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ORATION
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 125-138

Indocleftcon 2022 Millard Oration: My tryst with challenges and complications in cleft and craniofacial surgery


Director, Centre for Craniofacial Anomalies, Kanachur Institute of Medical Sciences, Mangalore, Karnataka, India

Date of Submission08-Jul-2022
Date of Acceptance12-Jul-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Dr. Mustafa Khader
1st Floor, Somayaji Building, Bunts Hostel Road, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_17_22

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How to cite this article:
Khader M. Indocleftcon 2022 Millard Oration: My tryst with challenges and complications in cleft and craniofacial surgery. J Cleft Lip Palate Craniofac Anomal 2022;9:125-38

How to cite this URL:
Khader M. Indocleftcon 2022 Millard Oration: My tryst with challenges and complications in cleft and craniofacial surgery. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2022 Oct 2];9:125-38. Available from: https://www.jclpca.org/text.asp?2022/9/2/125/354291



In sync with the theme of the conference, the topic for the prestigious Millard's oration was “MY TRYST WITH CHALLENGES AND COMPLICATIONS IN CLEFT AND CRANIOFACIAL SURGERY” delivered by Dr. MUSTAFA KHADER.

The oration detailed the challenges faced by surgeons in an attempt to confer a comprehensive treatment, highlighting the complications that may appear in each phase.

The author commenced the talk with the concepts of unilateral primary lip repair by Millard's rotation and advancement technique and modifications of the same that he generally implements to obtain optimal results. They are listed as follows:

  1. Mohler's incision: Increases the columellar length
  2. Mucocutaneous incision on cleft side with no perialar incision
  3. Delaire's principle of muscle repair to establish the adequate position of the alar base 4) closed nasal dissection
  4. Medialization of the nasal septum
  5. McComb's stitch: To stabilize the displaced lower lateral cartilage after closed nasal dissection.


The most significant challenge in unilateral cleft lip repair is to achieve nasal symmetry; as rightly quoted by John Mulliken


  “Achieving Nasal Symmetry is the Holy Grail for Every Cleft Surgeon.” Top


The author advocated a triad of techniques to achieve the same:

  1. Preoperative nasoalveolar molding to lessen the severity of nasal deformity. The timing of the therapy and patient compliance are essential challenges to achieve desirable outcomes
  2. Intraoperative primary semiopen rhinoplasty with marginal incisions for precise and symmetrical positioning of the Lower Lateral Cartilage (LLC) and
  3. Postoperative use of nasal conformers to sustain the results obtained.


The cases reported by the author exhibited significantly better long-term results in achieving nasal symmetry, improving nostril height, and nasal axis by use of a semiopen approach without adversely affecting the nasal growth; emphasizing primary semiopen rhinoplasty should be considered a standard of care for improving nasal symmetry [Figure 1].
Figure 1: Unilateral cleft lip deformity: Pre-versus post. (a) Frontal and (b) submental

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The two important challenges of note in the repair of bilateral cleft lip deformity are:

  1. Short columella
  2. Protruding premaxilla.


The two entities may occur in isolation, or as an effect of the other.

To overcome these challenges, the author suggested the use of nasoalveolar molding to ensure a more acceptable positioning of the protrusive premaxillary segment before primary lip repair. In cases reporting late, he advocated primary cheiloplasty with simultaneous premaxillary osteotomy and setback. However, he added a note of caution regarding the increase in the severity of Cleft maxillary hypoplasia (CMH), while performing the same.

The challenges pertaining to severely protrusive premaxilla with collapsed maxillary arches were described. The first one was managed by transverse orthodontic maxillary expansion with simultaneous premaxillary osteotomy and cheiloplasty [Figure 2]. The second, a medically compromised patient having multiple cardiac anomalies with poor prognosis, was managed with a single-stage LeFort I osteotomy to create space for premaxillary setback along with simultaneous lip repair [Figure 3], [Figure 4].
Figure 2: Bilateral cleft lip deformity: Pre-versus post. (a) Frontal and (b) submental

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Figure 3: Premaxillary osteotomy with simultaneous cheiloplasty

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Figure 4: Premaxillary osteotomy with simultaneous cheiloplasty. Pre-versus post. (a) Frontal and (b) submental

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For palate repair, two main challenges were highlighted:

  1. Avoiding oronasal fistula
  2. Achieving velopharyngeal competence.


Bilateral cleft of the palate is more likely to present with a shortage of local tissue for primary closure, thus requiring the use of locoregional flaps or tissue expanders. Regardless of the technique and timing of repair, speech determines the success of the palatal repair.

