Canadian Society of Plastic Surgeons Société Canadienne des Chirurgiens Plasticiens

Abstract

Atrophy plays an extremely important role in facial aging.The current model of aging is based upon loss of volume in the face as the primary physical sign of aging followed or accompanied by sagging or descent of soft tissues.Restoration of fullness to the atrophic, aging upper and midface is essential for successful rejuvenation.Adding fullness to the face is a natural, logical approach to rejuvenation.In the early 1990's, I first noted that transplanted fat did more than just create fullness.The implanted fat improved the quality of the tissues into which it was grafted.This initial improvement is then usually followed by a continued, gradual long-term improvement in the quality of the skin.Wrinkles soften, pore size decreases and pigmentation improves in patients followed over ten years.In addition, fat grafted under depressed scars not only relieves the depression, but also softens or even completely eliminates the specific scar tissue, making it look like normal skin.More recently we have noted the effect of fat grafts on therapeutic radiation injuries.But grafted fat does more than simply restore fullness.Changes occur in skin overlying the grafted sites over time (for instance, immediately after implantation, in the first months, at one year, three years, five years, eight years etc).The volume of the fat appears to stabilize four months after the procedure, but the texture of sun damaged or scarred skin continues to improve dramatically in the ensuing months.The improvement usually continues up to five years and in many cases for almost a decade.While fat grafting was used mainly in aesthetic surgery for many years, we are now applying these same techniques for reconstructive surgery to restore or create facial or corporal forms by manipulation of soft tissues. MethODs:A retrospective review of a single surgeon's prospectively acquired database was undertaken.The study describes: 1) the demographics of the patient population, 2) the distribution of cleft palate type (Veau and Kernahan \& Stark classifications) and cleft severity (palate length and cleft width), and 3) early (fistula rate) and mid-term (rate of secondary surgery for VPI) results.resuLts: 524 palatoplasties were performed from January 1, 2000 through January 1, 2010.Of these cases, 485 primary palatoplasties were performed.The mean age was 20.4 months (range 6.6 months -17.7 years).There were 276 males and 209 females.Clefts were classified according to Kernahan and Stark (CP=260, CL/P=225) and Veau Class (I=85, II-175, III-165, IV-60).Palate length was assessed according to Randall's classification (I=81, II=319, III=58, IV=2).Palate width, measured on the day of surgery, averaged 7.7 mm (range 0-19 mm).The surgical technique used was dictated by cleft type (Veau classification); 78 Furlow, 101 Veau, 191 von Langenbeck, 114 Clarke, and 1 other.There were 4 fistulas (0.8%).To date 50 patients have undergone secondary procedures for VPI (22 secondary Furlow palatoplasties and 28 pharyngeal flap pharyngoplasties).Over this 10 year period, the protocol has been consistent, with two exceptions to be discussed.COnCLusIOns: Demographics, procedures, and results of 485 consecutive palatoplasties are reviewed.The fistula rate is less than 1 percent.The intermediate VPI rate is at least 10 percent.Learning Objectives: After viewing this presentation, the learner will:Be familiar with the demographics of palatal clefts. •Have reviewed one surgeon's protocol for and results of primary • palatoplasty.Be familiarized with current trends in cleft palate repair.• thE OUtcOME OF priMAry pAlAtE clOsUrE At thE sAME tiME As clEFt lip rEpAir l bergeron, l caouette-laberge, n Ouatik, h El-KhatibPurPOse: Closure of the primary palate with a vomer flap at the time of cleft lip repair is controversial.It is often suggested that it should be delayed since additional scarring could negatively affect maxillary growth.Our center has routinely closed the primary palate at the time of lip repair since 1963 and no additional growth disturbance has been noted.The purpose of this study is to compare sagittal maxillary growth of patients operated in our center to published series of cleft and normal children.MethOD: Patients with complete unilateral cleft lip and palate operated between 1983 and 1989 were included.SNA and ANB cephalometric values at 9 and 17 years old were compared to well documented series from other centers and a normal reference group.Statistical analysis was conducted to determine if our group was equal or better than reported results.resuLts: 34 patients were identified.Maxillary growth, documented with SNA and ANB angles, was better than reported in other large series of cleft children (p<0.05,one tailed t-test).As in other series, the values obtained for our cleft patients were inferior to the normal population except for ANB measurements at 9 years old, which were similar.