Surgical Atlas of pediatric otolaryngology - part 10 ppt

768 Surgical Atlas of Pediatric Otolaryngology Suturing • The first “key” suture (3-0 or 4-0 Vicryl) is placed deeply from the back-cut to the superior edge of the advancement flap at or lateral to 9. This advances the lateral lip flap and reduces tension on the orbic- ularis oris sutures (Figure 33–1 C). It also produces more normal con- vexity to the lip. • The orbicularis oris muscles are approximated with interrupted 4-0 or 5-0 Vicryl (Figure 33–1 D). Assessment of lip length and symme- try is made after each suture is placed to ensure that the lip has not been shortened. This closure includes the muscle fibers present in the vermilion edge to avoid notching at the vermilion border (the whis- tle-tip deformity). • The position of the alar base is determined, and it is sutured into position (Figure 33–1 D). The tip of the alar base flap is sutured to the anterior nasal spine with 4-0 or 5-0 Vicryl to create symmetry with the noncleft side. There should be minimal, if any, trimming of the alar base to avoid narrowing or stenosis of the nostril (a secondary deformity that is very difficult to correct later). If needed, a small crescent of cheek skin may be excised to prevent excessive narrowing of the nostril. • The skin edges are trimmed, if necessary, and slightly undermined to allow the edges to be everted. • The “c” flap is advanced upon itself to lengthen the columella and/or is utilized for nasal sill reconstruction. • The “white roll” flap is incised if needed. If additional rotation is required to horizontally align the Cupid’s bow, a small incision at the VCJ is made at 3. If the position of Cupid’s bow is adequate, a small triangular skin excision at 3 is made the same size of the “white roll” flap. Subcutaneous 6-0 chromic or Vicryl secures the flap into place. • Using interrupted 7-0 nylon sutures, the skin edges are approximat- ed and everted (Figure 33–1 E). The vermilion-cutaneous junction is carefully approximated with 7-0 nylon at the vermilion border. • The mucosa is approximated with 5-0 or 6-0 chromic suture. This incision may lend itself to a broken line closure, or a Z-plasty may be done to decrease the tendency of contracting with healing. Postoperative Care and Complications • As described above under Cleft Lip Repair. 770 Surgical Atlas of Pediatric Otolaryngology BILATERAL CLEFT LIP REPAIR The goal of the bilateral cleft lip repair is to create a symmetric lip and nose contour. Several methods are available, the most popular of which, in the United States, is the Millard technique (described below). This technique also provides tissue for future repair of the nasal columella. Careful preoperative assessment of the patient’s deformity allows the surgeon to modify and adjust the procedure to meet the specific needs in reconstructing the defect. Indications • Any bilateral cleft lip (including any combination of complete or incom- plete cleft lip, with or without a prior lip adhesion) is included. • In general, the operation is performed when the child is 8-12 weeks of age, has 10 g/dL hemoglobin level, and is about 10 pounds in weight. A trend toward earlier lip repair is underway, however, only in healthy growing infants. • If lip adhesion has been performed (either bilateral lip adhesion in the wide bilateral cleft lip or unilateral lip adhesion in the asymmetric bilat- eral cleft lip [one side wide and complete, the other incomplete, for example]), the definitive bilateral lip repair follows 3 to 4 months later. Anesthetic Considerations and Preparation • As described above under Cleft Lip Repair. Procedure Surgical landmarks • The following points (Figure 33–2A) are located and marked on the skin with gentian violet: • Prolabium 1. Midpoint of the vermilion-cutaneous junction on the prolabium (the future low point, or midline, of the Cupid’s bow) 2. Right prolabium Cupid’s bow peak (measured 2.5 to 3 mm later- al to 1) 3. Left prolabium Cupid’s bow peak (measured 2.5 to 3 mm lateral to 1) 4. Right prolabium columella junction 5. Left prolabium columella junction ♦ The distance from 1 to 2 is equal to 1 to 3. ♦ The distance from 2 to 4 is equal to 3 to 5. • Lateral lip (right and left) 6. Right lateral lip vermilion-cutaneous junction (point of white line attenuation) 7. Superior extent of right lateral lip flap 8. Left lateral lip vermilion-cutaneous junction (point of white line attenuation) 772 Surgical Atlas of Pediatric Otolaryngology • The lateral lip incisions are then made (Figure 33–2C) and extended a variable distance along the alar crease. It is often necessary to mod- ify the height of the lateral lip by excising a small triangular wedge of tissue from under the nares above points 6 and 8. • The two small vermilion flaps, 6 to ★ and 8 to ★, are incised through and through on the lateral lip elements (Figure 33–2 D). • Lateral gingivobuccal sulci incisions are made to allow for adequate relaxation and advancement medially. Limited dissection around