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   Table of Contents - Current issue
Coverpage
January-June 2021
Volume 8 | Issue 1
Page Nos. 1-84

Online since Wednesday, January 13, 2021

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EDITORIAL  

A tumultuous year Highly accessed article p. 1
Divya Narain Upadhyaya
DOI:10.4103/jclpca.jclpca_46_20  
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OBITUARIES Top

IT Jackson: End of an era p. 3
Ramesh K Sharma
DOI:10.4103/jclpca.jclpca_41_20  
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Tribute to a smilemaker and an amazing storyteller p. 6
Karoon Agrawal
DOI:10.4103/jclpca.jclpca_44_20  
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INVITED ARTICLE Top

Challenge and response: Cleft care in an unprecedented pandemic p. 9
Mamta Carroll
DOI:10.4103/jclpca.jclpca_48_20  
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ORIGINAL ARTICLES Top

Composite axial eyelid flap in the surgical management of orbitopalpebral neurofibromatosis Highly accessed article p. 14
Parit Ladani, Hermann F Sailer, Megha Shah, Angad Shetye
DOI:10.4103/jclpca.jclpca_32_19  
Background: Orbitopalpebral neurofibroma is a progressive and debilitating disease with the potential of affecting the orbital, temporal and facial region. Lack of capsule and its infiltrative nature yields to difficulty in complete removal. Aims and Objectives: In this interventional case study, nine patients between the ages of 12–30 years diagnosed with orbitopalpebral neurofibromatosis underwent palpebral remodeling with composite axial eyelid flap for esthetic purpose and alleviation of visual impediment. Material and Methods: The clinical course for every individual was scored using Ptosis, Canthal involvement, and Oculopalpebral Diastasis (PCD) score on regular follow-ups. Results: For majority of the cases, an improvement was noted on the PCD scale. Conclusion: This series demonstrates that a tailored approach to each individual helps in attaining a balance between function and esthetic outcomes.
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Cephalometric evaluation of soft palate changes after maxillary advancement in lip and palate cleft patients p. 21
Kamal Qaranizade, Alireza Jafari, Mona Farahmand, Hamidreza Mahaseni Aghdam, Leila Talebzade Shooshtari
DOI:10.4103/jclpca.jclpca_6_20  
Introduction: Changes in the soft palate and velopharyngeal function are among the most important concerns for maxillofacial surgeons in patients with midface deficiency, especially in those with cleft palate who needed maxillary advancement. In this study, we evaluated cephalometric changes in soft palate after maxillary advancement. Materials and Methods: This study included 16 cleft patients (7 females and 9 males), with a mean age of 22 ± 3.47. The maxillary advancement alone was done in 10 patients and bimaxillary osteotomy in the other six patients. Cephalometric characteristics were assessed before and 6 months after the surgery, and the results were analyzed using paired t-test or Wilcoxon test. Results: The results showed a 6% increase (P < 0.05) for PNS-U (soft palate length) index. In addition, PTM-UPW (upper pharyngeal space) and U-MPW (middle pharyngeal space) increased by 5% (P < 0.05) and 5% (P < 0.08), respectively, after the surgery. V-LPW (lower pharyngeal space) also increased by 0.6% but was not statically significant. Conclusions: According to the results of this study, after surgical maxillary advancement, changes were observed in upper and middle pharyngeal spaces, soft palate length, and inclination, but lower pharyngeal space remained unchanged.
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Epidemiological patterns of patients managed for cleft lip and palate during free outreach camps at a peripheral hospital in Kenya p. 26
Gathariki Mukami, Muoki Angela, Nang'ole Ferdinand Wanjala
DOI:10.4103/jclpca.jclpca_8_20  
Context: Clefts involving lip and palate are the most common craniofacial anomalies. The prevalence varies widely according to various factors. There is a paucity of epidemiological data on cleft deformities in African populations. Aims: The aim was to determine the epidemiological patterns of patients managed for cleft lip and palate during free outreach camps in Kenya and subsequently compare it with other studies done nationally, regionally, and internationally. Design: Prospective Cohort Study. Subjects and Methods: This was a prospective cohort study. Data were collected during five cleft surgery outreach camps held at Kitale County Referral Hospital in Trans-Nzoia County, Kenya, between January 2016 and January 2018. Statistical Analysis Used: The study was statistically analyzed by the Statistical Package for the Social Sciences Windows version 21 software for descriptive characteristics. Results: A total of 84 patients were reviewed, of which 74 underwent surgical management. The study population included nine different Counties in Kenya (with one patient from Uganda) and were reported to have traveled between 3 and 450 km. The age range was from 5 weeks to 35 years with patients below 2 years of age making up the majority (58.3%). There was a male preponderance (61.9%). The most common cleft deformities were cleft lip (46.4%), cleft lip and palate (34.6%), and cleft palate (15.5%). Unilateral clefts were commonly left-sided (62%). Sex distribution varied with clinical diagnosis, and familial and syndromic association was rare. Conclusions: More initiative programs are recommended to address the unmet medical and surgical needs of the cleft deformities in various parts of the region.
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Characterization of Mexican pediatric nostril sill: Classification and topographic findings p. 30
Rodrigo Davila-Diaz, Daniel De-Luna-Gallardo, Tatiana Izchel Castillo-Torres, Patricia Elizabeth Arguelles-Lopez, Christian Morales-Orozco
DOI:10.4103/jclpca.jclpca_38_20  
