Plastics

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=====Dr. Phuong Introduction=====

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===== Operative Reports =====

**Diagnosis:**\\
1.	Unilateral Cleft Palate\\
2.	Residual Cleft Lip Deformity\\
 
**Procedure:**\\
1.	Primary cleft palate repair using hybrid left-sided Von Langenbeck bipedicled flap and right sided due to pedicled Bardach flap with intravelarveloplasty\\
2.	Right-sided pedicled buccal fat flap\\
3.	Secondary cleft lip revision for shortened lip\\
4.	Kenalog injection to left lip\\
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**Findings:** Left-sided unilateral cleft palate, Veau 3.  Previous nasal floor closure of anterior palate. Shortened lip status post previous repair.\\
 
Indications for Operation: This is a 13-month-old male with a history of complete unilateral left cleft lip, alveolus and palate.  He previously underwent primary lip repair in January 2024.  He did well from this.  However over time his lip scar began to shorten and contract.  He was now ready for his cleft palate repair as previously scheduled.  I also discussed that we could perform a lip revision at the same time with the patient's parents.  Risks of today's surgery include but are not limited to bleeding, infection, pain, injury to surrounding structures, fistula, poor wound healing, need for reoperation.  They understood these risks and wished to proceed.\\
 
Procedure in Detail: The patient was brought to the operating room table and placed in supine position.  After adequate intravenous access was established he was given general anesthesia and intubated using an oral rae tube.  The patient's face was then prepped and draped in standard surgical fashion a surgical timeout correctly identifying the patient and the procedure was performed.  We began with the palate.  A Dingman retractor was placed into the oral cavity.  Upon initial inspection the patient did have a unilateral complete cleft palate which is a Veau 3.  The anterior nasal floor had previously been closed during the lip repair.  The palatal defect with at the hard soft palate junction was 9 mm.  Thus at this time we infiltrated both palatal sides with a 50-50 mixture of 1% lidocaine with epinephrine and 0.25% bupivacaine with epinephrine.  We began on the left side.  This was lesser segment.  We began by incising along the lateral edge behind the retromolar trigone and extending anteriorly.  We left the anterior segment intact as this would be a bipedicle flap.  We then incised the medial mucosa using 11 blade down to the level of the uvula.  We continued anteriorly using a 15 blade.  We then used a Cottle elevator to elevate the palatal flap off the hard palate.  The greater palatine artery was identified and preserved.  We then continued dissection laterally through the tensor veli palatini any of the hamulus.  Next we then used a 15 blade as well as a tenotomy scissors to dissect the palatoglossus and levator veli palatini off of the nasal mucosa and oral mucosa.  There was is then retroposition and brought medially.  We then dissected off the nasal mucosa off the hard palate using a Cottle elevator.  Attention was turned towards the right side.  This was the greater segment.  Lateral incision was made with a 15 blade and deepened with electrocautery.  We then brought this up such that the anterior aspect of the palatal flap was disconnected and this would be a pedicled flap off the greater palatal skin vessel.  The greater palatine vessel was identified and preserved.  There was a foramen here and we did use a small osteotome to liberate it and its posterior edge.  We then dissected the medial edge using 11 blade through the uvula.  We dissected off the palatoglossus and levator really palpitated again off of the nasal mucosa and oral mucosa using a 15 blade.  This was also retroposition.  We further dissected the nasal mucosal off of the vomer and this was flipped over such that we could get nasal floor closure.  We also dissected the tensor regular palpitating off of the hamulus.  These maneuvers allowed us to medialize the 2 flaps for straight line repair.  We began by repairing the uvula using interrupted horizontal mattress 4-0 Vicryl suture.  We then closed the nasal floor using buried 4-0 Vicryl sutures moving from posterior to anterior.  Next we then performed an intravelar veloplasty using interrupted 4-0 Vicryl sutures through the levator veli palatini muscle bundles.  Next we then performed oral closure using interrupted sutures for the uvula and horizontal mattress 4-0 Vicryl sutures moving from posterior to anterior.  At the level of the alveolus we did perform a 3 point suture horizontal mattress in order to completely close off the primary palate.  This left us with a relatively large raw space at the lateral gutter.  Thus we then made an incision along the right buccal mucosa.  We then used a right angle dissector to tease out the buccal fat.  This was pedicled.  We then brought this behind the retromolar trigone and inset this into the raw gutter using 4-0 Vicryl sutures.  We then closed the donor site using interrupted 4-0 Vicryl sutures.  The wounds were irrigated with normal saline.  We then instilled saline through the nose and there was no leakage through the palatal repair.  The Dingman retractor was removed.  Next we then turned our attention towards the lip.  He did have a shortened lips from the previous anatomic subunit repair.  He also had a hypertrophic scar.  We designed a diamond-shaped ellipse to go through two thirds of the cutaneous lip and into the wet lip.  After infiltration of our local anesthetic we made incision with a 15C blade.  This went through the dermis leaving behind the orbicularis oris which was well approximated.  We then dissected up subdermal flaps using a combination of cautery and iris scissors.  We then used the Rose Thompson affect in order to lengthen this lip by closing the ellipse.  This was done using 5-0 Monocryl suture for the deep dermis taking care to align the vermilion border.  We also aligned the wet dry lip junction using 5-0 chromic sutures in vertical mattress format in order to evert the edges.  The remainder of the cutaneous lip was closed with 5-0 Monocryl suture for the deep dermis and 6-0 chromic sutures for the skin.  We then injected 1 cc of Kenalog into this closed wound.  It was covered with Dermabond.  The patient tolerated the procedure well.  He was awakened and extubated and taken to the postanesthesia care unit in stable condition. As the attending surgeon I was present for and performed all the critical aspects of this procedure.


