General body growth in children with cleft palate and related disorders: age differences

Clefts of the lip and palate, separately or in combination, are among the most frequent congenital defects seen today. Their etiology is heterogeneous and may include hormonal factors, which suggest the possibility of growth effects. Whether affected children are smaller than others has not been determined. We recently showed that growth status is associated with type of cleft. We hypothesized genetic alterations in metabolic pathways that alter prenatal growth, producing clefts; some of these alterations also alter postnatal growth. Since the levels of growth-regulating hormones change during ontogeny, we expected age differences in the degree of growth deficit seen. To test this hypothesis, we examine here the cross-sectional means and distributions of standard deviation (z) scores for height and body mass indices (BMIs) for 144 children with the diagnoses unilateral cleft lip and palate (uCLP) and isolated cleft palate (iCP). We find that alteration in growth status is associated with age group as well as sex and diagnosis.

Simultaneous posterior pharyngeal flap and tonsillectomy

Posterior pharyngeal flap (PPF) construction in patients with hypertrophied tonsils raises a significant concern for adequate airway maintenance. Most often, tonsillectomy, as a separate procedure, is done first. The authors have preferred to do both the PPF and the tonsillectomy simultaneously. Twenty consecutive cases are reviewed retrospectively to determine whether this has increased morbidity. All patients underwent posterior pharyngeal flaps for correction of velopharyngeal incompetence (VPI). Postoperative fevers that resolved without specific treatment occurred in four patients. Three patients experienced postoperative bleeding problems, but only two were of tonsillar origin. No patient developed immediate airway obstruction, although a single patient was observed overnight in the intensive care unit. Another developed sleep apnea several months after the operation, which required that the posterior pharyngeal flap be taken down. This patient had an unusual amount of hypertrophic scar in the nasopharyngeal area, but not in the oropharynx. No other operative or postoperative complications were experienced. The average hospitalization was 4.2 days. It is concluded that simultaneous tonsillectomy and PPF construction may be performed safely in patients who need both procedures.

General body growth in children with clefts of the lip, palate, and craniofacial structure

This paper discusses general body growth in children with craniofacial clefts. Body growth is important in such patients because morphology reflects the cumulation of metabolism over time. The same hormones that direct general body growth also govern the ontogeny of the head and face. Body growth varies in children with different types of clefts. We found no average differences from US norms for those with isolated clefts of the lip alone or those with bilateral clefts of the lip and palate. Children with unilateral clefts of the lip and palate and with isolated cleft palate were significantly shorter than their unaffected peers. Males with these defects were also thinner than normal based on average standard deviation scores for body mass indices. Both unilateral and bilateral clefts of the lip and palate predominated in males, while isolated cleft lip was more frequent in females. Our results indicate that congenital metabolic variation contributes to the development of orofacial clefting and influences postnatal development in certain types of cleft. Accordingly, cleft type is important to growth prognosis, and growth status is relevant to optimization of therapy in orofacial cleft patients.

An effect of injury on thermoregulation in man

The effect of trauma on human thermoregulation has been studied using a behavioural test and the vascular response to cold exposure. It was confirmed, in controls, that a pleasurable temperature for the hand (Thand) depended on core temperature (Tc) to which it was negatively related. Shortly after moderately severe fractures in a leg this relationship was lost and in the patients the slope of this regression line was not significantly different from zero and they usually chose a Thand towards the upper end of the normal range irrespective of Tc. This effect was not imitated in controls by removing 500 ml blood but Thand was increased by occluding the circulation to one leg. Naloxone did not alter Thand in controls but when given in a suitable dose it reduced the rise in Thand during a short period of limb ischaemia. Immersing one hand and forearm in water at 17 degrees C reduced the blood flow through the contralateral forearm and hand. The reduction in flow was positively related to the initial rate of flow in both controls and injured but the slope of the regression line was significantly less after injury. It is concluded that thermoregulation is affected by trauma in man.

Experience with the Furlow double-reversing Z-plasty for cleft palate repair

One-hundred and six cases of soft palate closure using the Furlow double-reversing Z-plasty technique have been reported. Most of these patients have been done in the past 2 years. There seem to be a number of worthwhile advantages to this procedure, with few disadvantages or complications. The operation is adaptable for use in early soft palate closure (3 to 6 months) as well as late closure (12 to 14 months), in submucosal clefts, as well as in secondary palatal repair where lengthening and repositioning of the levator muscle is desired. With this type of palatoplasty, the need for raising or shifting large mucoperiosteal flaps from the hard palate has been completely avoided. The operation can be combined with a primary posterior pharyngeal flap if desired, although this is not advised if early palatal closure (3 to 6 months) is used because of a high incidence of sleep apnea. Preliminary speech results are very encouraging.

An improved fixation technique for the rhabdocoel turbellarian Mesostoma Ehrenberg 1835

Standard procedures employed to fix the rhabdocoel turbellarian of the genus Mesostoma Ehrenberg 1835, a widespread predator of mosquito larvae in central Alberta, caused considerable shrinkage of the body following an excessive secretion of mucus on its body surface. A new, simple, and highly satisfactory method involves the quick freezing of live specimens at a temperature of −6 to −9 °C in 70% ethanol with CO2 ice for about 2 min prior to fixation. Fixation by either AFA (alcohol–formaldehyde–acetic acid) or 10% Formalin for about 6 h at room temperature permits retention of the original body size and shape. Additionally, staining with either Harris' hematoxylin or Semichon's carmine enhances the contrast of internal organs.

