miércoles, 17 de septiembre de 2014

Botulinum Toxin to Improve Results in Cleft Lip Repair



A scar represents dermal fibrous replacement tissue and results from a wound that has healed by resolution rather than regeneration. Undesirable scars, such as hypertrophic or keloid scars, occur most frequently over the anterior chest, shoulders, scapular area, lower abdomen, and suprapubic region.6 The skin of the upper lip is also at risk of hypertrophic scars because of the repetitive movements of the underlying orbicularis oris muscle during speech, eating and drinking, and facial expression that transmit tension forces that distract and widen the healing wound. The incidence of hypertrophic upper lip scars ranges between 12 and 27 percent in the mixed population but increases when controlled for ethnicity to 32.2 percent in Hispanics and 36.3 percent in Asians.1,7,8 In addition, primary cheiloplasty scars are more conspicuous because they do not align with the relaxed skin tension lines of the face.

A patient’s cheiloplasty scar is a lifelong marker that he or she was born with a cleft lip. The position of a cheiloplasty scar makes it difficult to conceal, and its conspicuity can inflict significant psychological impact on its bearer. According to a structured semiquantitative survey of 97 elective/aesthetic surgical patients, 91 percent would value even a small improvement in the quality of their scar.9 Patients were dissatisfied with surgical scars irrespective of their sex, age, ethnicity, or geographic location, and wished their scars were less noticeable. With current cheiloplasty techniques, the anatomy of the lip can be restored adequately.10 As a result of charitable funding from the Noordhoff Craniofacial Foundation, almost all patients presenting to our center with cleft lip are able to undergo cheiloplasty at approximately 3 months of age. Our own survey of patients treated at our center revealed that more than 90 percent would regard even a small improvement in their cheiloplasty scar to be worthwhile (unpublished data). This is despite our use of several established strategies to attempt to optimize cheiloplasty scars in our center.

First, we repair the orbicularis oris muscle so that it bears the majority of the tension of the wound. This causes the overlying skin to become slightly redundant (and therefore tension-free), which allows enough skin for philtral column reconstruction on the cleft side. Second, we strictly use wound taping to minimize tension across the lip. These tapes span across the upper lip from cheek to cheek and are placed purposefully so that the nasolabial folds are deepened (and thus the skin is redundant) and the upper lip protrudes. Adhesive tape has been used by plastic surgeons for decades, with or without sutures, to reduce wound tension to prevent hypertrophic scar formation.11–13Third, we strictly use silicone gel sheeting over the scar when the baby is asleep. Topical silicone preparations have been recommended in the management of hypertrophic and keloid scars and are known to reduce the recurrence of hypertrophy following scar revision surgery in patients at higher risk of hypertrophic scarring.14,15 The benefit of topical silicone is less clear in patients who lack a history of abnormal scarring.15 Although there remains a lack of consensus as to whether topical silicone gel sheets should be applied routinely for upper lip cheiloplasty scars, this has remained routine practice at our center for many years.10 The compliance with lip taping and silicone sheets is very high in our population. The parents are well supported in this regard both by each other (many, if not most, of the parents of our children who have been operated on are routinely in contact on social media groups to encourage compliance) and by our Noordhoff Craniofacial Foundation social workers. The use of taping and topical silicone and the method of lip repair were all constant in this study; the only variable, which was blinded, was whether the vial for injection contained botulinum toxin or vehicle alone.

The contraction of the muscles of facial expression cause increased skin tension and the accentuation of dynamic rhytides that are often considered cosmetically undesirable. Carruthers et al. first realized that patients treated with botulinum toxin chemodenervation for blepharospasm experienced concurrent improvements in their dynamic glabella rhytides, sparking its widespread use in aesthetic practices ever since. Similarly, Gassner et al. injected botulinum toxin around frontal wounds to chemoimmobilize underlying musculature and therefore reduce wound tension during scar formation, with resultant improvements in cosmetic outcomes in an animal study.16Several human studies have since demonstrated that the injection of botulinum toxin can improve facial scars.17–20 Tollefson et al. first published the use of botulinum toxin to immobilize the upper lip for cheiloplasty in three cleft infants aged 3 to 6 months.2 However, it was unknown whether the botulinum toxin was responsible for the satisfactory aesthetic results that they reported. Galárraga injected the upper lips of five children undergoing cheiloplasty intraoperatively.3Electromyographic tracings proved that significant reductions in orbicularis oris muscular activity were resulting from the botulinum toxin treatment. Again, although the author hypothesized that this chemoimmobilization might benefit scarring, no direct evidence for the benefit of botulinum toxin was provided.

