Nine-year experience with extended use of the commissure-based buccal musculomucosal flap

This study reports on the extended use of the commissure-based buccal musculomucosal (CBMM) flap. Large lip defects and medium-size intraoral defects have the general problem of being too large for primary closure to avoid a major functional and aesthetic impairment. Elaborate free flaps, such as axial flaps, although excellent in large defects, may not provide mucosa-equivalent sensitivity, motility, volume, and texture to replace lost tissue with a similar kind of tissue. A total of 60 flap procedures were performed with bilateral and unilateral flaps up to 7.5 x 4 cm in size. The partial and total upper and lower vermilion, gingivobuccal sulcus, floor of the mouth, lateral tongue margin, oropharynx, and hard and soft palates were reconstructed. Partial necrosis was seen in four flaps; all patients recovered with good oral function in speech and swallowing, good aesthetics, and prosthetic rehabilitation if necessary. The donor site could be closed primarily. In flaps with dorsal advancement, the mucosal excess above and below was closed, creating two small dog-ears. Facial expression and mouth opening returned to normal after less than 2 months. The parotid duct had to be marsupialized in large flap preparations, but this did never provoke stasis or infection. The two-point sensitivity of the flaps was, on average, equal to that of the nonoperated mucosa in intraindividual correlation, and the flaps lost, on average, 15 percent of their original size. In the authors' estimation, the results indicate a reliable and technically easy option for intraoral, medium-size defect reconstruction that yields sensitivity and facilitates the rehabilitation of oral function in speaking and ingestion.     

Short stay after cleft palate surgery

Although algorithms for the repair of soft and hard palatal clefts continue to be debated, the appropriate length of postoperative stay has not yet been defined. Recent reports of cleft palate repair advocate a 2- to 5-day hospitalization. The plastic surgery service at St. Joseph Hospital frequently uses same-day admission with 23-hour observation postoperatively, with no increase in complications from the reported 2- to 5-day stay.The authors inspected the records for all the cleft palate patients undergoing cleft repair at St. Joseph Hospital Cleft Clinic from August of 1988 through June of 1998. After excluding syndromic patients and secondary or revision surgical cases, 79 patients remained in the study. These 79 patients underwent 104 procedures; all procedures were performed by a single surgeon (E.D.C.) with resident assistance. Short-term morbidity, length of stay, and operation performed were studied. All patients were admitted the day of surgery.Mean age at the time of operation was 13.2 months, with a range of 6 months to 20 years. The length of operation averaged 1 hour and 37 minutes; 94 percent of patients stayed 24 hours or less postoperatively, and 97 percent stayed 36 hours or less. The longest stay was 72 hours, which was related to delay in resuming adequate oral intake. The overall complication rate was 3.8 percent for this cohort, which included two partial palatal dehiscences and two small fistulas. No blood transfusions were needed, and no infections were noted postoperatively. No patients required readmission postoperatively for bleeding, respiratory compromise, or inadequate oral intake.The authors do not advocate a 1-night stay for all cleft palate cases. However, they do think it is safe for a healthy group of patients undergoing routine cleft palate surgery. The decision to discharge a patient early must always be left to the treating physician.     

Effect of cleft palate repair and pharyngeal flap surgery on upper airway obstruction during sleep

The effect of von Langenbeck palatoplasty and pharyngeal flap surgery on upper airway obstruction during sleep was studied by obtaining polysomnographic sleep studies on 10 patients undergoing each procedure at 1 to 2 days prior to surgery, 2 to 3 days postoperatively, and approximately 3 months postoperatively. The effects of von Langenbeck palatoplasty on sleep-related upper airway obstruction were usually minimal and clinically insignificant, whereas severe obstructive sleep apnea was present in all but one of the patients undergoing pharyngeal flap surgery at 2 to 3 days postoperatively. In most patients the upper airway obstruction was resolved at the 3-month postoperative sleep study. These data suggest that palatoplasty carries with it a very slight risk of upper airway obstruction, whereas pharyngeal flap surgery has as a very frequent concomitant the occurrence of severe obstructive sleep apnea in the immediate postoperative period.