Introduction: The nostril sill is defined as the “facial subunit composed of fibro-adipose soft tissue whose topographic delimitation is given by four anatomical limits: the medial crura of the columella on its medial limit, the nasal wing on its lateral limit, the nasal vestibule in its upper limit, and the upper lip on the lower limit.” It represents an essential element in the appearance, balance, and function of the nose. The study and classification of the nostril sill in the healthy Mexican pediatric population are the necessary tools for facial reconstruction since it is generally affected in patients with cleft lip and palate and craniofacial malformations. Objective: The objective of the study is to describe the nostril sill in the Mexican pediatric population using standardized photographs taken in frontal and basal projections and classifying according to Oh et al. and to study if there is a significant relationship between nostril sill with age and gender. Materials and Methods: An observational cross-sectional study was carried out in a sample size of 83 healthy children aged between 3 and 12 years, simple randomly chosen. The classification was performed with facial photographs in frontal and basal projections. The data analysis was performed with descriptive statistics, kappa concordance coefficient was used between observers, and bivariate analysis was used to evaluate the association of the nostril sill classification with age and gender. Results: Of the 83 volunteers, 51.8% (n = 43) were female and 48.2% (n = 40) male, with a mean age of 7.38 years. The 74.6% (n = 62) were classified as a nostril sill Type I, 14.4% (n = 12) as Type III, and 10.8% (n = 9) as Type II, with a Cohen's kappa coefficient between observers of 0.92 (almost perfect agreement). In the bivariate analysis with Chi-square test, no statistically significant association was found between age (P = 0.420) and sex (P = 0.524). Conclusion: The nostril sill of the nostril represents a fundamental nasal subunit that every reconstructive surgeon must recognize and locate. It is crucial to describe and classify the nostril sill according to ethnic and racial characteristics, in the Mexican pediatric population, the most frequent corresponds to Type I, followed by Type III and finally the least frequent Type II, and that gender and age are not associated with a specific type.
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A comparative assessment of secondary surgeries between nasoalveolar molding-treated and non nasoalveolar molding-treated patients with unilateral cleft lip and palate p. 35
Tulasi Nayak, Bonanthaya Krishnamurthy, Renu Parmar, Pritham N Shetty
DOI:10.4103/jclpca.jclpca_36_20  
Introduction: Secondary surgeries are a commonly documented element of cleft treatment. It adds to the surgical and economic burden of care. Nasoalveolar molding (NAM) is one of the techniques which has gained popularity as it has proven to reduce the pre surgical severity. NAM has also been proposed to reduce the need for future secondary surgeries. In this retrospective study, we aimed to compare the incidence of secondary surgeries in NAM treated and non-NAM-treated patients with unilateral cleft lip and palate (UCLP). Methods: In this retrospective study, all consecutively treated NAM and non-NAM patients with UCLP who had undergone primary surgeries in 2011–2013 were considered. Only those patients who had a complete clinical and surgical record at 5 years of age were included for this study. Thirty-eight patients in NAM group and 48 patients in non-NAM group were compared. All patients had received the same protocol with the exception of NAM. The cleft severity index was used to check the preoperative cleft severity. The type of lip defect was described for all patients who had received the secondary surgery. Results: Pre NAM clefts were found to be more severe than the non-NAM group. However, after the NAM therapy, the cleft severity was less than the non-NAM group. Non-NAM group had a statistically higher number of lip revision surgeries with a broader variety of defects than the NAM group. There was no statistically significant difference for the Fistula closures. Conclusion: NAM reduced the cleft severity at the pre surgical stage. At 5 years of follow-up, NAM-treated patients had a lower surgical burden of care in comparison to the non-NAM-treated patients.
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Rationale for the treatment of unilateral cleft lip – GC4 protocol p. 41
Anhad Mehra, Hiteswar Sarma
DOI:10.4103/jclpca.jclpca_30_20  
Introduction: The aim of this study is to retrospectively analyze the surgical outcomes of 200 patients who were treated for unilateral cleft lip (UCL) over a period of 4 months in our cleft care center. Materials and Methods: This is a retrospective audit of all the patients who had undergone UCL repair from January to April 2019. The patients were stratified based on the cleft severity. Fisher technique was employed for the correction of incomplete cleft lip while modified Mohler technique was the choice of repair for complete cleft lip. Clinical records including each patient's preoperative and postoperative photographs were taken into consideration. Results: Of the 200 patients who had undergone lip repair, 56% were male and 44% were female. The average age of the patients treated was 10.5 months. Visual Analog Scale (VAS) and Scar Assessment Scale were used to evaluate the scar, taking into account pigmentation, vascularity, acceptability, parent comfort, and contour. The results ranged from “excellent” and “good” in the case of incomplete cleft lip repair to “good” and “acceptable” in the case of complete cleft lip repair. Postoperative follow-up revealed that 5 of them had complications related to dehiscence and bleeding. Conclusion: Fisher's method in patients with unilateral incomplete cleft lip proved the effectiveness in improving the esthetic results with good symmetry while the Mohler modification of Millard technique helped achieve optimal lip length with acceptable esthetics.
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REVIEW ARTICLE Top