The challenge in cleft palate repair may be compounded in patients with associated syndromic conditions and Pierre Robin sequence, where the initial goal of the surgical therapy is to alleviate the airway obstruction secondary to a retrusive mandible. Most of these infants can be managed conservatively, but severe cases of obstructive sleep apnea (OSA) may require an interventional procedure in the form of either tongue-lip adhesion or mandibular distraction osteogenesis [Figure 5], [Figure 6]. Hence, the challenge lies in the choice of optimal surgical procedure to overcome the OSA and feeding issues for the patient. Any lower airway obstruction, as can be ascertained through a nasoendoscopy, requires tracheostomy.
Figure 5: Tongue–lip adhesion in a case of Pierre Robin sequence

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Figure 6: Tongue–lip adhesion: Long-term follow-up results

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The author subsequently described a case of cleft palate which was compounded by temporomandibular joint ankylosis. The challenge was to restore the dual functional shortcomings of speech and jaw function. Gap arthroplasty with simultaneous cleft palate repair was performed to achieve acceptable mouth opening and velopharyngeal function [Figure 7]. The postoperative polysomnography report showed encouraging results with the resolution of OSA [Figure 8].
Figure 7: Case of cleft palate compounded with TMJ ankylosis. Intraoperative images showing ankylosis release with simultaneous palatoplasty. TMJ: Temporomandibular joint

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Figure 8: Pre- versus postoperative images with clinical mouth opening

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A clinical scenario of a patient with bilateral cleft lip and palate (CLP) deformity compounded by trigonocephaly was described. Following the conventional repair of the CLP, calvarial bone remodeling involving frontal craniotomy superior to the supraorbital bandeau was executed [Figure 9]. The postoperative photographs showed an improved contour of the forehead with increased volume of the anterior cranial fossa [Figure 10].
Figure 9: Case of bilateral cleft deformity with trigonocephaly. Intraoperative images demonstrating frontal craniotomy

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Figure 10: Pre- versus postoperative images showing improved forehead contour

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Adult cleft palate repair is challenging not in terms of achieving good closure but optimal speech. A case of an adult cleft patient was described with an unrepaired palate having a deficient velar length with poor speech articulation and hypernasality. The patient was managed using a buccal myomucosal flap for velar lengthening along with a suspension pharyngeal flap [Figure 11], [Figure 12]. The postoperative closure ratio showed significant improvement with acceptable hypernasality, reduced nasal air emission, and touch closure [Figure 13].
Figure 11: Intraoperative image of adult cleft palate repair using buccal myomucosal flap

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Figure 12: Use of suspension pharyngeal flap to achieve better speech outcomes

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Figure 13: Pre- versus post-VFS images demonstrating significantly improved CR. CR: Closure ratio

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Cleft maxillary hypoplasia (CMH) is often an unavoidable sequela in CLP patients who have undergone timely surgical intervention. The primary surgeries of the lip and palate begin to show its retrusive effect on midface growth within 6–8 years.

Some of the secondary cleft deformities that may require subsequent corrective surgeries are:

  • Palatal fistula/large palatal defects
  • Velopharyngeal incompetence
  • Midface hypoplasia with related dental malocclusion
  • Cleft nasal deformity.


A challenging case of a huge palatal fistula with little/no palatal soft tissue was presented. Several attempts were made previously with various locoregional flaps such as lattismus dorsi and Pectoralis Major Myocutaneous (PMMC) all of which failed to close the defect. Satisfactory closure of the same was subsequently brought about by temporalis myofascial flap [Figure 14], [Figure 15].
Figure 14: Case of a huge palatal fistula with little/no palatal soft tissue treated using temporalis myomucosal flap

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Figure 15: Pre- versus Post-VFS images demonstrating complete closure of the palatal defect

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In addition, three other cases were illustrated demonstrating the mobilization of available tissues and usage of local flaps such as tongue flap, buccal flap, and pharyngeal flap [Figure 16], [Figure 17].
Figure 16: Case of binders syndrome with significant nasomaxillary hypoplasia

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Figure 17: Anterior palatal fistula closure in the same patient by tongue flap

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There has been a paradigm shift in the way modern-day cleft surgeons assess the success of palate repair. The aim is to create the muscle sling and lengthen the palate to establish velopharyngeal competence. It was Kilner who emphasized the importance of speech in cleft palate. He stated, “Ask not for a spatula and torch to check your cleft palate repair but listen to your patient speak.” If the child does not speak well, the operation is a failure.

