the anterior crus of the an theli x through the heli­ cal rim . The top part of the ear h as thus become bent and pointed . The drawing depicts ca rtil age config ura­ tion in a poster ior view. The patien t is a fi ve y ear old girl ; her left ear is normal and no simil ar malfo rma­ tion is known within the family.

Conventional otopl asty techniques fail to o ffer a sa tis­ factory operation f o r correcting this abno nmal ity. As a method for repair, it was decided to unfold the car­ tilage and to restore the norma l anatomy of the car­ tilage by a perichondrioplasty .

Operative procedure

Incisions 64 On the posterior surface , the skin has confor med to the reduced ear dim ensions. An in cision is made opposite the abnormal transv erse fold and ca rri ed into and along the postauricular groove. The skin was then undermined in the upper portion of the ear as far as the level of a normal anthelica l ridge .

277

Unfolding the cartilage

I

I

65 On exposure, the deformed cartilage was found to be fixed in an abnormal posi­ tion by a thin layer of scar-like tissue ex­ tending the length of the fold. These fibrous adhesions were cut and radically removed by sharp dissection , ca re being taken not to damage the adjacent cartilage. A fine double-edged dissector (Yasargil), used in microsurgery, proved to be an ideal in­ strument.

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lage unfolded and the ear regained its normal size. It then became apparent that the flattened cartilage surface lacked a normal sculptured appearance, in particular, an antheli cal ridge was ab­ sent. For recon stru cting this ridge, an incision through the perichondrium is planned (blue) to meet the normal ant­ helix, present in the lower portion of the ear. In the area of dissection the perichon ­ drium has been stripped off the carti­ lage .

I 278

Perichondrioplasty, utilizing flaps and a free graft

67-68 Two perichondrial flaps have been raised , care being taken to ensure that no perichondrial tissue is left on the cartilage . The flaps have a firm fibrous nature , which limits the deg ree of retraction.

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69 The perichondrial flaps are easily ad­ justed to curve the underlying cartilage into a normal appearing anthelical ridge. A few non-absorbable (Supramid) sutures and 5/0 Dexon hav e been used.

The scissors ly ing under the united flaps demonstrates the comparatively small re ­ construction that could be accomplished by available perichondrium.

279

70 At this stage, the mi d -portion of the ear lacked stability in the area where th e peri­ chondrium had been removed. To bolster the repair it was decided to cover th e peri ­ chondrial defect w ith a free graft, taken from the back of the au ral concha. The perichondrial graft has been dissected free and is now being removed.

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71 The free graft is held just above the denuded donor site, spread out between a forceps and hemostats. The re is lillie ap­ parent difference betwe en its oute r and in ­ ner surfaces. Yet, it i s i m po rta n t that the orientation be maintai ned with the cartiiag i · nous side facing downward s. This inne r sur­ face only possesses a co v ering cell layer capable of generating cartilage_

72 The graft has been secured over the defect with 5/0 Dexon sutures. This com­ pletes the perichondrioplasty.

280

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Immediate result

77-78 The normal size and shape of the ear is restored. The heli­ cal rim presents an even conto ur and the antheli ca l c rura have reappeared . Only a minor irregularity still indicates the original fold at the posterior border of the anthelix. For additional support during the healing period , a roll of vas e­ line gauze is fitted over this area and held in place with two cat­ gut sutures . In addition, a simple protective bandage was worn for ten days, at which time the catgut sutures had dissolved and healing was complete .

Final result 79-80 The immediate operative result has remained unchanged over a th ree months follow-up period . The reconstructed por­ tion of the anthelix curves naturally between the reformed scapha and triangular fossa. Subcutaneous scarring is in­ significant but a slight, even thickening of the cartilage can be palpated along the entire perichondrioplasty and it completely stabilizes the ear. The postauricular skin flap has pro v ided ade­ quate coverage for the posterior surface.

282

l

•

References

Baruch J. : Correctio n des o reilies d ecoliees par striation anterieure de l'anthelix . Ann chirp last 75: 159, 1970. Cloutier M . l.: Correcti on of outstanding ears. Plast Reconstr Surg 28: 412, 1961. Luckett W . H.: A new operation for prominent ea rs based on the anatomy of the deformity. Surg Gynec Obsl 70: 635,1910. McEvitt W . G. : The problem of the protruding ear. Plasl Reconslr Surg2: 481,19 47. Muhlbauer W . D.: Eine ein f ache und physiologische Methode der Kor­ rektur abstehender Ohren. Chirurgica p laslica 7: 126,1972. Skoog T.: Sy n punkte r pa den operativa behandlingen av utstaende bron . Reported to the Scandinavian Association of Plastic Surgeons, 7th Congress, Sept 5, 1958. (Not pub li shed.) Skoog T., Ohlsen L. and Sohn S. A. : Perichondrial potential for car­ tilaginous regeneration. Scand J Plasl Reconslr Surg 6: 123, 1972. Skoog T .: En ny operati onsmetod fbr utstaende bron . Read at the an­ nual meeting of the Swedish Surgical Society, November 29, 1973. Stenstrom S .: A " natural" technique for correction of congenitally prominent ears. Plasl Reconslr Surg 32: 509, 1963.

283

Chapter XII

Perichondria l potential for generating cartilage Experiments in rabbits

Introducti on 287

I. Regeneration of ear ca rtilage 288

Experiment 1

Experiment 2

Experiment 3

Experim ent 4

II . Growth of cartilage from free perichondrial grafts 293

Experime nt 5

Experi ment 6

III. Pathogenesis of cauliflower ear 295

Expe rim ent 7

Conclusions 296

References 298

I

Title page: In an experim ent designed to elu cidate th e pathogenesis of cau li ­ flower ear, a hematoma was created between perichondrium and carti lage in a rabbit's ear. Aft er four weeks, new cartilage has formed extensively within the collection of b lo od . The raised perichondrium is retracted and correspondingly the o ri ginal ea r car­ tilage bu lges over the mass. (Toluidine b lue, x 50 .1

284

Cartilage Regeneration

Ear cartilage

Regenerated cartilage

Experimental research

Peflchondflum

Introduction

Numerous experiments have been devised to mold diced auto­ logous costal cartilage into a useable structure, as a surgically shaped cartilage would be an invaluable clinical adjunct in re­ constructing the human ear, either following injury, or in con­ genital deformities (Peer 1955, Kruger 1964, and others). How­ ever, the earl y inve stigations yielded no or insignificant new car­ tilage (Walia et al. 1962, Peer et al. 1966). These researchers failed to generate growing cartilage because they did not re ­ cognize the vast potential of the seemingly unimportant peri­ chondrium and thus ignored it completely in their respe ctive ex­ periments.