**Bilateral complete Cleft Primary Repair **\\
Indications for Operation: This is a 10-month-old female with a history of bilateral complete cleft lip and palate and alveolus.  She previously underwent primary cleft lip repair on 7/12/2024.  She had done well from this overall.  However she did develop a bit of scar contracture at the wet lip midline.  She was now ready for her palate repair as well as lip revision.  We discussed repair of this.  Risk include but are not limited to bleeding, infection, pain, dehiscence, oral nasal fistula, and need for reoperation.  They understood these risks and wished to proceed.  Informed consent was obtained today.
 
Procedure in Detail: The patient was brought to the operating room table and placed in supine position.  After adequate intravenous access was established she was given general anesthesia and intubated endotracheally with an oral rae tube.  The patient's face was then prepped and draped in standard surgical fashion.  A surgical timeout correctly identifying the patient and procedures performed.  Began by placing a Dingman retractor into the intraoral cavity.  We infiltrated the palate with a 50-50 mixture of 1% lidocaine with epinephrine and 0.25% bupivacaine.  It was a wide cleft palate, Veau 4.  It was 12 mm width at the hard soft palate junction.  Attention was then turned towards the lip while obtaining epinephrine vasoconstriction.  There was a central divot at the midline mucosa.  We marked out an ellipse measuring 1 cm x 8 mm.  After infiltration with local anesthetic incision was made with a 15 blade down to the level of the orbicularis oris.  This was left intact.  We removed the central mucosal segment.  We then developed flaps bilaterally each side above the orbicularis oris.  We then used horizontal mattress and interrupted 5-0 chromic sutures in order to evert this mucosa such that she would not have a contracted concavity.  This was a adjacent tissue transfer measuring 1 x 1 cm.  Attention was then returned towards the palate.  We planned on bilateral bardach flaps.  Began on the left by incising the medial edge with a 15 blade and the lateral edge with a 15 blade up through the anterior portion of the hard palate.  This was then elevated using a Freer elevator off the hard palate.  The greater palatine vessel was identified and preserved.  It was encased in bone as a foramen.  We then dissected over the hamulus as well using electrocautery.  We then began dissecting the levator really pellety any and palatoglossus muscles off of the nasal mucosa using a tenotomy scissors.  This was pushed back towards the levator tunnel and brought towards the medial edge said that it was a muscle bulk.  We then dissected the nasal mucosal lining off using a Cottle elevator off the hard palate.  We performed the same maneuvers on the right side again preserving the greater palatine vessel.  This was also encased within bone.  As such we did use a small 2 mm osteotome in order to liberate the vessel from both sides.  This afforded more medialization of the oral mucosal flaps such that we could get a little decreased tension closure.  Once all these maneuvers were performed we then began our closure.  The uvula was approximated using interrupted 4-0 Vicryl suture.  The nasal lining was closed in interrupted fashion using buried 4-0 Vicryl sutures.  At the level of the hard soft palate junction there was significant tension.  As such we used a vomer flap by incising down the midline of the vomer and elevating the vomer mucosa using a Cottle elevator bilaterally.  We then closed these on each side using interrupted 4-0 Vicryl sutures for complete nasal lining closure.  Next we performed an intravelar veloplasty of the levator really palpitating and palatoglossus muscle bundle.  This was done using figure-of-eight 4-0 Vicryl sutures.  Of note the muscle was somewhat tenuous and we ensured that it was brought over past the midline for horizontal coverage.  Lastly we then closed the oral mucosa using interrupted horizontal mattress 4-0 Vicryl sutures.  With the addition of the liberation of the palatine vessels from the bony foramen that we were able to get a relatively tension-free closure.  This resulted in raw side gutters of the donor site.  We did make an incision through the cheeks bilaterally use electrocautery in order to attempt a buccal pedicle fat flap.  However after further dissection it did not appear that there was significant buccal fat tissue that could be brought into this defect.  Unfortunately this was the case bilaterally.  As such we then close using a running 4-0 Vicryl suture for the cheek mucosa.  We placed Surgicel within the gutters and a spanning 4-0 Vicryl suture to keep them in place.  A throat pack placed at the beginning of the case was removed.  The patient tolerated the procedure well.  As the attending surgeon I was present for and performed other critical aspects of this procedure.  Amber Matzoll, PA-C was my first assist as there were no qualified residents available.  She assisted in dissection elevation of the flaps and palatal closure as well as the adjacent tissue transfer of the upper lip.