In addition to the universal speech assessment, instrumental analysis can be carried out to objectively determine the choice of the surgical procedure. The closure ratio, which is obtained using lateral view videofluoroscopy, is one of the cardinal determinants for the choice of speech corrective procedure (Furlow's palatoplasty ± suspension pharyngeal flap). If the closure ratio is <0.7, Furlow's palatoplasty may not suffice and warrants an additional augmentative pharyngeal flap as demonstrated by the author.

The key challenges in alveolar bone grafting (ABG) are to assess its timing and the need for presurgical orthodontics. The latter can be determined by the surgical access for grafting. Tooth eruption (spontaneous/orthodontically-assisted) through the graft will ensure its success. Inversely, if there is no tooth that can occupy the grafted site, then Secondary Alveolar Bone Grafting (SABG) can be avoided, as the graft will ultimately resorb (Wolff's law).

Over the course of the child's growth, cleft-associated maxillary hypoplasia becomes evident. Some of the modalities described for maxillary protraction are:

  1. Dentally anchored protraction facemasks
  2. Skeletally anchored modalities


    1. Skeletally anchored protraction facemasks
    2. Bone-anchored maxillary protraction (BAMP)


  3. Alternate rapid maxillary expansion and constriction.


There exists a lack of congruence in selecting the ideal treatment modality among the various options available. Dentally anchored facemask has been the most popular modality for maxillary protraction. It brings about the anterior displacement of the maxilla (by 2–3 mm) with undesirable sequelae such as dental compensations, clockwise rotation of the mandible, and a higher tendency for relapse due to unrestricted mandibular growth. Patient compliance is unpredictable adding to the burden of care.

BAMP, described by DeClerck et al., has recently started gaining some traction. Three-dimensional assessment of the dentoskeletal and soft-tissue facial changes with BAMP has shown to produce favorable skeletal protraction of the maxilla with simultaneous mandibular growth restriction and better vertical growth control, thereby enhancing the facial soft-tissue profile in cleft individuals, as portrayed in the cases demonstrated. In addition, BAMP facilitates better patient compliance and the freedom to carry out orthodontic treatment simultaneously [Figure 18].
Figure 18: Profile changes in a case of cleft maxillary hypoplasia undergoing bone-anchored maxillary protraction

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Rigid external distractor (RED) can be used in case of severe midface hypoplasia. A case of severe midface hypoplasia presenting at a young age with hyperlacrimation and OSA was illustrated that was managed by LeFort III rigid external distraction [Figure 19]. There was significant midface advancement (25 mm at point A and 15 mm at the infraorbital level). This resulted in increasing the pharyngeal airway space with a resolution of OSA. However, the pronounced advancement of the maxilla lead to the deterioration of speech. The collateral damage was corrected by Furlow's palatoplasty for palatal lengthening and tongue flap was used to close the preexisting palatal fistula [Figure 20], [Figure 21].
Figure 19: LeFort III distraction using RED. RED: Rigid external distractor

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Figure 20: Pre- versus postdistraction images post RED. Also illustrates the closure of the palatal defect using a tongue flap. RED: Rigid external distractor

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Figure 21: Improvement in pharyngeal airway space postskeletal correction

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The effect of maxillary skeletal procedures on speech was discussed. A few striking points made were:

  • Type of surgical intervention LeFort I (CO vs. DO) did not present significant differences in velopharyngeal functions and speech
  • CLP patients treated with the advancement of the maxilla are more likely to develop speech disorder than noncleft surgical patients as the velum is unable to adapt to the new size of the pharynx due to scarring and inadequate velar stretch
  • Preoperative Videofluroscopy (VFS) is one of the modalities for the assessment of speech


Besides speech, emphasis was also placed on the stability of the results obtained. The most notable factor in achieving optimal stability was the soft tissue around which the bone is moved. In accordance with the functional matrix theory proposed by Moss, any movement of the jaw will be less stable or more liable to recur if the movement stretches the soft tissues/muscles beyond its adaptive capacity. When the anterior-posterior movement of any one jaw exceeds one centimeter, the surgeon should consider an alternative surgical technique such as Bijaw surgery, distraction osteogenesis, or concomitant bone grafting.

The status of the speech will determine the choice between LeFort I osteotomy (CO or DO) and anterior maxillary distraction (AMD). Although AMD prevents further deterioration of speech, its two most significant drawbacks are:

  1. No scope for differential sagittal movement of the segment which does not allow the yaw correction that may be essential in a unilateral cleft maxillary hypoplasia owing to the greater segment–lesser segment discrepancy.
  2. The movement is greater in the nasolabial region as compared to paranasal or parazygomatic region. Thus, AMD does not treat midface hypoplasia in its entirety.