We investigated botulinum toxin injection as an additional potential intervention that might further improve our cheiloplasty scars over and above our established protocolized techniques. To our knowledge, this current study represents the first objective and subjective evaluation of scars following botulinum toxin injection into the upper lip during cheiloplasty. Although there was no significant difference in Vancouver Scar Scales between the experimental and control groups, photographic visual analogue scale and photographic measurements both revealed consistently better appearing and narrower scars as a result of botulinum toxin treatment compared with vehicle controls


No complications (i.e., infection, bleeding, wound dehiscence, oral incontinence, or feeding dysfunction) were found. Pascual-Pascual and Pascual-Castroviejo studied the safety of botulinum toxin type A in children younger than 2 years. The dosage used for obstetric brachial plexus palsy and cerebral palsy of 6.55 units/kg, which is much higher than the dosage required for chemodenervation of the orbicularis oris muscle, was considered safe.21 Moreover, neither of the previous studies that used botulinum toxin type A injection into the orbicularis oris muscle reported complications such as feeding difficulties.

CONCLUSIONS


These results indicate that our established method of upper lip repair and mechanical immobilization by taping is controlling well against wound tension in infants caused by orbicularis oris but that botulinum toxin has an additional beneficial effect on scar width that, although small, is subjectively noticeable. According to the Vancouver Scar Scale, however, botulinum toxin provided no additional benefits for scar pigmentation, vascularity, pliability, or height of cheiloplasty scars.


REFERENCE

1. Soltani AM, Francis CS, Motamed A, et al. Hypertrophic scarring in cleft lip repair: A comparison of incidence among ethnic groups. Clin Epidemiol. 2012;4:187–191

2. Tollefson TT, Senders CM, Sykes JM, et al. Botulinum toxin to improve results in cleft lip repair. Arch Facial Plast Surg. 2006;8:221–222

3. Galárraga IM. Use of botulinum toxin in cheiloplasty: A new method to decrease tension. Can J Plast Surg. 2009;17:e1–e2

4. Noordhoff MS, Chen Y, Chen K, et al. The surgical technique for the complete unilateral cleft lip nasal deformity. Oper Techn Plast Reconstr Surg. 1995;2:167–174

5. Chang CS, Por YC, Liou EJ, Chang CJ, Chen PK, Noordhoff MS. Long-term comparison of four techniques for obtaining nasal symmetry in unilateral complete cleft lip patients: A single surgeon’s experience. Plast Reconstr Surg. 2010;126:1276–1284

6. Ogawa R. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg. 2010;125:557–568

7. Wilson AD, Mercer N. Dermabond tissue adhesive versus Steri-Strips in unilateral cleft lip repair: An audit of infection and hypertrophic scar rates. Cleft Palate Craniofac J. 2008;45:614–619

8. Onizuka T, Ichinose M, Hosaka Y, Usui Y, Jinnai T. The contour lines of the upper lip and a revised method of cleft lip repair. Ann Plast Surg. 1991;27:238–252

9. Young VL, Hutchison J. Insights into patient and clinician concerns about scar appearance: Semiquantitative structured surveys. Plast Reconstr Surg. 2009;124:256–265

10. Chen PKT, Noordhoff MS, Kane ANeligan PC. Repair of unilateral cleft lip. Plastic Surgery. 2013;Vol. 3 New York Elsevier Saunders:517–549 In:

11. Atkinson JA, McKenna KT, Barnett AG, McGrath DJ, Rudd M. A randomized, controlled trial to determine the efficacy of paper tape in preventing hypertrophic scar formation in surgical incisions that traverse Langer’s skin tension lines. Plast Reconstr Surg. 2005;116:1648–1656; discussion 1657

12. Reiffel RS. Prevention of hypertrophic scars by long-term paper tape application. Plast Reconstr Surg. 1995;96:1715–1718

