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Multisutural syndromic synostosis

Synopsis ■ Patients with syndromic synostosis require protocolized treatment coordination from a multidisciplinary craniofacial team. ■ Treatment of cephalocranial disproportion requires early and sequential surgical intervention. ■ All protocols include monitoring for obstructive airway disease and hydrocephalus. ■ Sequential surgical treatment can be tailored to the presenting craniofacial dysmorphology. Introduction Premature fusion of the cranial sutures can occur in isolation or may occur along with consistent…

Nonsyndromic craniosynostosis

Synopsis ■ Patients with nonsyndromic craniosynostosis are at increased risk for developing subtle neurocognitive deficits, which may or may not, be altered through surgical intervention ■ The goals of cranial vault reconstruction include to optimize cerebral blood flow via expansion of intracranial volume and to improve the head shape ■ Reconstruction is an age-dependent approach with early diagnosis simplifying and directing operative management ■ Surgical timing…

Craniosynostosis: introduction

Introduction For those specializing in pediatric conditions, assessment of infants and children with abnormal head shapes is a common practice. Enhanced awareness through the use of social media and access to the internet has created a generation of informed parents that has resulted in an unprecedented level of advocacy. The diagnosis of an overt condition such as a cleft lip is immediate and abrupt but the…

Craniofacial clefts

Synopsis ■ Congenital craniofacial clefts are abnormal disfigurements of the face and cranium occurring in a variety of patterns and varying degrees of severity. ■ Craniofacial clefts are thought to occur spontaneously, except for syndromes with clefting combinations (numbers 6, 7, and 8), like Treacher Collins syndrome or hemifacial microsomia. ■ If normal embryologic neuroectoderm migration and penetration do not occur, the epithelium breaks down to…

Orbital hypertelorism

Synopsis ■ Hypertelorism is not a disease in itself; it is just a symptom which may belong to various conditions. ■ It is mainly present in facial clefts but may accompany faciocraniosynostosis, where craniosynostosis has to be corrected independently before 1 year of age. ■ In mild forms such as familial brachycephaly associated with Muenke mutations, it is rarely treated, and the bicoronal synostosis is treated…

Pediatric facial fractures

Synopsis ■ Traumas that would likely produce fractures in adults often do not in children due to intrinsic anatomical factors. ■ In addition to the unique anatomy of the pediatric patient, future growth and development must be accounted for when addressing these injuries. ■ In deciding between operative and nonoperative management of pediatric facial fractures, the practitioner is essentially weighing the risk of growth disturbance against…

Cleft and craniofacial orthognathic surgery

Synopsis ■ The goal of orthognathic surgery is to establish ideal dental occlusion with the jaws in a position that optimizes facial form and function ■ The Le Fort I osteotomy, bilateral mandibular sagittal split osteotomy, and osseous genioplasty are mainstay surgical techniques which can produce skeletal movements to optimize occlusion and aesthetic appearance ■ Dentofacial deformities or skeletal dysplasias of the jaws affect about 20%…

Secondary deformities of the cleft lip, nose, and palate

Access video content for this chapter online at Elsevier eBooks+ Introduction Identifying and treating secondary cleft lip and palate deformities is a challenging endeavor for even the most experienced surgeon. Proper diagnosis involves an understanding of previous operations as well as a thorough physical examination. Surgical timing depends on deformity severity, age of patient, and understanding and willingness of family members. Examination and evaluation Children born…

Velopharyngeal dysfunction

Synopsis ■ Individuals with known or suspected velopharyngeal dysfunction (VPD) are best treated in the context of an interdisciplinary cleft/craniofacial team. ■ Diagnosis of VPD requires obtaining a comprehensive patient history, perceptual speech evaluation, physical examination, and appropriate instrumental and imaging studies. ■ Successful surgical management of VPD requires precision in diagnosis and individualization of treatment. ■ VPD may be the result of velopharyngeal insufficiency, velopharyngeal…

Orthodontics in cleft lip and palate management

Synopsis ■ Patients with orofacial clefts (OFC) are best treated through a team approach. ■ Close collaboration between the orthodontist and surgeon is critical during the care of patients with OFC. ■ A developmental approach needs to be undertaken by orthodontists treating patients with OFC. ■ In infancy the orthodontist can support the surgeon with nasoalveolar molding and maxillary orthopedics. ■ In the primary dentition stage…