Comparison of conventional Le-fort I advancement, anterior maxillary segmental distraction, and distraction osteogenesis of maxilla for surgical management of cleft maxillary hypoplasia: A systematic review p. 49
Taher Abbas Mistry, Abbas Mistry
DOI:10.4103/jclpca.jclpca_28_20  
This systematic review compares conventional Le-fort I advancement (CLO), anterior maxillary segmental distraction (AMD) and distraction osteogenesis of maxilla (DOM) for the treatment of cleft maxillary hypoplasia in terms of the amount of maxillary advancement achievable, relapse, residual velopharyngeal incompetence and soft tissue changes. All patients with maxillary hypoplasia secondary to cleft palate repair were taken into consideration irrespective of their gender, age and ethnic background. Literature research was done in databases PubMed, Ovid and Google scholar beta. From the original 429 articles identified, 17 articles were finally included, which passed the critical appraisal checklist and met the inclusion criteria. The mean advancement ranged from 6.59 mm to 16.5 mm for DOM, 6–14.28 mm for AMD and 5.17–7.2 mm for CLO. Relapse was 8.24%–45% for DOM, 4.6%–7% for AMD and 21.63%–63% for CLO. Velopharyngeal insufficiency increased significantly following Le-fort I advancement, while there was no significant change after anterior maxillary distraction and DOM. The ratio of soft tissue to hard tissue changes was greatest with AMD, followed by DOM and then CLO. Distraction osteogenesis of the maxilla and AMD are plausible treatment options for cleft maxillary advancement. Due to less stability and restricted amount of possible advancement, Le-fort I osteotomy should be reserved for minor skeletal discrepancies in cleft patients.
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CASE REPORTS Top

