04 Surgery

Question 1

Describe a lip repair

Answer 1

To repair the muscular continuity of the upper lip
(Orbicularis oris)
To make the lip aesethelicty pleasing by closing the lip
This is done first unless there is a bilateral cleft

Question 2

What is the rules of 10s?

Answer 2

Rule of 10’s. 10 lbs., 10 grams of hemoglobin (O2 in the blood) to tolerate the effects of anesthesia, and about 10 weeks of age

Question 3

What is NAM (Nasal-Alveolar Molding)

Answer 3

-other procedures to bring the cleft segments closer together

Question 4

with a Bilateral cleft you need to do what first?

Answer 4

You need to do a procedure to move the lip down, premaxilla, and nasal spine into the place with taping

Question 5

The first type of lip repair was ___________

Answer 5

straight line repair

-Pulls down the nose and nare (kind of like a flap)
you cut off some tissue, raise tissue on the other side, and overlap the tissue
-used as an adhesion to pull alveolar segments together across a really wide alveolar cleft AND then do a typical repair later

Question 6

What is the problem with a straight line repair?

Answer 6

It can be too tight so it tends to impede the growth of the maxilla

Question 7

What is a Triangular flap repair, aka Tennison-Randall?

Answer 7

• Cuts out a section of tissue on both sides and then the lip can be pulled down, so you lengthen the lip a little bit
• Although you get lengthening you get tightening because tissue is removed
• Longer rostral dorsal line, but have more tension laterally from left to right
• Good for unilateral cleft

Question 8

What is the Millard rotation-advancement technique ?

Answer 8

• is much more useful for a bilateral cleft because –you are not cutting out any tissue & pulling it away
• it’s a geometric design in order to get lengthening of the lip but no tissue is removed
• not as tight

Question 9

When surgeons do a palate repair it is usually a ________

Answer 9

soft tissue repair

Question 10

Describe a one stage surgical repair

Answer 10

• Done around 10-24 months of age
• Free flap repair
• The tissue is cut from the palatal shelves that are present—or surrounding structures—placed over the cleft and sutured into place

Question 11

What are the two types of tissue you can cut from the palatal shelves?

Answer 11

a oral surface and nasal surface

Question 12

Name the 5 types of free flap, one stage repair surgeries.

Answer 12

1. Furlow z-plasty
2. Von Langenbeck
3. V-Y retroposition procedure, aka Wardill pushback
4. Vomer flap

Question 13

Explain a free flap repair

Answer 13

-Tissue taken from some place else and transplanted
-The exception: if you can’t scrape up enough tissue in the palate
Problem: establishing blood supply

Question 14

T/F the furlow z-plasty if for the soft palate repair

Answer 14

True it is velum repair
-So they’ll cut the tissue, shift the tissue towards the posterior, and lengthen the soft palate

• tissue is removed from the nasal and oral side from the palatal shelves –> double cross over so the tissue pair is as strong as you can make it
• a z-plasty is normally a revision surgery if they didn’t get enough length in the first palatal repair

Question 15

the Von Langenbeck surgery is typical for a _______ repair

Answer 15

hard palate repair

• Pulling up flaps of tissue, and then bringing it to the midline, bridging edges of tissue together with a surgical stitch
• can be done on oral or nasal surface
• pulling palatal tissue and tapering it over with the soft tissue

Question 16

Describe the V-Y retroposition procedure, aka Wardill pushback

Answer 16

• There is no bone graphed
• they’re cutting these slits almost like vents or darts in the tissue
  
  • > it will give you more length in the tissue
• you open up a gap by cutting it and pull the tissue backwards

-Lengthening your repair which will lengthen the velum

Question 17

The Vomer flap may go with Wardill pushback, why?

Answer 17

• it creates Nasal septum flaps on the superior surface to cover a really massive gap
• on the oral side it’s not flaps, its opening vents BUT on the nasal side it may take tissue to close the clefts
• on the inferior surface (oral side) you might take off tissue from the nasal septum and paper over the large gap

Question 18

What is a two stage surgery?

Answer 18

-Done around 12 and then 24 months
-A same surgical procedure but you fix the velum (z-plasty) wait a little bit for facial growth and then close the hard palate
-You Repair soft palate first
BUT no advantage so will disappear speech is worse

Question 19

T/F a spreader causes a fistulae

Answer 19

False, it is due to pressure placed in that area;

at some point there is tissue dehiscence

Question 20

Does a fistula always affect speech?

Answer 20

• no, effects depends on size and location
• In the alveolar ridge (anterior) practically has no affect, no matter the size
• A posterior fistula even though it’s really small may have a huge affect on speech

Question 21

A functional fistula has an affect on what sounds and functions?

Answer 21

• on pressure consonants air will leak
• If a fistula has an effect on speech, eating, or drinking, as in air, food, or liquid can pass through it and gets into the nose

Question 22

Orthognathic surgery is usually on the ?

Answer 22

• the most simple and most common surgery is the alveolar bone graft because of cleft in the alveolus
• Bone graft to the alveolus
• when the repair is initially done, it goes to the alveolus and it stops
• they remove bone from iliac crest (hip and skull are best)

Question 23

Timing of the bone graft is controversial in Orthognathic surgery. What is the the average year?

Answer 23

about 9 or 10 years of age because incisors are coming in

• remember the issue is having enough room for the teeth to come in
• The hope is that the incisors and cuspids will come in where they’re supposed to through living bone

Question 24

What is a maxillary osteotomy ?

Answer 24

-Surgical repairs on bone/tissue disrupt blood supply, nerve supply, growth.
-So, palate repair no matter what kind, in infancy may then later require corrective surgery to approximate a normal growth pattern
normalize profile and bite
-Cleft on it’s own has facial retardation growth and then tissue ruins growth

Question 25

What are the Le Fort procedures?

Answer 25

maxillary corrective surgery are done by an oral-maxillary surgeon.

Three types of Le Forts

Question 26

Explain what happens in the Le Fort I

Answer 26

JUST the alveolar area of the maxilla is brought forward to match the upper and lower arch
-it fixes mid face hypoplasia growth
(lack of mid face growth)
-Move upper alveolar arch forward (with teeth and all)
-so they cut the jaw, separate a section, pull the alveolar ridge forward

Question 27

Explain a Le fort II

Answer 27

• A much bigger part of the maxilla is moved/advanced

- Including the bridge of the nose

Question 28

Explain a Le For III

Answer 28

• cranial surgeon
• includes the maxillary all the way to the orbit of the eye is pulled forward
• the skin is peeled off from the skull

Question 29

T/F Maxillary advancement can create velopharyngeal disfunction

Answer 29

True, you can potentially create a new problem

• pull forward the velum (because its attached to the hard palate) and you can potentially create hyper nasality
• because your pulling it away from the posterior pharyngeal wall

Question 30

What is a Mandibular osteotomy?

Answer 30

The mandible is cut to make it shorter in class 3 malocclusions

• May done with Fort I to shorten the jaw
• May done in combination with Fort II

Question 31

Distraction osteogenesis is good for Pierre Roband, Golden heart syndrome—hemifacial microsomia. Why?

Answer 31

• You cut one side of her mandible & every day you turn a screw
• Bone lays down but you turn and move the structures every day so as you move the structure, bone is moving in
• when your done with the spreader her mouth will be straight
• Principally this is done for her dentition