Alveolar clefts

Synopsis ■ There is still much debate regarding the optimal treatment for alveolar reconstruction in cleft care. ■ Current treatment protocols differ regarding timing of repair, graft material, and surgical technique. ■ Secondary alveolar autogenous bone grafting remains the standard of care. ■ Pioneering research has demonstrated that use of alternative treatments and osteoinductive graft adjuncts can provide similar results to autogenous bone graft; these initial…

Oral fistula closure

Access video content for this chapter online at Elsevier eBooks+ Introduction Cleft palate closure has evolved over the past several decades. Successful palatoplasty involves repair of the clefted mucosal layers and re-positioning and approximation of aberrant musculature of the palate. Outside of velopharyngeal insufficiency, repair dehiscence resulting in an oronasal fistula (ONF) remains an undesirable complication following primary cleft palate closure. Although ONF may occur at…

The buccal fat pad flap

Introduction Cleft palate repair poses challenges to the reconstructive surgeon that must be overcome to achieve a durable and functional closure. The paucity of available palatal tissue and the inability to recruit additional local tissue frequently demand the surgeon make certain compromises to reliably close the defect. In the hard palate, the lateral gutter(s) that are created from medial movement of the palatal flaps are commonly…

Buccal myomucosal flap palate repair

Access video lecture content for this chapter online at Elsevier eBooks+ In this chapter, we approach the use of buccal myomucosal flaps in great detail for what they are, a fundamental and core surgical procedure. They are incredibly useful, but are not the magic bullet we sometimes seek. The magic bullet of radical success comes not from any single procedure, but from the process of approaching…

Double opposing Z-palatoplasty

Access video content for this chapter online at Elsevier eBooks+ Introduction The double opposing Z-palatoplasty technique for soft palate repair was first presented in the United States by Leonard Furlow at the Southeastern Society of Plastic Surgeons Annual Meeting in 1978. Dr. Furlow pioneered the technique in his own plastic surgery practice at the University of Florida in 1976. At that time, the standard of care…

Straight line repair with intravelar veloplasty (IVVP)

Access video content for this chapter online at Elsevier eBooks+ Introduction The aim of cleft palate repair should be to produce the best possible speech and hearing outcomes but to minimize the detrimental effects of scarring on maxillary growth and function. Repair of the cleft palate requires an understanding of the normal cleft anatomy. The technique described in this chapter aims to correct the anteriorly orientated…

Cleft palate: introduction

Access video lecture content for this chapter online at Elsevier eBooks+ History and evolution of palatoplasty Cleft palate surgery has been refined over hundreds of years. Early cleft care simply focused on physically separating the oral cavity from the nasal cavity. In the thirteenth century, Jehan Yupperman, a Flemish surgeon, found that he could correct hypernasal speech of untreated cleft patients by plugging the palatal defects…

Repair of bilateral cleft lip

Synopsis ■ A child born with bilateral cleft lip should not have to suffer because of an ill-conceived and poorly executed primary repair. The operative principles for synchronous nasolabial repair are established: ■ Maintain symmetry ■ Secure primary muscular continuity ■ Design proper philtral size and shape ■ Construct median tubercle from lateral labial elements ■ Position/secure lower lateral cartilages and sculpt nasal tip and columella.…

Anatomic subunit approximation approach to unilateral cleft lip repair

Access video content for this chapter online at Elsevier eBooks+ Introduction Management of cleft lip requires a unique understanding of the various dimensions of care. The breadth of treatment spans multiple disciplines and the length of treatment spans infancy to adulthood. Although this chapter focuses on technical aspects of repair, treatment by a multidisciplinary team that can address all aspects of care is critical to ensuring…

Extended Mohler repair

Synopsis ■ Primary cleft lip and nasal repair seeks to achieve lasting symmetry to the lip and nose while camouflaging scars within the contours of the face. This surgery is often the first step in the larger treatment plan for cleft care, therefore the quality of the repair sets the direction of the function and appearance for the patient. As the surgeon should strive to affect…