The "SMAS sling": an additional fixation in face lift surgery

A pennant-shaped "SMAS sling" is developed from the preauricular SMAS, leaving it attached inferiorly between the level of the earlobe and the angle of the mandible. This is rotated posteriorly over the mastoid process, tension is applied, and it is secured with nonabsorbable sutures to the mastoid fascia, thereby providing a backward and upward lift to a very secure area. Minimal problems and complications occurred in 34 patients over the past four years.

The anesthetics of ear placement: an experimental study

The angle between the axis of the ear and the bridge of the nose was measured in 46 normal subjects as being 14.9 degrees. This was a statistically significant difference (p less than 0.00001) from being parallel--the orientation recommended in the literature for placement of a reconstructed ear. Observers asked to choose the most aesthetically pleasing ear orientation from a group of four possibilities overwhelmingly chose an orientation with the helix more anterior than the parallel one. Recommendations are given for placement of a reconstructed ear.

Levator muscle reconstruction: does it make a difference?

Eighty-five children from 6 to 8 months of age underwent palatal reconstruction between 1972 and 1978. Forty had palatal repair without levator reconstruction, and 45 had an intravelar veloplasty. Speech assessment was performed at 2 years after surgery. Any nasal escape or hypernasality, whether consistent or not, was included as abnormal speech. The data revealed that 70 percent (28 of 40) had abnormal speech when no muscle reconstruction was performed compared with 63 percent (24 of 45) after having had an intravelar veloplasty. We conclude that the added operative dissection adds no morbidity to the procedure and that the improved speech results probably justify performing an intravelar veloplasty when doing a palatal repair.

The fate of the below knee amputee

A retrospective study of 47 patients undergoing 51 below-knee amputations over a six year period on one unit is reported. An overall success rate of 84.4% was achieved and the factors influencing this are discussed. Diabetics had equally good results as those patients with peripheral arterial disease.

Cleft palate closure at 3 to 7 months of age: a preliminary report

The evolution and present criteria for early soft palate closure are reviewed. A definitive group of patients (operated on at 3 to 7 months of age) is reviewed at least 2 years following their surgery. They are compared with our general clinic population (operated on at 12 to 18 months of age) and had significantly fewer secondary operations for velopharyngeal incompetence. The possible advantages and disadvantages of early soft palate closure are discussed.

The effects of gastric hyperosmotic glucose feedings on regional perfusion in the neonatal piglet

Regional blood flow and intestinal wall perfusion were studied in 13 anesthetized 1-5 day old neonatal piglets before and after gastric glucose infusion. The radionuclide labeled microsphere technique was used with 15 +/- 3 mu microspheres (85Sr, 141Ce) given in two separate left atrial infections. The 10% glucose with a patent blue dye marker did not affect CO but produced significant increases in blood flow to the adrenals bilaterally, to all layers of the proximal small intestine and to the mucosa of the distal small intestine. The glucose also caused a significant reduction in the animals' arterial pH, PaO2, and total CO2 with an increase in the blood glucose level. This response to gastric glucose infusion is different from adult animals since lower glucose concentrations produced blood flow changes in all layers of the exposed small intestine and the adrenals in our neonatal animals.

Effect of age on diagnostic usefulness of stimulated plasma renin activity and saralasin test in detection of renovascular hypertension

The diagnostic usefulness of the timed intravenous pyelogram (IVP), isotopic renal flow study (renal flow), stimulated plasma renin activity (SPRA), saralasin infusion test, and renal vein renins (RVR) in detecting possible renal vascular hypertension was studied in relation to age. Among patients who had been off medication for 2 weeks and who had normal renal X-ray findings, the percentage of those with a high SPRA dropped from 22.3% in those aged 20-29 to 4.2% in those aged 60-69 years, and that in those showing a positive saralasin test dropped from 8.3% in those aged 20-29 to 4.3% in those aged 60-69. But among those with abnormal renal X-ray findings, the percentage rose from 5.7% to 20% (high SPRA) and from 16.3% to 33% (positive saralasin test). A high SPRA or positive saralasin detected a renal abnormality in 11.7% and 50%, respectively, of patients aged 20-29, and 75% and 85.7%, respectively, of those aged 60-69. The percentage of all patients on or off medication with abnormal renal X-ray findings and a renal vein renin ratio > 1.5 increased from 14.2% among those aged 20-29 to 84.2% among those aged 60-69. The results indicate an increasing usefulness with age of a high SPRA or a positive saralasin test in indicating an abnormal renal X-ray and an abnormal renal vein renin ratio, and thus a potentially correctable lesion.

Conjunctival incision for herniated orbital fat

The approach to herniated orbital fat of the lower eyelid through a conjunctival incision is described. This is an effective method of removing the herniated fat pads in patients who do not have redundant lower eyelid skin and results in excellent cosmesis. The candidates for this procedure are usually in a younger age bracket.

