Complications in Cleft Lip and Palate Surgery
Introduction
Cleft lip and palate (CLP) and cleft palate alone (CP) are some of the most frequent craniofacial malformations, and in Europe affect ~ 1 in 700 newborns. It is therefore an epidemiologically relevant disease, and its consequences can be severely impairing. For these reasons, it is considered of considerable medical and social importance. Treatment of CLP and CP is essentially surgical, along with orthodontists and speech pathologists, and requires several subsequent steps during the life of the patient. Most often, the treatment is completed only at the end of the patient′s puberty.
During each of these surgical sessions, complications can potentially occur, which will be examined separately in this chapter. Complications after the following will be discussed: cheilorhinopalatoplasty, gingivoperiosteoplasty and cleft alveolar bone grafting, maxillary osteotomy and maxillary distraction osteogenesis, and velopharyngoplasty. For each phase, we will describe the immediate and late complications as well as unfavorable results.
Cheilorhinoplasty, Palatoplasty
Primary treatment of CLP is not uniformly coded. The ideal period to treat the cleft of the lip and of the palate is still debated. Different centers often adopt nonhomogeneous protocols that differ greatly in terms of timings, which must be considered when describing the frequency of complications and unfavorable results. Surgery of the lip when performed at 4 to 6 months of age (as in our center) is associated with an exceptionally low frequency of early complications.
Hemorrhage is extremely rare and infection is even rarer (short-term antibiotic treatment is administered prophylactically). Hemorrhage during the preparative phase, namely during flap sculpting and lip–nasal and maxillary undermining, usually come from the lip coronary artery and are easily managed with bipolar cautery.1 However, in the literature there are reports of substantial perioperative hemorrhage needing blood transfusions.2
Lip Surgery
Lip wound infection is also exceptionally rare,2,3 but can lead to dehiscence with delayed healing and secondary retracted scars. According to some recent investigations, patients with van der Woude syndrome may be more prone to wound infection. Infection at the tip of the nose after primary rhinoplasty is also very rare.4 Infection and dehiscence must be treated conservatively with cleansing and disinfection. If a secondary deformity occurs, this should be treated with a secondary correction, waiting at least 6 months after the previous surgery. In surgical correction of bilateral CLP, necrosis of the central cutaneous flap containing the prolabium as the result of incorrect dissection with disruption of the nourishing vascular network has been described. As a consequence, there is poor reconstruction of the central part of the upper lip and of the columella ( Fig. 14.1 ).
Late complications of lip surgery are essentially hypertrophic scars or keloids. These conditions are often the result of the patient′s biological response and are therefore difficult to cure. Treatment relies essentially on the use of local steroids and compressive silicone sheets. Unfavorable results consist of residual deformities affecting the lip, the nose ( Fig. 14.2 ) or the septum ( Fig. 14.3 ). These should be addressed individually.
Cleft Surgery
Corrective surgery for CP can be performed with various techniques. If the cleft is very large (and always with some techniques), lateral releasing incisions must be performed ( Fig. 14.4 ). However, these are associated with a definite risk of tearing the palatine vessels and hemorrhages are therefore more likely. Releasing incisions are frequently filled with hemostatic gauze. In any case, the overall risk of bleeding or infection is very low, especially if one takes care to seek and minimally cauterize bleeding at the level of the lateral releasing incisions at the end of the intervention.
If bleeding complicates a palatoplasty, this normally produces a self-limiting hematoma. Conversely, if bleeding continues, there is the need to revise the site to look for the bleeding source so that it can be cauterized. Finally, a bulky palatal or pharyngeal hematoma can impede breathing and therefore must be promptly evacuated.
Complete wound breakdown can occur on occasion ( Fig. 14.5 ). This is devastating and must be addressed secondarily with a new palatoplasty.
Conversely, in any palatoplasty there is a risk of developing a residual fistula or velopharyngeal incompetence.5,6 The main problem with fistulas after palatoplasty is that they have an extremely high chance of relapse. Accordingly, every effort should be directed toward preventing them by meticulously suturing the nasal, muscular, and oral layers avoiding tension and using atraumatic horizontal mattress stitches. The correction of fistulas relies on local flaps ( Fig. 14.6 ) or, sometimes, on a lingual flap (wide, anterior fistulas). Velopharyngeal incompetence can be a complication of incorrect muscular reconstruction or may simply be due to suboptimal results. The most troublesome consequence is altered speech. The timing for correction of velopharyngeal incompetence is critical—late corrections bear the highest chance of leaving definitive speech impairment.7
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