I

Our attention was turned to the perichondrium after studying the following phenomena. The cauliflower ear, the common dis­ figurement that besets wrestlers, develops from the trauma of bumping and twisting the ear . In the acute stage there appears to be hemorrhage beneath the perichondrium, which lifts it up off the underlying cartilage . New cartilage is formed in this blood-filled space, and repeated trauma perpetuates this process and adds still more cartilage. As cartilage itself is known to have little innate regenerative acti v ity, the source of this cartilaginous proliferation is probably the perichondrium. The situation is thus analogous to that seen in the periosteum-bone relation­ ship described in Chapters II and VII . Initiated by the above observations of periosteal bone formation and the postulated pathogenesis of new cartilage development in cauliflower ears, a series of experiments was conducted to investigate the chondrogenic potential of the perichondrium. These inv esti.gations were carried out in 2- 3-month-old rabbits (Skoog, Ohlsen and Sohn).

287

I. Regeneration of ear cartilage

Exp eriment 1

A. In the rabbit ear, the peri chondrium is grossly unremarkable and there is little to di sting uish it from ordinary co nne ctive ti s­ sue. In a pilot study (Skoog et al. 1972), thi s thin, nondescript t issu e layer was carefully dissecte d off the cartilage and rai sed as a flap. A 10 x15 mm oval shaped defect in the underlying car­ tilag e w as created , and the perichondrium covering the poste ri or surfa ce of the cartilage w as removed w ith the specimen . The perichondrial flap was then repositioned ove r the gap in the cartilage to re-establi sh perichondrial con tinuity. The other ear served as a co ntrol and there the rese ction of cartilage in cluded the coveri ng peri cho ndrium on both sides .

Results

No growth of ca rtilage was found in the co ntrol group, and after fo ur weeks a distinct breach remained between the cut edges (Fig . 1) . In the rabbits that were left f or a long er per io d of o b­ se rvation , some fi bro us scarring did occur. Thi s cicatri cin g pro­ cess de creased t he size of the defect and somewhat deform ed th e ear. In marked contrast , the defe cts that had been brid ge d w ith a perichondrial flap showed the d evelopm ent of new cartila ge (Figs. 2 and 4). The degree of response varied, but there wa s a con sistent formati o n of new cartilage in all cases w here a peri­ chondrial flap had been left to bridge the defect. The dev elop­ ment was more pronoun ced at four week s than earlier, but even in the le ss advanced cas es new ca rtilage formation was clearl y evident.

1 This ph otom icrogra ph demonstrates the per­ sistent gap in rabbit ear cartilage four weeks after surgical rem oval of a full thickness section of ca r­ tiJage and cove ring peri­ chondrium . (Hematoxy lin and eosin, x25.)

288

Cartilage Regeneration

2 In this specimen , where a br idge of peri ch o n­ drium was placed across a created defect in the cartilage, new, lighter staining cartilage has formed between the cut ends two weeks after surgery . The thi ckened appearance of the original perichondrium , as well as the regen ­ erated perichondrium covering the upper car ­ tilage surface can be seen . (Hematoxylin and eosin, x 45.)

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Regenerate d carltlage

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• 3 The high powered view of the normal cartilage (upper half), with its mature cells, can be com­ pared with the young cartilage derived from the peri chondrium . The matrix of the new cartilage has formed up to the cut edge of the original cartilage and appears firmly adherent to its sur­ face. (Hematoxylin and eosin, x 17 5.)

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4 This mi crophotograph from the center of the new cartilage shows it at an immature stage . There are several examples of active mitosis and the cells have become surrounded by the car­ tilage matrix . The regenerated perichondrium is seen at the top . (Hematoxylin and eosin, x 175.)

289

8. The defect in the first experiment was relatively small and thus , in a succeeding stud y the size of the removed segment of cartilage was enlarged. Another difference in experimental con­ ditions was that in one group of this second series a blood clot was placed in the created defect before repositioning the peri ­ chondrial flap . In the remaining rabbits no blood was added before replacing the flap .

Results

No appreciable difference was found between this experiment and the earlier work , where short perichondrial flaps had been utilized to generate cartilage . The response was directly related to the duration of the experiment. In the cases where the peri­ chondrial flap was pos itioned on a bed of clotted blood new cartilage completely filled the defect. In the remaining cases , the formation of new cartilage was more sparse. In contrast to the malformed control ear, the " flap " ear developed much more normall y . These studies clearly demonstrate the chondrogenic potential of the aural perichondrium, though it might be argued that regeneration took place from the cut edges and that the peri­ chondrium merely acted as a scaffold to guide the development of cartilage from both sides of the gap . To refute this possibility a second study was designed.

Experiment 2

A. A perichondrial pocket was constructed by removing a sec­ tion of cartilage while still leav ing the anterior perichondrium in­ tact. The cut cartilage edges were then brought together and sutured shut. This puckered the perichondrium into a bulb­ shaped recess, which had no continuity with any raw cartilage surface. 8. In another experimental model a " reversed " perichondrial pocket was created in the following way. The cut edges of the ovalshaped defect were approximated after hav ing folded the previously freed and reconstituted perichondriu m between the cut edges of cartilage . Suturing the elliptical defect shut, bunched the posterior skin about the folded perichondrium . The " activ e" surface of this perichondrium was thus facing outwards and the cut cartilage edges were completely sealed with a con­

290

•

Cartilage Regeneration

tinuous perichondrial layer bulging out under the skin. In one group of rabbits blood was placed subcutaneously, between the skin layer and the perichondrial flap, while in another group this was not done.