the piriform aperture and maxilla in the supraperiosteal plane is per- formed for additional release if needed. • The remaining mucosa and vermilion of the prolabium and premax- illa are pedicled inferiorly and sutured to the superior attachment of the premaxilla at the nasal spine (see Figure 33–2 D). Figure 33–2 C, Remaining pro- labium mucosa is advanced superiorly and sutured to line the anterior premaxilla; the lat- eral lip flaps are incised. D, Small lateral vermilion flaps are created on the lateral lip elements. C D Cleft Lip and Cleft Palate 773 Suturing • Closure begins by approximating the inner lateral lip mucosa with interrupted 4-0 chromic sutures, beginning at the superior aspect and continuing inferiorly (Figure 33–2 E). • The orbicularis oris muscle from the lateral lip elements is advanced medially and closed with several interrupted sutures of 4-0 Vicryl (Figure 33–2 F). • The edges of the vermilion flaps are closed with 5-0 Vicryl (deep), 5- 0 chromic (inner mucosa), and 7-0 nylon (outer mucosa). A small space posterior to the flaps is left open for inserting the “e” flap (Fig- ure 33–2 G). E F G Figure 33–2 E, The lateral lip buccal mucosa is sutured to create the inner lip lining. F, Approximation of the orbicularis oris muscles recreates the oral sphincter. G, The small vermilion flaps are sutured at the midline. A small pocket is present on the buccal surface of the lip for the “e” flap. 774 Surgical Atlas of Pediatric Otolaryngology • The philtrum flap is fitted into position between the lateral lip flaps and sutured in place with 7-0 nylon (Figure 33–2 H). • The “e” flap is tucked behind the inferior vermilion flaps and sutured with 5-0 chromic. The “e” flap helps to create the central vermilion tubercle. • The two lateral prolabium flaps (forked flaps) are sutured into posi- tion under the nostrils with 5-0 Vicryl for the deeper tissues and 7-0 nylon for the skin edges (Figure 33–2 I). These two small flaps are considered “banked” for future use in reconstructing the columella. Postoperative Care and Complications • As described above under Cleft Lip Repair Figure 33–2 H, The “e” flap is tucked into its pocket and sutured into position. I, The philtrum and forked flaps are sutured into position. H I Cleft Lip and Cleft Palate 775 LIP ADHESION UNILATERAL LIP ADHESION The procedure may be performed either low in the lip (near the vermilion), which minimizes soft tissue undermining from the maxilla, or high in the lip (superior lip-nasal sill), which is the technique described below. The proce- dure is described for both unilateral and bilateral clefts. Although it requires some dissection of the lip from the maxilla, this technique provides relief from excessive tension where the basic deficiency is greatest—high in the lip. Indications • A very wide complete unilateral cleft lip in which a definitive procedure could be performed only under excessive tension • A very asymmetric bilateral cleft lip in which one side is complete and the other is incomplete; a unilateral lip adhesion may result in improved symmetry • For unilateral lip adhesion, the infant should be at least 4 weeks of age, have satisfactory weight gain, and no other significant untreated medical problems. Anesthetic Considerations and Preparation • As described above under Cleft Lip Repair Procedure Landmarks and incisions • The landmarks for a definitive procedure are determined (see rota- tion-advancement method, Figure 33–1 A) and marked with gentian violet. The cleft edge mucosa/vermilion flaps are placed well away from the definitive landmarks. • The cleft mucosal edges are marked with gentian violet to create small mucosal flaps in an “open book” fashion (Figure 33–3 A). Flap elevation and undermining • A 6300 Beaver blade is used to incise and elevate the cleft edge mucosal flaps (Figure 33–3 B). • An incision is made along the pyramidal aperture of the nasal vestibule (dotted line in Figure 33–3 B); this frees the alar sill for medial advancement. • Undermining from the premaxilla should be minimal (if needed at all); on the lateral maxilla, supraperiosteal undermining should also be con- servative and just enough to allow sufficient advancement for closure. Suturing • The sutures are placed in the following order and kept untied: 1. A retention suture (3-0 nylon) is placed through the membranous septum, deep into the lateral lip/alar incision, and back through the septum (Figure 33–3 C). 2. Mucosal sutures, usually three or four 4-0 or 5-0 chromic are placed to approximate the inner lip mucosa. 776 Surgical Atlas of Pediatric Otolaryngology 3. The orbicularis oris and subcutaneous tissues are approximated with three or four sutures of 4-0 or 5-0 Vicryl. 