Raphaël B, Morand B, Bettega G, Lesne V, Lesne C, Lebeau J
Service de Chirurgie Maxillo-Faciale et Stomatologie, CHU de Grenoble, Hôpital Albert Michallon, B. P. 217, 38043 Grenoble.
Rev Stomatol Chir Maxillofac. 2001 Jun;102(3-4):182-9.
The wide diversity of bilateral facial clefts makes it most difficult to assess surgical success, particularly in terms of long-term outcome. The aim of this work was to examine the rationale for the current protocol used for cleft surgery at the Grenoble University Hospital. In a first group of 28 children, a 3-step surgical protocol was applied. The first two steps were performed between 4 and 8 months with at least 3 months between each procedure. Skoog's unilateral cheilo-rhino-uranoplasty was used, associated with a periosteal tibial graft. The third step, performed between 10 and 12 months, was for staphylorraphy. Outcome was analyzed at 15 years and evidenced the deleterious effect of excessive and asymmetrical premaxillary scars, of the 2-step cheiloplasty and of columella lengthenings from the lip. The frequency of secondary revision of the superior labial vestibule and the medial labial tubercule (43%) was considered to be high; this procedure should be re-examined as should be osteotomy (32% revision). Palatine closure, acquired in 82% of the cases and premaxillary stability, achieved in 86%, would appear to favor use of the periosteal tibial graft. The osteogenic capacity of this graft tissue was less satisfactory after a second harvesting (from the same tibia three months later). These results have led us to modify our protocol, favoring early and total closure of the bony palate and continued use of the periosteal tibial graft. We now use the following operative protocol: premaxillary alignment using an active orthopedic plate at 2 months, lip adhesion associated with staphylorraphy and passive palatine contention plate at 3 months, definitive bilateral cheilo-uranoplasty associated with a single periosteal graft at 7 months. The preliminary results with this protocol in a group of 12 children have shown better quality scars, more harmonious maxillary arches, an excellent occlusion of the deciduous dentition, and preservation of the positive results obtained with the periosteal tibial graft.
双侧面部裂隙的多样性极大，使得评估手术成功率极为困难，尤其是从长期效果来看。本研究的目的是探讨格勒诺布尔大学医院目前用于腭裂手术的方案的理论依据。在第一组28名儿童中，应用了一种三步手术方案。前两步在4至8个月之间进行，每次手术之间至少间隔3个月。采用了斯科格的单侧唇鼻腭裂修复术，并结合胫骨骨膜移植。第三步在10至12个月之间进行，为腭成形术。在15岁时对结果进行了分析，结果表明上颌前部过度且不对称的瘢痕、两步唇成形术以及唇部鼻小柱延长术产生了有害影响。上唇前庭和唇内侧结节的二次修复频率（43%）被认为较高；该手术以及截骨术（32%的修复率）都应重新审视。腭裂闭合率为82%，上颌前部稳定性实现率为86%，这似乎有利于使用胫骨骨膜移植。在第二次取材（三个月后从同一胫骨取材）后，这种移植组织的成骨能力不太令人满意。这些结果促使我们修改方案，倾向于早期完全闭合硬腭并继续使用胫骨骨膜移植。我们现在采用以下手术方案：在2个月时使用活动矫形板进行上颌前部对齐，在3个月时进行唇粘连联合腭成形术和被动腭对抗板，在7个月时进行确定性双侧唇腭裂修复术并联合单次骨膜移植。在一组12名儿童中采用该方案的初步结果显示，瘢痕质量更好，上颌弓更协调，乳牙列咬合良好，并且保留了胫骨骨膜移植所取得的积极效果。
