Plastics

• Blank
  

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.