Taking the severity of the hypoplasia and the inherent disadvantages of each procedure, the author put forth the following recommendations for the management of cleft maxillary hypoplasia (CMH):

  • Mild CMH, well-coordinated arches: LeFort I advancement
  • Mild CMH, well-coordinated arches, compromised speech: AMD
  • Mild CMH involving periapical/nasolabial regions, crowding: AMD
  • Mod CMH, well-coordinated arches: LeFort + Bilateral Sagittal Split Osteotomy (BSSO) ± genioplasty
  • Mod CMH, well-coordinated arches, compromised speech: AMD + BSSO ± genioplasty
  • Mod CMH, crowding: AMD + BSSO ± genioplasty
  • Severe CMH, negative overjet ↑ 12 mm, compromised speech: AMD + LeFort I + BSSO ± genioplasty
  • Severe CMH involving paranasal and parazygomatic regions, negative overjet ↑ 12 mm: LeFort I distraction + BSSO ± genioplasty
  • Bilateral CMH: Abbe flap (option), deficit soft tissue.


Thus, severe cases of CMH may require the use of an intermediate procedure, such as an AMD, to reduce the quantum of the eventual Bijaw surgery that the patient may require.

The use of maxilla-mandibular complex (MMC) rotation must be considered a modality of treatment, where the occlusion is compensated, but the skeletal deficit persists. The author demonstrated multiple cases wherein the clockwise rotation of MMC brought about desired skeletal changes in a patient with correction of midface deficiency without any obvious change in occlusion [Figure 22], [Figure 23].
Figure 22: Case of cleft maxillary hypoplasia with concomitant roll, pitch, and yaw discrepancy corrected with Bijaw surgery pre versus post

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Figure 23: Radiographic representation of pre- versus postresults obtained

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However, these surgical cases with complex jaw discrepancies do present with complications, especially in cleft cases, where the patients have undergone multiple surgical interventions previously. A case of CMH requiring roll, pitch, and yaw correction was presented wherein there was wound dehiscence bilaterally on the 12th postoperative day, indicating the compromise of the buccal pedicle. It was managed by surgical wound debridement every alternate day, use of pentoxifylline and Vitamin E supplements, administration of antibiotic therapy, oral hygiene measures, and use of topical placental extract. The exposed plate across the cleft segment was also removed. The patient showed good recovery by the 45th postoperative day with healthy granulation tissue covering the buccal surface of the maxilla.

Another example of a Bijaw surgery for a 20-year-old male patient was presented which showed a more severe type of avascular maxillary necrosis with the compromise of both buccal and palatal pedicle. The patient reported large palatal ulceration with buccal wound dehiscence on the 12th postoperative day [Figure 24].
Figure 24: Case of avascular necrosis of the maxilla: Initial recognition on 12th day postoperative versus resolution of the condition 3 months postoperative

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A few of the most common causes mentioned for avascular necrosis in the literature are ligation of descending palatine artery, segmental osteotomies, smoking, palatal perforations, extensive advancement, etc., among others. The exact cause of Avascular Necrosis (AVN), in this case, could not be conclusively ascertained. The treatment involved surgical wound debridement, administration of antibiotic therapy, use of pentoxifylline to improve capillary perfusion, and oral hygiene measures. He also underwent 15 cycles of hyperbaric oxygen therapy. The patient showed progressive improvement and at the end of 3 months, regeneration of healthy gingival tissue with the resolution of the palatal ulceration was seen [Figure 24].

The author further went on to discuss the soft-tissue deficit in the upper lip in patients with bilateral cleft lip deformity. Mild negative lip step is a normal feature despite the circumference of orbicularis oris in the upper and lower lip being proportional. However, in cases of bilateral cleft lip, the prolabium is devoid of muscle which is mobilized from the lateral lip elements. This leads to a circumferential difference, in turn, everting the lower lip. This may give an erroneous impression of skeletal deficiency, which must be distinguished from soft-tissue deficit. Lateral cephalograms will aid in differentiating the same. Thus, any deficiency of the soft tissue, with a normal appearing maxilla may need restoration with Abbe flap to establish the circumferential proportion. The author demonstrated multiple case scenarios with accentuated lip esthetics and better facial profile post-Abbe flap reconstruction [Figure 25].
Figure 25: Case of soft-tissue circumferential deficiency of the upper lip musculature treated with Abbe flap demonstrating better lip esthetics and facial profile

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He then dwelled on the challenges and complications encountered in cleft rhinoplasties. The first case described, of severe nasomaxillary hypoplasia wherein the hard-tissue correction was done by anterior maxillary osteotomy, nasomaxillary distraction, mandibular setback, and genioplasty. The nasal deformity correction was planned with a costochondral graft and nasolabial flap. The flap underwent necrosis and the entire columellar skin was lost. Subsequent reconstruction of the columella was done with the help of a forehead flap.