"Apple coring" the nipple in subcutaneous mastectomy

A simple technique is described for removing the ductal tissue from the nipple in a subcutaneous mastectomy. We believe that complete removal of all the ductal tissue is desirable in this operation, and that it will also decrease the incidence of subsequent infection. The operative technique, the problems, the advantages, and the disadvantages of the procedure are described.

A retrospective study of hearing impairment in three groups of cleft palate patients

Three groups of cleft palate patients were evaluated for hearing impairment and secretory otitis at age five to determine the effect of myringotomy and tube placement. Each group consisted of 23 patients (46 ears). Hearing levels and otoscopic evaluations were obtained retrospectively from medical records. Group I had had no myringotomies. Group II had myringotomies after the initial palate closure and only when deemed necessary. Group III had had myringotomies at the initial palate closure and subsequently as needed. Optimal timing for myringotomy in cleft palate patients to maximize hearing at school age could not be determined. The need for myringotomy must be determined by clinical judgement on an individual basis.

The case for the inferiorly based posterior pharyngeal flap

The superiorly based and inferiorly based posterior pharyngeal flaps are compared. Reasons for choosing one or the other in specific cases are given. The complications with each are enumerated. The results obtained in speech comparing the two flaps in two retrospective series and one prospective series of cases failed to show a significant difference between them. Therefore, with little difference in the results and some good reasons for preferring one or the other under certain conditions, it would seem logical to select the one best suited for the particular problem.

Craniofacial surgery: present and future

The possibilities for radical craniofacial restructuring have increased dramatically in the past 6 years with the development of craniofacial surgery. The field developed from a background of patients with major craniofacial birth defects allowing orderly planning and expansion to correction of a multitude of other craniofacial structural problems. The procedures concentrate upon changing the skeletal structures using extensive subperiostial dissection of soft tissue, and adding bone to fill in areas of deficiency. There are three grades of complexity in craniofacial procedures. After extensive soft tissue sub-periostial stripping about the orbits and upper face, the simplest form consists of onlay bone grafts. The next most complicated involves osteotomies to shift the face into a more normal position. In its most complicated form, abnormal proportions of bone are removed and the orbits or cranium are shifted into a new or normal position. We have had experience with 69 patients since September, 1972. Thirty-six have had intracranial procedures. Infection has been the most serious problem, and there have been no instances of death or blindness. A number of lesser problems occur. Future applications of craniofacial surgery are appearing with great frequency as more experience is gained with its uses. It has particular application in acute and late reconstruction of patients with traumatic defects about the face. Preventive osteotomies are an area with great potential, by releasing stenotic areas of bone and allowing the developing brain to mold the upper face and orbits. There is also applicability in surgery of tumors about the craniofacial structure and in cosmetic surgery.

Airway hazards associated with pharyngeal flaps in patients who have the Pierre Robin syndrome

We describe 3 patients with the Pierre Robin Syndrome who developed severe problems of airway obstruction after having the cleft palate closed and a pharyngeal flap done simultaneously. We now believe that, even at a later age, pharyngeal flaps should be done in these patients only after a most careful assessment of the airway competence.

Preservation of a posterior pharyngeal flap during maxillary advancement

In maxillary advancement procedures, a previously existing posterior pharyngeal flap can be preserved by lengthening it. A technique for this and its results in two cases are presented.

Structural goals in craniofacial surgery

Major craniofacial abnormalities can be considered as a group for purposes of operative planning. Known normal relations define what is abnormal and indicate goals to be achieved with the craniofacial operative procedures. The principle syndromes with significant facial structural changes amenable to such surgical corrective procedures are craniofacial stenoses, hypertelorism, mandibulofacial dysostoses, median facial clefts, residua of encephaloceles, and trauma. Deformities primarily involve the middle and upper thirds of the face. In planning, abnormal relations and structures must be clearly defined utilizing patient examination, x-rays, dental study models, and photography. Standards of norm indicating goals for the corrective procedure are also based on studies using these tools, data from previous publications, and measurements directly from skulls. Precise measurements about the orbits and maxillary-mandibular relation are the keystone for planning. Soft tissue, nose, and ear alterations are based on already widely known concepts of norm and symmetry. Bony interocular distance, medial intercanthal distance, height and width at the orbital rim of the bony orbits, orbital shape, orbital axis, and orbital volume as determined by measurement with an exophthalmometer are useful in determining what is to be done about the orbits. Cribiform plate level, anterior cranial base, length and contour, and size of the zygomatic arches are important dimension considerations. Paranasal sinus size and location is important. These considerations are essential prior to any major facial structural changes.

Velopharyngeal incompetence. Pseudo mental retardation as a consequence

Velopharyngeal incompetence (failure of the soft palate to affect closure of the nasopharynx) may result in hypernasal or unintelligible speech, chronic otitis media with secondary conductive hearing loss, or even pseudomental retardation. Such devastating consequences make early diagnosis mandatory.

Here is an excellent ca se illustration, review of the literature, and a diagnostic checklist for office use.