Results

A. When the perichondrium was simply raised and brought to­ gether along the bases , new cartilage developed inside the pocket, the mass being clearly defined by the enclosing mem­ brane.

B. In the cases where the perichondrial pocket had been turned inside out, to form a pocket, an irregular clump of new cartilage had grown between the raised perichondrium and the covering skin. No cartilage developed inside the pocket, which became completely obliterated . Thus , the generation of cartilage does originate from the deep, dissected surface of the perichondrial membrane only; though there is little to distinguish one side from the other, both grossly and microscopically. In the group, where a blood clot had been placed between the perichondrium and the skin, a subjective increase in cartilage was seen. In several cases the sutures used to close the car­ tilaginous defect had ruptured due to a heavy growth of new cartilage . This new cartilage was found to arise between the car­ tilage edges and the perichondrial flap .

Experiment 3

In view of the forementioned technical difficulties of keeping the cartilage edges sealed, the experiment failed to unequivocal­ ly pinpoint the growth of cartilage to the perichondrial flap and to exclude the possibility of the cartilage edges participating in the chond rogenesis . A way to isolate the development of new cartilage was to raise a perichondrial flap and set it down across a 1 cm diameter teflon ring. This completely separated a portion of the peri­ chondrium from the cartilage. In this "perichondrium through a hoop" experiment new cartilage developed in the middle of the ring. There appeared to be some mechanical limitations, caused by elevating the flap too far off the vascular surface, but though there was some decrease in the rate of growth, new cartilage did develop . 291

In a group of rabbits, where a blood clot had been used to fill the ring, the effect of hematoma as a matrix for perichondrial cartilage growth was strikingly evident. This experiment confirmed that the perichondrium was indeed the source of this new growth, not the cut ends of the remain­ ing cartilage.

Experiment 4

With the virility of perichondrium becoming established, the chemistry of the tissue was further investigated (Wasteson et al. 1974). In the rabbit ear, a control defect and the standard car­ tilage resection leaving the perichondrium to bridge the gap on one side , were consecutively made. At weekly intervals, for six weeks,5 mm punched speci mens were taken from the control area, the flap, and the untouched cartilage and tested on its ability to incorporate " SO •. The results showed that the uptake was approximately the same for both normal cartilage and the tissue which was derived from the perichondrial flap. Both tis­ sues contained papain resistant material which was precipi­ table by CPC (cetylpyridinium chloride) , demonstrating the presence of polysaccharides. The macromolecular characteristics were also identical when tested by gel chromatography . Control areas, where cartilage and covering perichondrium were com­ pletely removed did not take up any radiosulphate. Thus, biopsies taken from regenerated cartilage showed that the newly formed tissue synthesizes a substance which with regard to its chemistry and macromolecular composition seems to be identical with chondroitin sulphate.

292

II. Growth of cartilage from free perichondrial grafts Having established the chondrogenic potential of the peri­ chondrium of the preceeding experiments , it was then necessary to further elucidate the involved mechanisms and to better de­ fine the limitations and possibilities of utilizing this tissue for reconstructive purposes.

Experiment 5

The first study programmed along these lines was an outgrowth of utilizing the long perichondrial flap. In the previous work the raised flaps were based on rather precarious and tenuously suf­ ficient pedicles. This indicated that free grafts might thrive equally as well. A study was thus devised to further test the perichondrium by removing it from its original blood supply and transferring it as a free graft (Sohn et al. 1974). The trachea was chosen at the recipient site for the graft, because tracheal reconstruction has been a vexing clinical problem and many dif­ ferent material sources have been tried to rebuild stenotic and gaping defects. As cartilage is the normal supporting matrix of that structure , it would be an obvious advantage to be able to position perichondrium over a defect and obtain new cartilage. A two-thirds resection of two cartilaginous rings was carried out in two different areas, separated by three to six tracheal rings. Care was taken to preserve, intact, the mucous membrane lin­ ing of the trachea. If a puncture was inadvertantly made, the site was closed and a new area was chosen. A coating of blood was allowed to collect and partially fill the defect. After taking the perichondrial graft from the ear in the usual manner, it was immediately transferred and secured to the more superior defect. The second gap was left undisturbed, to serve as a control.

Results

Two to ten weeks after surgery, the results conclusively showed that new cartilage had developed where the grafts had been positioned. In contrast, in the control areas there was no growth of cartilage, where the defect was occupied by non-specific granulation tissue. The developing segments were irregular, and more cellular than the neighboring tracheal cartilage (Fig. 5). When compared to the normal hyaline cartilage of the trachea the new cartilage cells had less developed lacunae and were not as compartmen­ talized as the mature, original chondrocytes. As with the spec i­

293

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5 A longitudinal section through an experimental trachea demonstrates the de· velopment of new cartilage four weeks after a free peri· chondrial graft was positioned. The regenerated cartilage is paler and broader than the ad­ jacent, original cartilages . (Hematoxylin and eosin. x 45.)

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mens obtained in earlier experiments using perichondrial flaps of the ear, the cartilage that was generated across the trachea did not possess dark elastic fibrils, though a lighter elastoid pattern could be discerned. This suggested that the regenerated cartilage more closely resembled its aural precursor.

l

The new cartilage was found to be completely enclosed in peri­

chondrium. The exterior part. representing the original peri­ chondrium, was definitely thicker than the original perichondrium , whereas the newly formed perichondrium covering the remain ­ der of the growing cartilage was of a normal, thin appearance.