13. Gibson EW, Poate WJ. The use of adhesive surgical tape in plastic surgery. Br J Plast Surg. 1964;17:265–270

14. Mustoe TA, Cooter RD, Gold MH, et al.International Advisory Panel on Scar Management. International clinical recommendations on scar management. Plast Reconstr Surg. 2002;110:560–571

15. Liu A, Moy RL, Ozog DM. Current methods employed in the prevention and minimization of surgical scars. Dermatol Surg. 2011;37:1740–1746

16. Gassner HG, Sherris DA, Otley CC.. Treatment of facial wounds with botulinum toxin A improves cosmetic outcome in primates. Plast Reconstr Surg. 2000;105:1948–1953; discussion 1954–1955

17. Gassner HG, Sherris DA, Friedman O. Botulinum toxin-induced immobilization of lower facial wounds. Arch Facial Plast Surg. 2009;11:140–142

18. Gassner HG, Brissett AE, Otley CC, et al. Botulinum toxin to improve facial wound healing: A prospective, blinded, placebo-controlled study. Mayo Clin Proc. 2006;81:1023–1028

19. Wilson AM. Use of botulinum toxin type A to prevent widening of facial scars. Plast Reconstr Surg. 2006;117:1758–1766; discussion 1767

20. Flynn TC. Use of intraoperative botulinum toxin in facial reconstruction. Dermatol Surg. 2009;35:182–188

21. Pascual-Pascual SI, Pascual-Castroviejo I. Safety of botulinum toxin type A in children younger than 2 years. Eur J Paediatr Neurol. 2009;13:511–515
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miércoles, 10 de septiembre de 2014

