Success and Failure for Children Born with Facial Clefts in Africa: A 15-Year Follow-up

Background: This study reviews the 15year program of our Department of Pediatric Surgery for the treatment and follow-up of children born with a cleft in Benin and Togo. Methods: We analyzed files of children born in Africa with a cleft. They were referred to us through a nongovernmental organization (NGO) between 1993 and 2008 and assessed in Africa by local pediatricians before and after surgery. Operations were performed by our team. Results: Two hundred files were reviewed: 60 cases of unilateral cleft lip, seven of bilateral cleft lip, 44 of unilateral cleft lip palate (UCLP), 29 of bilateral cleft lip palate (BCLP), 53 of cleft palate (CP), three of bilateral oro-ocular cleft, one of unilateral and two of median clefts (Binder), and one of commissural cleft. Sixty-nine (35%) of these cases were not operated in Africa: 25 (12.5%) had not shown up, 28 (15%) were considered unfit for surgery (Down's syndrome, HIV-positive, malnutrition, cardiac malformation), and 16 (7.5%) were transferred to Switzerland. Palatal fistula occurred in 20% of UCLP, 30% of BCLP, and 16% of CP. Evaluation of speech after palate surgery gave less than 50% of socially acceptable speech. Conclusions: Our partnership with a NGO and a local team makes it possible to treat and subsequently follow children born with a cleft in West Africa. Surgery is performed under good conditions. If aesthetic results are a success, functional results after palate surgery need further improvement to promote integration in school and social lif

Insuffisance vélo-pharyngée chez l'enfant

Velopharyngeal insufficiency (VPI) represents an incomplete closure between the soft palate and the posterior pharyngeal wall. Its etiology can be anatomical (cleft palate), neurologic, or iatrogenic (after adenoidectomy). The evaluation of a VPI begins with a through speech and language assessment and can be complemented by instrumental investigations. VPI treatment relies on its early identification, followed by a specific speech therapy management. Surgery is performed in case of no improvement with speech therapy or in case of an anatomical defect not allowing the child to improve. IVP management requires a multidisciplinary team

Grommets and speech at three and six years in children born with total cleft or cleft palate

Grommets may be considered as the treatment of choice for otitis media with effusion (OME) in children born with a cleft. But the timing and precise indications to use them are not well established. The aim of the study is to compare the results of hearing and speech controls at three and six year-old in children born with total cleft or cleft palate in the presence or not of grommets

Interventional calendar and protocol for cleft lift and palate repair at the maxillofacial and plastic surgery department of the Armand Trousseau Children’s Hospital (AP-HP, Paris)

Parents want their children’s’ faces, the most visible part of their bodies, one that marks their identity throughout life, to be perfect. To satisfy this understandably urgent desire, a high quality of primary treatment for cleft lip and palate is essential and must satisfy a double objective: restore normal morphology and normal function. The functional, morphological, and esthetic prognoses depend on the character of the defect, whether it stands alone or is associated in a syndrome with other malformations. Important sequellae flow from the quality of the initial repair, as a consequence of the surgery and other therapies as well as from the deformity itself. Before the year 2000, the Maxillo-facial and Plastic Surgery Service at the Armand Trousseau Hospital of the Pierre and Marie Curie Faculty of Medicine adhered to the protocol that Malek had described, making an initial repair of the soft palate at 3 months and then a cheiloplasty, with upper and lower triangles, and closure of the hard palate at 6 months. Since then we have adopted the more functional approach that Talmant described, integrating systematic nasal surgery and the type of lip surgery that Millard suggested without leaving any residual exposed bone after closure of the osseous cleft. We then perform gingivo-periosteal surgery with bone grafts on patients when they were between 4 and 6 years of age, after orthodontic therapy had been completed. This constitutes the last stage of primary treatment. The therapeutic approach we have been using on our service, which has evolved of over the last 20 years, has come to define its principal objective as integration of extensive rehabilitation into the very first stages of our multi-disciplinary therapy so as to minimize the establishment of faulty functioning of phonation, lip competence, and ventilation while avoiding any intervention that would have a harmful impact on facial growth. This multi-disciplinary approach, which integrates surgical evaluation and protocol, is indispensable and fully justifies treatment of patients with cleft lip and palate at accredited centers