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The tracheal lumens were of normal caliber throughout and there was no evidence of any collapse or significant narrowing that might have compromised respiration. During the course of the experiment the tracheal size increased considerably. Despite this marked change no stricture occurred , which may indi cate that the new cartilage grew commensurately with the rest of the rabbit.

Experiment 6

294

The possibility of using free perichondrial grafts in other parts of the body were also studied (Ohlsen et al 1974). Molds of mesh wire were then utilized as a scaffol d on which the peri­ chondrium was draped. The rolled wire surfaces with the at­ tached perichondrium, sometimes with active surface facing in­ wards sometimes with the order reversed, were then placed in various parts of the rabbit body. These mesh molds were placed in the omentum , the li ve r, and the neck area. Cartilage was generated from them in all instances, though not in large amounts .

III. Pathogenesis of cauliflower ear

A review of the literature fails to give a clear account of the mechanism of the cauliflower ear Kelleher et al. (1967) felt that the traumatic event that caused the ear deformity was the shearing of a thin layer of cartilage along with the perichondrium and the subseq uent development of a serous collection be­ tween this very thin layer of cartilage and the remaining surface . Microscopic studies were used to corroborate their hypothesis. The specimens were taken from clinical cases examined a few days after the initiating traumatic event. This delay is the im­ portant factor in evaluating the study. In the light of our previous research it seems more likely that the perichondrium alone had been sheared away with the anterior skin surface, and in the time interval between the insult and the analysis, new cartilage cells had begun to proliferate. Thus, when examined under the microscope some three days later, it appeared that a layer of ca rtilage had been stripped away with the perichondrium, while actually this was an actively proliferating layer arising from the perichondrium itself. That the cartilage was sheared away is un­ likely because of mechani cal limitations and secondly because it would mean that the new cartilage must develop from the old layer of cartilage which has previously been shown to be a very slow if nonexistent precursor of new ca rtilage. Converse (1964) localized the patholog y to the anterior ear surfa ce because the skin here is firmly adherent to the perichondrium and co n­ sequently, when trauma occurred the perichondrium was rip­ ped away from the cartilage by this shearing force. In his opinion, the new tissue that developed was not new ca rtilage , but merely nonspecific granulation tissue.

Experiment 7

Appreciating that there was an incomplete understanding of the pathogenesis of cau liflower ears an experimental study was designed to demonstrate the pathophysiology of this deform ­ ity (Ohlsen, Skoog and Sohn 1974) . In one ear, a co llection of blood was placed under the raised peri cho ndrium which was then sutured back in place and the skin closed . In the other ear, an equal amount of blood was deposited between the intact perichondrium and the skin .

Results

In the first study, new cartilage developed under the perichon­ drium, but in the ear in which the blood was left above the sur­ fa ce of the cartilage covered by the perichondrium complete resorption of the clo t occurred (Figs. 6-7). The cauliflower ear was thus shown to be mushrooming ca rtilage, arising from a

295

i

6 This section of a rabbit ear was made 4 days aher an experimentally created hematoma in the subcutaneous tissue layer. The collection of blood is seen adjacent to the undisturbed peri­ chondrium. (Hematoxylin and eosin , x45.)

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7 After 14 days, the subcutaneous hematoma is largely absorbed without causing any rea ction in the underlying perichondriu m and cartilage. There is still a slight thickening of the ear ; in another week the anatomy was fully restored . (Hematoxylin and eosin , x15.)

..

layer of raised perichondrium which was further stimulated by a sero-sanguinous medium. The subperichondrial hematoma was extensively invaded by chondroblasts within two weeks, and over a period of four weeks the new tissue gradually changed into more mature cartilage (Figs. 8-11) . It was a consistant finding that the separated perichondrium retracted to form a flat surface, which caused the original cartilage to raise and buckle over the hematoma. Similarly to what is observed in human pathology. Based on this instructive series of experiments successful methods for treating cauliflower ears have been developed .

•

Conclusions

This series of experiments have demonstrated the perichon­ drium to be an active, adaptable and malleable tissue which has promising possibilities in reconstructive surgery. Clinically , the work has so far led to the technique of perichondrial oto­ plasty for correction of protruding ears, as described in Chapter XI. This potent tissue may prove to be a valuable asset in sol v ­ ing structural enigmas in the ear and in other parts of the body.

296

•

Two weeks

8-9 Two weeks prior to collecting this specimen, a subperichondrial hematoma w as placed on the front of a young rabbit 's ear . There has been a massive migra­ ti on of cells into this medium. Cha racteristically, the covering ear cartilage is rai sed and thinned , whereas the bordering, straightened perichondrium has thickened . The higher-power view of the newly developed t issue indicates the impending formation of ca rtilage in the aggregation of mesen chyme-like ce lls . (Hematoxy lin and eosin , x 15 and x 40.j

Four weeks

10- 11 At 4 weeks, the tissue developing with in a subperichondrial hematoma presents the characteri stics of young cartilage. Along the border of the original cart il age, residuals of the imp lanted h em atoma are still present, now trans­ formed into islands of vascularized, non­ specific connective ti ssue.

At greater magnifi ca ti on the newly formed tissue revea ls marked histo logi c changes in two weeks. The cells have proliferated and become rounded , a car­ tilage matrix has form ed separating the cells from each other demonstrating the fibrillar structure o f ear cartilage. (Hematoxylin and eosin , x 40 and x 130.)