Cleft Lip & Cleft Palate

Cleft lip, cleft palate, and combinations of the two are the most common congenital anomalies of the head and neck. The incidence of facial clefts has been reported to be 1 in every 650–750 live births, making this deformity second only to clubfoot in frequency as a reported birth defect.
The cleft may involve the floor of the nostril and lip on one or both sides and may extend through the alveolus, the hard palate, and the entire soft palate. A useful classification based on embryologic and anatomic aspects divides the structures into the primary and the secondary palate. The dividing point between the primary palate anteriorly and the secondary palate posteriorly is the incisive foramen. Clefts can thus be classified as partial or complete clefts of the primary or secondary palate (or both) in various combinations. The most common clefts are left unilateral complete clefts of the primary and secondary palate and partial midline clefts of the secondary palate, involving the soft palate and part of the hard palate.
Most infants with cleft palate present some feeding difficulties, and breast-feeding may be impossible. As a rule, enlarging the openings in an artificial nipple or using a syringe with a soft rubber feeding tube will solve difficulties in sucking. Feeding in the upright position helps prevent oronasal reflux or aspiration. Severe feeding and breathing problems and recurrent aspiration are seen in Pierre Robin sequence, in which the palatal cleft is associated with a receding lower jaw and posterior and cephalic displacement of the tongue, obstructing the naso-oropharyngeal airway. This is a medical emergency and is a cause of sudden infant death syndrome (SIDS). Nonsurgical treatment includes pulling the tongue forward with an instrument and laying the baby prone with a towel under the chest to let the mandible and tongue drop forward. Insertion of a small (No. 8) nasogastric tube into the pharynx may temporarily prevent respiratory distress and may be used to supplement the baby’s feedings. Placement of an acrylic obturator or appliance has proved quite successful in alleviating the breathing difficulties by bringing the tongue down and permitting a better nasal airway. Several surgical procedures that bring the tongue and mandible forward have been described but should be employed only when conservative measures have been tried without success. Recently, the use of distraction of the mandible has shown some beneficial effects. However, it should be done with great caution in the neonate.
Treatment
Surgical repair of cleft lip is not considered an emergency. The optimal time for operation can be described as the widely accepted “rule of 10.” This includes body weight of 10 lb (4.5 kg) or more and a hemoglobin of 10 g/dL or more. This is usually at some time after the 10th week of life. In most cases, closure of the lip will mold distortions of the cleft alveolus into a satisfactory contour. In occasional cases in which there is marked distortion of the alveolus, such as in severe bilateral clefts with marked protrusion of the premaxilla, preliminary maxillary orthodontic treatment may be indicated. This may involve the use of carefully crafted appliances or simple constant pressure by use of an elastic band.
General endotracheal anesthesia via an orally placed endotracheal tube is the anesthetic technique of choice. A variety of techniques for repair of unilateral clefts have evolved over many years. Earlier procedures ignored anatomic landmarks and resulted in a characteristic “repaired harelip” look. The Millard rotation advancement operation that is now commonly used for repair employs an incision in the medial side of the cleft to allow the Cupid’s bow of the lip to be rotated down to a normal position. The resulting gap in the medial side of the cleft is filled by advancing a flap from the lateral side. This principle can be varied in placement of the incisions and results in most cases in a symmetric lip with normally placed landmarks. Bilateral clefts, because of greater deficiency of tissue, present more challenging technical problems. Maximum preservation of available tissue is the underlying principle, and most surgeons prefer approximation of the central and lateral lip elements in a straight line closure, rolling up the vermilion border of the lip (Manchester repair).
Secondary revisions are frequently necessary in the older child with a repaired cleft lip. A constant associated deformity in patients with cleft lip is distortion of the soft tissue and cartilage structures of the ala and dome of the nose. These patients often present with deficiency of growth of the structures of the mid face. This has been attributed to intrinsic growth disturbances and to external pressures from the lip and palate repairs. Some correction of these deformities, especially of the nose, can be done at the initial lip operation. More definitive correction is done after the cartilage and bone growth is more complete. These may include scar revisions and rearrangement of the cartilage structure of the nose. Recent approaches involve degloving of the nasal skin envelope with complete exposure of the abnormal cartilage framework. These are then rearranged in proper position with or without additional grafts. Maxillary osteotomies (Le Fort I with advancement) will substantially correct the midfacial depression. A tight upper lip due to severe tissue deficiency can be corrected by a two-stage transfer of a lower lip flap known as an Abbe flap.
In utero repair of cleft lip deformities has recently become a topic of discussion. In utero repair affords the potential to provide a scarless repair and correct the primary deformity. Furthermore, scarless fetal lip and palate repairs may prevent the ripple effect of postnatal scarring with its resultant secondary dentoalveolar and midface growth deformities. While these suggestions make in utero repair attractive, the risk of fetal loss remains high. Preterm labor is a major complication and one that is directly related to the large hysterotomy required for fetal exposure. Due to the great risks associated with it, intrauterine fetal surgery is still largely reserved for severe malformations that cannot be helped significantly by postnatal intervention.
Palatal clefts may involve the alveolus, the bony hard palate, or the soft palate, singly or in any combination. Clefts of the hard palate and alveolus may be either unilateral or bilateral, whereas the soft palate cleft is always midline, extending back through the uvula. The width of the cleft varies greatly, making the amount of tissue available for repair also variable. The bony palate, with its mucoperiosteal lining, forms the roof of the anterior mouth and the floor of the nose. The posteriorly attached soft palate is composed of five paired muscles of speech and swallowing.
Surgical closure of the cleft to allow for normal speech is the treatment of choice. The timetable for closure depends on the size of the cleft and any other associated problems. However, the defect should be closed before the child undertakes serious speech, usually before age 2. Closure at 6 months usually is performed without difficulty and also aids in the child’s feeding. If the soft palate seems to be long enough, simple approximation of the freshened edges of the cleft after freeing of the tissues through lateral relaxing incisions may suffice. If the soft palate is too short, a pushback type of operation is required. In this procedure, the short soft palate is retrodisplaced closer to the posterior pharyngeal wall utilizing the mucoperiosteal flaps based on the posterior palatine artery.
Satisfactory speech following surgical repair of cleft palate is achieved in 70–90% of cases. Significant speech defects usually require secondary operations when the child is older. The most widely used technique is the pharyngeal flap operation, in which the palatopharyngeal space is reduced by attaching a flap of posterior pharyngeal muscle and mucosa to the soft palate. This permits voluntary closure of the velopharyngeal complex and thus avoids hypernasal speech. Various other kinds of pharyngoplasties have been useful in selected cases.
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Estes JM et al: Endoscopic creation and repair of fetal cleft lip. Plast Reconstr Surg 1992;90:743.  [PubMed: 1410025] 
Lorenz HP, Longaker MT: In utero surgery for cleft lip/palate: minimizing the “ripple effect” of scarring. J Craniofac Surg 2003;14:504. 
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