Proboscis lateralis with cleft lip and palate and its surgical management p. 56
Srinivas Gosla Reddy, Megha Sahu
DOI:10.4103/jclpca.jclpca_16_20  
Proboscis lateralis (PL) is an uncommon facial abnormality presented as soft tubular structure with most often originating from the medial canthal region. PL is an ideal choice for heminose reconstruction, provided started at a younger age. This multiphase treatment implements the planning of cartilaginous supports in the late teenage. A 6-year-old female patient diagnosed with PL, conjoined with craniofacial deformities such as cleft lip and palate is discussed in this case report.
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Case report on congenital syngnathia: Surgery and a 4-year follow-up p. 60
Parit Ladani, Niyati Satish Balse, Bhalchandra Jayakar, Hermann Sailer
DOI:10.4103/jclpca.jclpca_24_20  
Syngnathia is an extremely rare craniofacial malformation affecting the upper and lower jaws, in particular, and adjacent bony and soft tissues, to lesser or greater extent. Fusion of jaws leads to complications such as compromised airway and breathing, feeding difficulty, and poor growth. An early multidisciplinary intervention, surgery at the appropriate time, and meticulous postoperative monitoring are most imperative in its management. We describe a case of a 6-month-old child with congenital syngnathia that was managed successfully. Four-year follow-up revealed satisfactory outcomes and the need for corrective jaw surgeries after growth completion for improved function and esthetics. Anesthesia considerations, feeding, surgical management, postoperative care, and follow-up as well as growth regulation have been discussed in detail.
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Tessier cleft type 5 craniofacial anomaly – A rare oblique facial cleft p. 65
Zynul Ali Sirsmith John, Sunita S Shrivastav, Nitin Bhola
DOI:10.4103/jclpca.jclpca_17_20  
One of the rarest types of craniofacial malformations is Tessier cleft type 5. These are oblique facial clefts with bony defect representing an alveolar cleft in the premolar region. This extends to the lateral surface of the maxilla up to the infraorbital rim and orbital floor. The cleft begins in the upper lip, just medial to the commissure, and extends up to the eyelid. They may also show deficient maxillary growth on the side of the cleft, clinically represented as constriction in the maxilla and occlusal cant. It becomes very challenging to treat such cases and requires a team approach. The goals of such cases include surgical repair of the lower eyelid and outer canthus, expansion of the arch and alignment, Bone grafting for the alveolar cleft, zygomatic region, and orbital rim to restore the continuity. The following is a case report of Tessier type 5 facial cleft describing the clinical features, diagnosis, and treatment approach for the case.
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Presurgical intervention of bilateral cleft lip and palate using nasoalveolar molding with a microfiber head cap p. 69
Najla S Alrejaye, Muhannad H Alharbi, Hussam M Alqahtani, Mosleh S Alharbi
DOI:10.4103/jclpca.jclpca_26_20  
Nasoalveolar molding (NAM) was introduced by Grayson et al. in 1993. NAM helps with reshaping of the maxillary arch deformity and nose before surgical lip repair. NAM involves lengthy and extensive use of taping and skin barriers to the infant's cheeks, which usually causes skin irritation and discomfort. This is a case report describing NAM, for an infant with bilateral cleft lip and palate and severely malpositioned premaxilla. In this case, a special head cap with straps was used to secure the NAM appliance instead of the conventional taping. After NAM, there was a significant improvement in the cleft deformity. The parents were very satisfied about the result and felt much more comfortable using the head cap with the special straps compared to the conventional taping because it reduced cheek irritation and was much easier to use.
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Management of median cleft lip p. 73
S Manu Prasad, P Aravind Nair, N Anushree, K Harish
DOI:10.4103/jclpca.jclpca_34_20  
Median cleft or midline cleft is a congenital vertical cleft through the center of the upper lip. Median facial anomalies are broadly divided into those with a deficiency of tissue and those with normal or excessive amount of tissue. The main objective of concern during surgery is both functional and esthetics.
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A case of congenital neurovascular hamartoma with midline cleft of the upper lip p. 76
Siddhartha Chatterjee, Debolina Pramanick, Vivek R Raythatha
DOI:10.4103/jclpca.jclpca_31_20  
Developmental hamartomas are dysmorphic proliferation of native tissues which unlike neoplasms do not grow continuously and are mostly seen in infancy and childhood. Hamartoma of neurovascular origin can present itself as upper lip malformation. These lesions sometimes regress spontaneously while some require surgical intervention. Here, we report a case of congenital neurovascular hamartoma with midline cleft of the upper lip, tongue tie, and lower lip pits in a 4-month-old baby, managed by surgical intervention.
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LETTER TO THE EDITOR Top

Cephalometric evaluation of skeletal base relationship in patients with cleft lip and palate in a tertiary hospital in South India p. 80
Isha Duggal, Aditya Talwar, Ritu Duggal
DOI:10.4103/jclpca.jclpca_40_20  
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ERRATUM Top

Erratum: Classification of cleft lip and palate p. 82

DOI:10.4103/2348-2125.168358  
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Erratum: Modifications in the mouth gag p. 83

DOI:10.4103/2348-2125.168357  
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NOTICE OF RETRACTION Top

Retraction: Pathologic anatomy of the soft palate, part 2: The soft tissue lever arm, pathology, and surgical correction p. 84

DOI:10.4103/2348-2125.306783  
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