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References

Converse J. M.: Acquired deformities of the auricle. Reconstructive Plastic Surgery. Ed. J. M . Converse, Saunders, Philadelphia , 1964, vol III , P 1107. Kelleher J . C., Sullivan J . G., Baibak G. J. and Dean R. K .: The wrestler's ear. Plast Reconstr Surg 40: 540,1967. Kruger E.: Die Knorpeltransplantation. Carl Hanser Verlag , M unchen, 1964. Ohlsen l. and Sohn S. A.: The chondrogenic potential of free peri­ chondrial grafts. Experiments in rabbits. (To be published in 1974.) Ohlsen l., Skoog T . and Sohn S. A. : The pathogenesis of cauliflower ear. Experiments in rabbits. (To be published in 1974.) Peer l.: Transplantation of Tissues II. Williams & Wilkins Comp, Baltimore, 1955. Peer l. , Walia I. and Bernhard W.: Further studies on the growth of rabbit ear carti lag e grafts. Brit J Plast Surg 79: 105, 1966. Skoog T., Ohlsen l. and Sohn S. A.: Perichondrial potential for car­ tilaginous regeneration . Scand J Plast Reconstr Surg 6: 123, 1972. Skoog T., Ohlsen l. and Sohn S. A.: The chondrogenic potential of the perichondrium. (To be published in 1974.) Sohn S. A. and Ohlsen L.: Growth of cartilage from a free peri­ chondrial graft placed across a defect in a rabbit's trachea. Plast Reconstr Surg 53 : 55, 1974. Walia I., Peer L. A., Bernhard W. G. and Gordon H. W .: Does growtn occur in young rabbit ear cartilage grafts transplanted in young rab­ bits 7 Plast Reconstr Surg 29: 259, 1962. Wasteson, A., Ohlsen L. and Sohn S. A .: Biosynthesis of chondroitin sulphate from perichondrial flaps. (To be published in 1974.)

•

298 •

Chapter XIII

Face-lift operation -

advancing the skin, subcutaneous tissues,

the buccal fascia and cutaneous muscles in a two-layer shift Introduction 302 General considerations 305 Su rgical procedure

Anatomy

Anesthesia

Operative procedure 308 Supplem enta ry intravenous anesthesia

Nerve block

Incisions

Dissection of the temporal and lateral cheek areas

Advancement of the superficial fascia over the buccinator area

Dissection of the postauricular area and neck

Advancem ent of th e platysma

Adjustment of the orbicularis oculi

Advancement of the superficial fascia of the cheek

Advancement and excision of redundant skin

Dressings

Result

Comments 324 Bleeding

Nerve lesions

Postoperative care

Healing

Advantages of a two-layer shift 326

Forehead wrinkles References 330

300

The Aging Face

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A method of correction

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Introduction

Self-love, my liege, is not so vile a sin As self-neglecting William Shake speare : Henry V (1598)

The Quixotic wanderings of Ponce de Leon epitomize man's endless quest for youth. With magical incantations , secret potions, and a vast array of ineffective devices, men have vainly sought to halt the relentless windmills of time. Nowhere is the harsh reality of aging more expressive than in the weathered and wrinkled face. Crossed with the tireless passage of deepening creases, the drooping folds and lax, overhanging skin pouch into sagging bags and unsightly jowels. The ev en contour of the youthful chin disappears, and the smooth tex­ tured surface turns to pleated parchment. Through each passing year, the furrowed profile remains unaided by a myriad of misleading panaceas. Only in plastic surgery is there a pragmatic alternative to the frustrating inevitability of aging. The face-lift operation has recently gained wide-spread accept­ ance by the lay popUlation and the medical profession at large. As in other aspe cts of plastic surgery, there has been a con­ tinuing search to improve techniques and achieve better and more lasting results , but surgical methods have remained basi­ cally unchanged and fairly routine. All the operations com­ monly employed share two principal features : (1) in under­ mining, the dissection is carried out almost exclusively within the subcutaneous tissue layer, close to the dermis, and always external to the superficial fascia and the platysma; and (2) in closure, tension is placed mainly on the skin (Hollander 1957, Gonzalez-Ulloa 1962, Pickrell 1967, Spira et al. 1967, Conley 1968, and others).

This fails to consider an important relationship in the aging face, for as Conley cogently recognizes, "The absorptive and atrophic changes in the skin are three dimensional; with relaxation of these soft contractile elements and their supportive structures. These deeper anatomic struc­ tures are in reality the foundation and architecture of the integu­ ment, and by deterioration in their position would automatically be reflected in facial form and expression. "

Yet, in spite of these studied remarks, in Conley's approach, as in the majority of methods, nothing is done to readjust or re­ position the deeper structures . Recently (1972) Pennisi and Capozzi recommended that the layer of fat, that lies beneath the skin flap, be separately suspended, but again this was done without undermining or other surgical interference. For a simi­ 302

The Aging Face

lar purpose, Aufricht (1960) plicated the subcutaneous tissues. The fascia and the facial mus culature, however, have thus far been essentially abandoned. In the face , as in the rest of the body, the skin and the sub­ cutaneous fat are intimately related to each other and form a compound morphological entity, enclosed by the superficial fas cia. An analysis of the mechanics of aging makes it apparent that the two interconnected layers will shih together and are equally responsible for the sagging fa ce, while the displaced cutaneous muscles, the platysma and the orbicularis oculi , produ ce wrinkling and folding . When these basic anatomical changes are ignored and the surgical correction concerns itself with the skin alone, the result is compromised . To remedy this fundamental error, a technique has been devel­ oped which is in part founded on a new set of principles. In addition to tightening and excising superfluous skin, the sub­ cutaneous fat layer with its fascia, as well as the cutaneous muscles of the neck and face, are repositioned (Skoog 1969, 1972, 1973).

303

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1 This illustration depicts the subcutaneous anatomy of the face and neck pert inent to the described technique for face-lifting .

304

General considerations

Surgical procedure

The bi-pronged hallmark of this operation is: (1) the mobiliza­ tion of skin and subcutaneous tissues at a level deep to the subcutaneous fascia of the cheek and to the platysma , and (2) a readjustment of redundant skin by a two-layer shift. advancing the cutaneous and fascial-muscle layers separately. This tech­ nique is based on certain distinguishing features of facial anat ­ omy.