4. All of the above sutures are tied in the sequence they were placed. • The anterior cleft edges are closed with interrupted 6-0 chromic sutures (Figure 33–3 D). • Cleansing of the sutures with hydrogen peroxide is not necessary unless the sutures become crusted. It is expected that the sutures will be absorbed in approximately 7-10 days. Complications • Breakdown of adhesion is usually caused by excessive tension and rarely by infection. The incidence of complete dehiscence is approximately 5%. Partial dehiscence (separation of the lower part of the adhesion) is more common and does not affect the overall goal of the procedure. • Scarring may occur when landmarks are violated. When the landmarks are not violated, scarring from the adhesion is not a factor in the defin- itive repair. • Maxillary growth disturbance is controversial with no definitive human subject data; however, not dissecting the maxillary periosteum will decrease any risk. 778 Surgical Atlas of Pediatric Otolaryngology BILATERAL LIP ADHESION Indications • Bilateral lip adhesion should be considered for the very wide complete bilateral cleft lip, when there is considerable asymmetry between the two cleft sides, or when the prolabium is very small. • For bilateral lip adhesion, the infant should be at least 4 weeks of age, have satisfactory weight gain, and no other significant untreated medical problems. Anesthetic Considerations and Preparation • As described above under Cleft Lip Repair Procedure Landmarks and incisions • Landmarks for a definitive (one stage) procedure are determined (see Bilateral Cleft Lip Repair, Figure 33–2A) and marked with gentian violet. The cleft edge mucosa/vermilion flaps are placed well away from the definitive landmarks (Figure 33-4 A). Flap elevation and undermining • A 6300 Beaver blade is used to incise and elevate the cleft edge mucosal flaps on the lateral lip elements and the vermilion/mucosal edge of the prolabium (Figure 33–4 B). • The prolabium should not be elevated from the premaxilla. Under- mining of the lateral lip elements from the maxilla should be mini- mal, just enough to allow for adequate release, and in the suprape- riosteal plane. Suturing • All deep sutures (mucosal and muscular) are placed prior to tying. • A retention suture (3-0 nylon) is placed as a horizontal mattress suture (Figure 33–4 C). Starting at the lateral lip orbicularis oris mus- cle, the suture is then passed between the prolabium and premaxilla in the supraperiosteal plane, then into the lateral lip orbicularis oris muscle, and then back between the prolabium and premaxilla in the supraperiosteal plane completing the mattress loop. • The inner lip mucosal sutures are placed, starting superiorly and con- tinuing inferiorly, with 4-0 chromic. • Additional support within the cleft edge muscle/subcutaneous tissue is provided with several interrupted 4-0 Vicryl sutures. • The first suture tied is the retention suture, then the mucosal and deep subcutaneous sutures. • The external lip mucosal closure is completed with 4-0 or 5-0 inter- rupted chromic sutures (Figure 33–4 D). Complications • As described above under Unilateral Lip Adhesion 780 Surgical Atlas of Pediatric Otolaryngology CLEFT PALATE REPAIR Palatoplasty creates an intact and physiologically adequate velopharyngeal mechanism for normal speech production. The primary goals are normal oronasal resonance, effortless production of non-nasal sounds in speech, and the absence of abnormal compensatory articulation patterns such as glottal stops and pharyngeal fricatives. Other goals include the anatomic separation of the nasal and oral cavities, elimination of nasal reflux of food and secretions, and possible improvement of eustachian tube function. Timing • The optimal age for palatoplasty is controversial, with potential trade-off between speech production and possible inhibition of maxillofacial growth: ♦ Optimum maxillofacial growth occurs when palatoplasty is delayed until after age 18 months, but this may result in more secondary pro- cedures to achieve velopharyngeal competency for speech production (pharyngeal flap and pharyngoplasty). ♦ Optimum speech production occurs when palatoplasty is performed at age 9-12 months. • Surgical timing also depends on sufficient palatal shelf width for the clo- sure, and adequate body size (minimum 8 kg), which appears to decrease upper airway risks. • In general, a “rule of tens” applies, in which the infant is about 10 months of age, 10 kilograms in weight, has at least 10 g/dL hemoglobin, and is a healthy thriving child. Anesthetic Considerations and Preparation • General anesthesia via oral endotracheal intubation, preferably with an oral RAE tube, administered by an experienced pediatric anesthesiolo- gist, is preferred. • 1% lidocaine (maximum dose 5-7 mg/kg) with 1:100,000 epinephrine is injected into the incision areas of the palate for hemostasis. • The endotracheal tube is taped at the midline of the lower lip and chin. • A Dingman mouth gag is used with a slotted tongue blade that holds the endotracheal tube in the center of the tongue. The gag is opened only wide enough to allow for adequate exposure to work within the mouth. Care is taken to prevent compression of the endotracheal tube or exces- sive pressure on the tongue with the gag. • The mouth gag is supported with a folded towel under the handle and usually not suspended from the Mayo stand. • A roll is placed under the patient’s shoulders to slightly extend the neck into Rose’s position. • The surgeon sits or stands at the head of the table. Headlight illumina- tion is desirable. Procedures • Many methods of palatoplasty have been described. [...]