Another case of rhinoplasty depicted loss of columellar flap postsurgery with exposure of the columellar strut. The author recommended the use of a columellar strut that is less bulky and ensuring a tension-free closure of the transcolumellar incision. Besides, the excision of the fibro-fatty tissue must be done beyond the dome of the nose. The columellar reconstruction was eventually performed, in this case, using a nasolabial flap [Figure 26].
Figure 26: Case of cleft rhinoplasty that underwent loss of columellar flap postsurgery. It was successfully reconstructed using the nasolabial flap

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In addition, a case of alloplastic implant failure was illustrated. The silicone columellar implant got extruded after 2 years. The implant was eventually removed. After 6 months, a revision rhinoplasty was performed using a costal graft combined with Abbe flap.

The cleft team's commitment to a family under their care is to ensure the newborn reaches adulthood successfully reconstructed.

Cleft reconstruction typically requires the transition through four stages of facial development:

  1. Stage I is the newborn with an unrepaired CLP
  2. Stage II is the young child with successful repair of the soft tissues of the CLP
  3. Stage III is the adolescent with nasomaxillary deformity and resultant difficulties with speech articulation, chewing ability, swallowing mechanism, breathing, and limited self-esteem
  4. Stage IV is the successfully reconstructed young adult.


In the current practice, the major challenge in cleft care is the successful surgical transition from stage III through stage IV.

A few completed cases with comprehensive treatment from Stage I repair to Stage IV reconstruction were discussed.

The first patient, with a nasomaxillary hypoplasia in the adolescent period, post successful primary lip and palate repair, was managed with a modified hybrid AMD appliance, the results of which duplicated a total maxillary distraction [Figure 27]. The pre- and postoperative computed tomography superimposition demonstrated the significant advancement of the nasomaxillary complex with the hybrid appliance [Figure 28]. Subsequently, a BSSO setback and genioplasty were performed to establish an orthognathic facial profile [Figure 29].
Figure 27: Pre- versus postfrontal and profile view of a patient who underwent anterior maxillary distraction using a hybrid AMD appliance for correction of cleft maxillary hypoplasia. AMD: Anterior maxillary distraction

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Figure 28: Lateral cephalogram images depicting the sagittal advancement achieved through the AMD appliance. AMD: Anterior maxillary distraction

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Figure 29: Completed treatment from Stage I to Stage IV of the same patient

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Another case of a bilateral cleft lip was managed by primary repair with subsequent orthognathic surgery and Abbe flap to obtain the mild negative lip step. The lip esthetics and overall facial profile showed significant improvement [Figure 30], [Figure 31], [Figure 32].
Figure 30: Case of multiple secondary cleft deformities corrected by skeletal and soft tissue procedures to attain an orthognathic facial profile

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Figure 31: Profile view with lateral cephalogram images of the patient in each phase of the treatment

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Figure 32: Completed treatment from Stage I to Stage IV of the same patient

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One of the most challenging cases described by the author demonstrated all the trappings of secondary cleft deformities. The patient presented with a huge anterior palatal defect with transverse and anteroposterior maxillary hypoplasia [Figure 33]. Management involved the use of a tongue flap for closure of the palatal defect followed by rapid maxillary expansion [Figure 34].
Figure 33: Case demonstrating multiple secondary cleft deformities with severe midface hypoplasia and huge anterior palatal fistula

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Figure 34: Correction of the deformities with a tongue flap and transverse maxillary expansion

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The hypoplasia was addressed using a RED. She subsequently underwent a mandibular BSSO setback to achieve an esthetic facial profile followed by an Abbe flap repair to correct the positive lip step [Figure 35], [Figure 36].
Figure 35: Profile change postsagittal advancement of the midface with rigid external distraction and orthognathic correction. Also depicts superior lip esthetics post-Abbe flap reconstruction

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Figure 36: Frontal images in each phase of the treatment for the same patient

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The author's concluding remarks emphasized the need for teamwork in rendering holistic care to these patients. It is hard work that will eventually take precedence over talent. One should not shy away from surgical failure as it is a part of the learning curve.

The oration ended with an inspiring quote:

“There is no talent here. This is hard work. This is an obsession. Talent does not exist; we are all equal as human beings. You could be anyone if you put in the time. You will reach the top, and that is that. I am not talented. I am obsessed.”




    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28], [Figure 29], [Figure 30], [Figure 31], [Figure 32], [Figure 33], [Figure 34], [Figure 35], [Figure 36]



 

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