Anatomy

On its external aspect, the platysma is intimately associated with the skin and subcutaneous tissue of the entire anterior neck . The under surface of the muscle, however, is not fixed to the deeper structures , and a potential space is present between the smooth fascia of the platysma and the external cervical fascia. This anatomical configuration allows the superficial layers to glide with the platysma over the deeper, fixed struc­ tures. Thus, the platysma provides a corner-stone for rearrang­ ing superficial neck tissues. Traction on the muscle redistributes the cutaneous .Iayers in a smooth, even plane. The span of the platysma varies with individuals, but generally a comparable advancement procedure can be performed in the mandibular area . In the face, the fascial architecture is another reference point for reconstruction. In the temporal , preauricular and particular­ ly in the parotid area, the facial , or deep, fascia is distinctly defined, covering major nerves and vessels which pass closely underneath. In these areas the superficial, or subcutaneous , fascia is fixed to the dense, deep fascia by fibrous adhesions. At the anterior border of the masseter muscle this close ana­ tomical relationship ceases. Anteriorly. over the expansile buc­ cinator. an areolar space exists just beneath the subcutaneous fascia, extending as far as the nasolabial fold. In dissection, when this cleavage plane is entered, the covering skin and the subcutaneous fat with its smooth fascial lining are easily raised en bloc. superficial to the fatty ball of Bichat, the suctorial pad. This lobulated mass of fat varies in size but is a constant finding , even in the thin and elderly . It covers the parotid duct and the facial nerves and vessels on the external surface of the buc­ cinator. As a result of this arrangement of the fascial framework , redundant skin and subcutaneous fat in the buccal area droops and bulges at the nasolabial fold, and conversely, lateral ad­

305

vancement of the superficial fascia (buccal fasci a) within this area effectivel y takes up any slack at the angle of the mouth and softens the pronounced nasolabial fold . To eliminate troublesome wrinkles situated at the late ra l canthus of the eye, the orbicularis oculi muscle may also be separately rearranged .

Anesthesia

Local anesthesia with a vasoconstrictive agent is preferred in all cases. There is a significant reduction in bleeding when compared to conditions under general anesthesia , even when supplemented by local infiltration. Fu rthe rmore , local anes ­ thesia eliminates the need for endotrache al equipment . T his facilitates draping and positioning the pa tie nt, while simulta­ neously reducing the possibility of operative field contamina ­ tion. The many hazard s associated with intubation are also avoided , and the recovery phase is quicker and easier. Adequate analgesia for this large operati v e field often requires the administration of an amount of anesthetic that approaches the maximum permissable dosage . Systemic reactions, m ani ­ fested by a rise in blood pressure and pul se are common. These side effects, in part caused by the va soconstrictor ag ent, can be reduced by employing regional block anesthesia w hich anesthetizes the area innervated by the infraorbital and man­ dibular nerves as well as the superficial cervical plexus . The immediate tract to be incised is infiltrated locally. This tech ­ nique has reduced the required anesthetic by about half; 1 per cent lidocaine (Xyl o caine ®) with epinephrine is used for the nerve block, and 0.5 per cent lidocaine with epinephrine for local infiltration along the lines of incision. Operative analgesia is established in five minutes and has a duration of three hours . In the block procedures, care must be taken to position the needle accuratel y . As the patient is asleep during the injection and paresthesiae cannot be confirmed, the surgeon must be completely familiar with the technique. Regional block anesthesia is superior to local infiltration as it does not obscure the anatomy with massive amounts of fluid . The lift can be more effecti vely and accurately executed when skin and subcutaneous tissues are undistorted. Furthermore, any change in facial nerve function can be detected during the operation, and pain and swelling are less in the post-operative period.

306

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The Aging Face

1

The patient is placed under intravenous general anesthesia while the block is performed to obviate the pain associated with repeated injections, and thus limit the psychomotor re­ sponse. Thiopental (Pentothal @) is preferred as it induces a short light sleep, and will often keep the patient sedated for a considerable part of the operation. Should there be discomfort during certain operative manipulations, the block may be tem­ porarily augmented by additional administration of Pentothal or any other desired anesthetic. When analgesia is inadequate, one should not hesitate to repeat the block . No complications have occurred with this biphasic technique, which has been used for many ye ars.' It has proved most satisfactory for pa­ tient and surgeon alike. It does require restriction of oral intake for at least six hours prior to surgery. If the entire procedure is expected to last for more than three hours, the operation is completed on one side before the other side is anesthetized. Again, the regional block is repeated under intravenous anesthesia. Even with nerve block anesthesia blood loss is insignificant. This surprising finding is basically a result of using an ana­ tomic plane of dissection, but in a large measure the physical and mental relaxation afforded by systemic sedation contribute to this diminished blood loss. In an analogous setting Webster (1972), Dingman (1972), and others co nfirmed this observation. They reported minimal bleeding when local anesthesia was supplemented by a combination of sedatives and tranquilizers.

I The technique has been developed in cooperation with Dr . S6ren Englesson, Associate Professo r, Department o f Anesthes ia, University Ho sp ilal , Uppsala , Sweden.

307

Operative procedure

2 In this procedure, the subcutaneous fascia within the buccinator area and the platys ma are identified at their lateral borders . These struc­ tures are freed on their deep surfaces and ad­ vanced in a postero-superior direction . The or­ bicularis o cu li may also be exposed and re­ arranged in the lateral canthal region. The limited area of sharp undermining is in­ dicated in yellow-green , while with in the blue space, mobilization can be accomplished by blunt dissection.

Supplementary general anesthesia

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3 The patient is placed in the recumbent posi­ tion on the operating table. The face is prepared for surgery and draped with self-adhering trans­ parent plasti c sheets 1 Under intravenous gen­ eral anesthesia , a regional nerv e block is ad ­ ministered . The surgical assistant must be pre­ pared to prop up the lower jaw if any sign of obstruction develops. An intravenou s ca nnula is maintained through­ out the operati ve procedure so that if needed, additional anesthesia or se dation may be given. The patient is carefully observed during surgery by monitoring pulse , blood pressure and heart fun cti o n by ECG when indi cated .