... mattress sutures 784 Surgical Atlas of Pediatric Otolaryngology Flap suturing • Closure begins by approximating the nasal mucoperiosteum, either side-to-side or to the vomer flaps, with interrupted sutures of 4-0 Vicryl (Figure 33–5D) Suturing begins at the anterior most aspect of the cleft and continues posteriorly to the mucosa of the soft palate and the uvula (closed with 5-0 or 6-0 Vicryl), with all... bundles 788 Surgical Atlas of Pediatric Otolaryngology DOUBLE REVERSING Z-PLASTY (FURLOW PALATOPLASTY) Indications • Submucous cleft palate or isolated soft palate cleft The procedure consists of a soft palatal lengthening Z-plasty with overlap of the mucomuscular flaps to re-align the levator sling • Double reversing Z-plasty is increasingly being used with the previously described two-flap palatoplasty... minimize the possibility of intraoperative intracranial contamination • Positioning of the patient can be determined with close communication between the craniofacial surgeon, neurosurgeon, and anesthesiologist • A coronal incision (Chapter 32) is used in all procedures to access the upper craniofacial skeleton and the posterior part of the skull 794 Surgical Atlas of Pediatric Otolaryngology Procedures... interrupted 4-0 and 5-0 Vicryl sutures (Figure 33–7D) • The oral mucosal flaps are then interdigitated and the tips are placed into position with 4-0 Vicryl suture 790 Surgical Atlas of Pediatric Otolaryngology • Although the muscles are overlapped in the inferior flaps, a 3-0 Vicryl suture placed in a horizontal mattress position through the muscle helps to “tighten” the levator sling • The limbs of the... Pfeiffer’s Recessively dominant syndromes include Antley-Bixler, Carpenter’s, and Gorlin-Chaudhry-Moss Chromosomal abnormalities can occur in the long or short arms of chromosomes I, III, V, VI, VII, IX, XI, XII, XIII, and XV Environmentally induced syndromes include retinoic acid and fetal hydantoin syndrome 792 Surgical Atlas of Pediatric Otolaryngology Secondary craniosynostosis refers to craniosynostosis... single-stage procedures are described in the next sections of this chapter: 1 V to Y pushback palatoplasty for clefts of the secondary palate, involving part or all of the secondary palate 2 Two-flap palatoplasty for complete cleft palates, involving the entire palate including the alveolus and the lip 3 Double reversing Z-plasty (Furlow palatoplasty) for submucous clefts or narrow clefts of the soft... bar with rigid fixation The gap left in the cranial vault corresponds to the amount of forehead advancement 798 Surgical Atlas of Pediatric Otolaryngology No 3 Metopic craniosynostosis • Trigonocephaly refers to the triangular morphology of the forehead caused by fusion of the metopic suture (vertical midline suture of the frontal bone) A prominent midline is evident with recessed lateral supraorbital... boat-shaped appearance 802 Surgical Atlas of Pediatric Otolaryngology No 5 Lambdoidal craniosynostosis • Posterior plagiocephaly refers to the asymmetry of the occiput caused by unilateral fusion of a lambdoidal suture (Figure 34–9) The ipsilateral occipitomastoid region is flattened and the contralateral coronal suture is often fused, producing a twisted head • Fusion of the lambdoidal suture is... unit This may be a neurosurgical intensive care unit, or a pediatric intensive care unit depending on the institution Figure 34–9 Posterior plagiocephaly caused by lambdoidal craniosynostosis compared with normal skull position (dotted line) Note flattening of the ipsilateral occipitomastoid region 804 Surgical Atlas of Pediatric Otolaryngology Complications • Mortality for craniofacial procedures is... of anesthetic safety is to describe risk in the context of other daily activities as shown in paragraph three of the education sheet (Figure 35–1).2–4 Assuming a 1:50,000 fatality rate from general anesthesia, an individual incurs the same risk of death by engaging in • 40 hours (2,000 miles) of automobile driving • 40 hours of bicycle riding • 24 hours of commercial airline flying (the risk is 1 0- fold . Surgical Atlas of Pediatric Otolaryngology DOUBLE REVERSING Z-PLASTY (FURLOW PALATOPLASTY) Indications • Submucous cleft palate or isolated soft palate cleft. The procedure con- sists of a soft. D 784 Surgical Atlas of Pediatric Otolaryngology Flap suturing • Closure begins by approximating the nasal mucoperiosteum, either side-to-side or to the vomer flaps, with interrupted sutures of 4-0 Vicryl. 768 Surgical Atlas of Pediatric Otolaryngology Suturing • The first “key” suture ( 3-0 or 4-0 Vicryl) is placed deeply from the back-cut to the superior edge of the advancement