Initial treatment of alveolar gaps in cases of labio-maxillary-palatal clefts

Treatment teams use different approaches for correcting the alveolar cleft sector of labio-palatal clefts. Age of patient, whether or not bone grafts are used, and the type of bone grafted are some of the differences. Our team performs a gingivoperioplasty with a graft of iliac cancellous bone on patients 4 to 6 years old. This procedure is carried out within the framework of orthodontic treatment designed to restore transverse dimension pre-operatively with a quad helix and to retain the expansion with 6 months of retention. The gingivoperioplasty is accomplished in a zone free of any scar tissue that might have resulted from a primary cheiloplasty followed by closure of the palatal cleft. In our view all teams must eventually utilize cone beam X-rays for their radiographic evaluations because they are the only tool that provides results of objective analysis that are of high quality and have demanded a very low level of radiation

Calendrier et protocole interventionnel des fentes labiopalatines au sein du Service de chirurgie maxillo-faciale et plastique de l’Hôpital d’Enfants Trousseau (AP-HP, Paris)

La face est la partie visible, celle que les parents imaginent parfaite, elle marque l’identité du sujet tout au long de sa vie. La qualité du traitement primaire des fentes labiopalatines est essentielle et répond à un double objectif : restaurer une morphologie normale et une fonction normale. Les pronostics fonctionnel, morphologique et esthétique dépendent du caractère isolé ou associé de la fente à d’autres malformations, du caractère syndromique ou non. De la qualité de la réparation primaire dépendra également l’importance des séquelles. Celles-ci peuvent être la conséquence autant de la chirurgie et des autres thérapeutiques que de la malformation princeps. Avant 2000, le protocole adopté au sein du Service de chirurgie maxillo-faciale et plastique de l’Hôpital Armand-Trousseau (AP-HP, Faculté de médecine Pierre et Marie Curie) était celui décrit par Malek : véloplastie première à 3 mois puis chéiloplastie (avec triangle supérieur et inférieur) et fermeture du palais osseux à 6 mois. Nous avons opté pour une approche plus fonctionnelle telle que décrite par Talmant intégrant une chirurgie nasale systématique, une plastie labiale selon Millard et l’absence de zone osseuse dénudée résiduelle après fermeture de la fente osseuse. La gingivopériostoplastie avec greffe osseuse est réalisée entre 4 et 6 ans après traitement orthodontique et constitue la dernière étape du temps primaire. L’approche thérapeutique au sein du service a progressivement évolué depuis 20 ans, le but principal étant de s’approcher d’une réhabilitation ad integrum et de minimiser les séquelles en insistant sur la restauration des fonctions phonatoires, labiales et respiratoires et en évitant tout geste délétère pour la croissance faciale. L’approche multidisciplinaire intégrant l’évaluation des protocoles chirurgicaux est indispensable et justifie le traitement des patients porteurs de fentes labiopalatines au sein de centres labelisés

Traitement primaire des brèches alvéolaires dans les fentes labio-maxillo-palatines

Différentes approches existent dans le traitement de la fente alvéolaire des fentes labio-palatines. Elles concernent l’âge de la gingivopériostoplastie, l’apport ou non d’os dans le même temps, et enfin le type d’os greffé. Au sein de l’équipe, nous réalisons une gingivopériostoplastie associée à une greffe d’os spongieux iliaque entre l’âge de 4 et 6 ans. Ce geste est encadré par un traitement orthodontique visant à restaurer en préopératoire la dimension transversale par quad’hélix et à maintenir le gain obtenu en postopératoire par une contention de 6 mois. La gingivopériostoplastie est réalisée dans une zone laissée indemne de toute cicatrice lors du temps primaire de chéiloplastie puis de fermeture de la fente osseuse. Les techniques d’évaluation radiologiques doivent à notre sens évoluer vers l’utilisation systématique du cone beam, qui est le seul outil permettant une analyse objective et peu irradiante de la qualité du résultat obtenu