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308

Nerve block

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4 Infraorbita l nerve block. The infraorbital fora­ men is located just below the infraorbital margin and about two cm from the lateral surface of the nose . Approximately 2 ml of 1 per cent Xylocaine® (lidocaine) with epinephrine is in­ jected around the nerve as it leaves the foramen .

5 Mandibular nerve block. In this technique an external route is recommended (Moore 1967). The puncture site lies just below the zygomatic arch, ove rlying the middle of the mandibular notch. At this point, approximatel y 1.5 cm in front of the tragus of the ear, a 5 cm 22 gauge needle is in serted at an angle perpendicular to the skin. At a depth of about 4 cm, the needle pOint usually meets the lateral pterygoid plate. The mandibular nerve is found just posterior to this bone. The needle tip is theref ore redirected posteriorly until it no longer co ntacts bone. In this area about 4 ml of 1 per cent Xyloca ine" with epinephrine is injected, but before infiltrat­ ing it is important to aspirate for blood so as not to inad vertantly give an intravascular bolus of anesthetic.

309

6 Superficial cervical plexus block. The superficial branches of the cervical plexus emerge behind the middle of the sternocleidomastoid muscle, along its posterio r margin. This area is similarly injected subcutaneously and subfascially with approximately 4 ml of 1 per cent Xylocaine® solution with epin ephrine, using a 22 -gauge needle. In addition to the nerve blocks, the area to be incised is infiltrated to ensure hemostasis. Approximately 10 ml of 0.5 per cent Xylocaine'" with epinephrine is injected bilat­ era lly. 7 The areas of skin anesthesia produced by nerve b locks correspond to the regions supplied by the infraorbital nerve, the mandibular nerve and the superficial cervical plexus.

310

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Infraorbital nerve

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Mandibular nerve

Cervical plexus

Incisions

8 The incision begins superiorly, appro ximately 2 cm within the frontoparietal area of the scalp, and angulates in an inferolateral dire ction to the preauri cu lar area. Inf erior ly it courses around the lobule of the ear and follow s the postauricular f old to the level of th e tragus whe re it angles posteroinferiorly, just w ith in the hairline, for a distance of about 4 cm. Initially, to hide the scar line, the preauricular incision was curved into the auditory canal. This , however, often even­ tually distorted the tragus w hich wa s far more object ion­ able than the in consp icuou s scar now obta ined . It also ob­ scured the delicate stru ctures of the tragus under the thicker skin advanced from the cheek. Some patients may object to a postauricula r scar pla ced beside the hairline . To av oid thi s the posterior in cisio n can be moved into the scalp region as was once suggested by M cindoe . As a result the hairline will be raised in this area . In men the temporal incision is usuall y made in front of the hairline . In time, it becomes possible to estimate the extent of tem­ pora l skin reduction . Starting 1 to 1.5 cm behind the tem­ poral hairline, the hair is cut close to the sca lp to coincide with the area to be rese cted . Th ere is no need fo r further hair removal, as the stra nds can easily be retra cted away from the operative field with ad hesive drapes .

311

Dissection of the temporal and lateral cheek areas

9 Dissection is begun in the frontoparietal area, in the loose areolar plane, superficial to the temporalis fascia and the temporal vessels . In developing this part of the flap, blunt dissection can be used anteri ­ orly to avoid damage to the frontal branches of the facial nerve. The degree of temporal undermining required for raising the eyebrow and for correcting the lateral canthal region depends on subcutaneous tissue mobility and is estimated prior to surgery .

10 Cheek undermining is begun with the scalpel and completed with a pair of scissors. Block anesthesia facilitates the dissection between the thin fascial under­ covering of the subcutaneous tissue layer and the deep fascia of the face , which is left undisturbed over the wound surface . A vascular network behind each fascial sheet is easily visible.

11 Comparatively few vessels pass between these two systems and any vascular communication can be separated and controlled without difficulty . The forceps point to a pair of connecting vessels. Char­ acteristically in this area an artery and vein run close together; when cut, both ends must be secured.

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Over the parotid fascia the subcutaneous tissue ad­ hesions are firmer and in the zygomatic area there are also rather tight attachments to the underlying bone.

A dvancement of the superficial fascia over the buccinator area

12 At the I~vel of the anterior border of the masseter muscle the anatomical plane of dissection changes abruptly. In front of this line, the tissue layers can be easily separated by cautiously spreading the scissors. In this manner, the instrument can be advanced to the nasolabial fold without effort. In the roof of this space, the clearly defined superficial fascia (b uccal fascia) bordering the subcutaneous fat layer, displays a char­ acteristically smooth surface. On the floor of the cavity, the buccal fat pad of Bichat protrudes, and is here shown between the scissor blades . Depending on the size of this well-defined mass of fat, the parotid duct, branches of the fifth and seventh cranial nerves and a few vessels may be visible. Exposure is readily completed without injuring the se vital structures, which are all transversely arranged. Frequently an intersecting vessel guards the entrance to this space and must be divided and ligated. (See Fig 1, P 304.)

13 The scissors have been introduced into the bucca l space and advanced by blunt dissection as far as the nasolabial fold. Here they meet resistance, as in front of this line the skin is firmly adherent to underlying muscle.

313

14-15 At this stage, shifting the subcuta­ neous fascia in the buc­ cinator area can be de­ monstrated. In the photo­ graph the lateral edge of the fascia is grasped with two pairs of forceps. The drawing shows the re­ lation of the fascia to overlying redundant sub­ cutaneous tissue and the masseter muscle. No traction has yet been applied .

-Buccal fas cIa Fat pad of aichat

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Masseter

16-17 Gently pulling the superficia l fascia backwards markedly redistributes the overly­ ing tissues and is partic­ ularly useful in correc ting the sagging cheek and the depressed nasolabial fold. An excess of skin and fat at the angle of the mouth can now be effectively eliminated . The extent of advance­ ment is usually about two cm . Overcorrection is possible .

The advanced fascia is fixed to the masseteric fascia by 3/0 Supramid' and 3/0 Dexon' sutu res. I

314

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Dissection of the postauri cular area and neck 18 In the postauricular area the superficial fascia is

rarely well-defined . It can be identified, however, when the skin is raised by sharp dissection, close to the mastoid fascia. Care is exercised to prevent damage to the sensory nerves that course im­ mediately beneath this fascia. The vascular plexus of the flap is also protected as shown here by staying in the correct plane of dissection .

19 Cervical skin dissection stops at the upper an­ terior margin of the sterno cleidomasto id muscle , where it is crossed by the platysma . At this level , the lateral edge of the platysma is identified and freed , starting at least 1 cm inferior to the mandible and con tinuing for approximately 3 cm. Here this dissection is performed just in front of the greater auri cu lar nerve.

20 In front of the sternocleidomastoid muscle, the dissection moves anteriorly for a few cm on the underside of the platysma , in co ntrast to the usual outer surface approach . On the inner aspect of the platysma the undermining is facilitated by using the anatomical cleavage plane, which lends itself to blunt dissection. The mandibular branch of the facial nerve is protected by proceeding bluntly and staying below the level of the mandible. The edge of the platysma is elevated , demonstrating the natural space deep to it. The tip of the scissors lies between the external jugular vein and the greater auricular nerve .

21 After sufficient mobilization , traction at the edge

pulls the entire platysma in a posterosuperior direc­ tion , producing a remarkable effect on redundant neck tissues. No further undermining is necessary to improve midline contour.

315

Advancement of the platysma

22-23 The edge of the platysma with its accompanying fascia is sutured to the mastoid fascia, level with and posterior to the ear lobe . The platysma should now be stretched tightly . The interconnecting ar­ rangements of the subcutaneous and cuta­ neous layers evenly dist ri bute this tension to the midline, thus permitting realignment of the integument of the entire neck. Over­ correction is possible and may temporarily produce an unpleasant feeling of tig htn ess over the larynx. The edge of the platysma is gene rall y advanced 2 to 3 em. N on­ abso rbable sutures are used for fi xat ion, ca re being taken not to include the sensory nerves in the sutures. For this reason, the needle should pass vertically through the mastoid fascia.

24 After suturing of the platysma, there is little area in the postauricular region left exposed . The anterior border of this small defect now als o represe nts the extent of effective subcutaneous undermining . This significant advancement has been made without applying direct traction to th e skin itself.

316

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25-26 In some individuals , a similar procedure can be car­ ried out at the inferior aspect of the cheek . Here, the range of the platysma varies and, when present, the muscle often does not hav e a clearly defined deep fascial surface. A more entailed dissection is thus required at the border. Traction on the facial platysma is less dramatic than in the neck, but it will effect a marked improvement in the man­ dibular contour. As is demonstrated in the second suture, the tissues can generally be advanced by approximately 2 cm. When the muscle is thin or absent the superficial fascia is included in the sutures. In all subcutaneous closure, 3/0 Dexon is used .

Adjustment of the orbicularis oculi 27 The lateral border of the orbicularis oculi is ex­

posed and held by for­ ceps. To smooth overlying skin and prevent excessive

wrinkling at the lateral canthus, the mus cle may be splayed out and sutured in this spread position. The or­ bicularis oculi may even be split laterally and the cut ends separated , without dis­ turbing eyelid fun ction. If correction of the eyelids is deemed necessary, this can be executed as a sep­ arate maneu ver, either at the beginning of the face­ lift operation or at a later stage. In conjunction with blepharoplasty, crawsfoot wrinkles may also be eliminated by local resection of the orbicularis muscle .

317

Advancement of the superficial fascia of the cheek 28 In the cheek area the full thickness of the flap is shifted in a posterosuperior direction and stabilized with a few interrupted Dexon sutures, placed between the subcutaneous fascia and the facial fascia covering the deep wound surface . Dead-space is thereby obliterated and tension on the preauricular suture line is also reduced by these support­ ing sutures . The effect of this fascial shift depends on the mobility between the skin and the re­ lated subcutaneous fascia. In most patients, the fibrous connecting bands are sufficient­ ly loose so that tightening the fascia does not restrict skin advancement. When the skin is lined with a heavy and distended adipose layer, tension applied to its fascia may not be fully transferred to the super­ ficial layers. Relaxing incisions through the fascia into the subcutaneous tissue will allow for an evenly extended shift across the entire face. Similarly, fibrous septa between the skin and its deeper layers may prevent the skin from being completely stretched. These connections should be identified and severed at this stage.

318

29 The major skin redundancy has been eliminated by merely shifting the deep tissue la yers . Tension has thus far only been applied to the platysma and the fasciae ; the skin and the subcutaneous fat have been almost fully advan ced w ithout interfering with the vascular supp ly to the flaps.

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Advancement an d excision of redun dant skin 30 The ski n i s now advanced to th e desi red tautness , and the overlapping ed ge is in cised at th ree se lected points, up to the excisional margin. A key tension su ture i s secured at each of these points . The first and m ost im portant stit ch is placed above the ear, at the anterior crus of the helix. T he second is positioned higher up in the temporal ·regi o n , and the third point is si tuated p os teriorly, at the peak of the postauricular incision. Thi s last suture is dem o n strat ed in a sub­ sequ ent photograph . Betwee n these sutures the un­ necessary skin is excised in a line para ll el with the adjacent skin edge. In the temporal area , excess scalp is removed in such a way that suturing the anterior, h air-bearing tem­ p o ral flap redi stributes the ten sion between the key sutures. In th is area 3 / 0 catgut ' is used . Thi s sub stance will produce no more scarring than nonabsorbable material , and it has the added advantage of disso lv­ ing in about o ne wee k.

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320

In tighten ing the skin, and drawing it upwards and backwards, a pu cke ring wil l generally become evident at the t op of the incision . Thi s triangular r ed undancy is transve rsely exci sed .

31 In correcting the neck area , t he skin is dra w n in the direction of the postauricula r f old . In this p arti c­ ular case, the flap e: