Aziz Shahid R, Rhee Samuel T, Redai Imre
Department of Oral and Maxillofacial Surgery, UMDNJ-New Jersey Dental School, Newark, NJ 07103, USA.
J Oral Maxillofac Surg. 2009 Aug;67(8):1581-8. doi: 10.1016/j.joms.2008.11.021.
The authors review their experiences during multiple cleft surgical missions to rural Bangladesh from 2006 to 2008. A significant number of patients who underwent primary palatoplasty or cheiloplasty were of adult age or size. Adult primary cleft lip and palate repair is often more challenging than repair at the standard age of fewer than 2 years. This patient population is rarely seen in the United States, but may be treated more often by American surgeons during surgical missions to the developing world. This report discusses the experiences of the authors' treatment of cleft lips and palates in rural Bangladesh.
One hundred forty-six cleft-lip and cleft-palate patients were treated during 3 missions to rural Bangladesh, from 2006 to 2008. Thirty-three (23%) patients were of adult size, and aged 13 to 35 years. One hundred thirteen (77%) patients were aged 12 years or younger. Unilateral cleft lips were repaired with a Millard advancement-rotation technique. Bilateral cleft lips were repaired via the 1-stage procedure advocated by Mulliken and Salyer. Cleft palates were repaired using a 2-finger flap method.
Overall, 8 of 146 patients (5.5%) had nonlife-threatening complications (infection or wound dehiscence) requiring subsequent revision surgery. The adult-sized patients had clefts of significantly increased size secondary to patient growth, as well as maxillary expansion transversely and anteriorly. Adult cleft-lip repair required significant soft-tissue dissection to close the cleft adequately, and ensure symmetry to the upper lip and alar bases. However, this procedure sometimes resulted in placement of the lip cicatrix in an anatomically disadvantageous position. In addition, with the increased transverse dimension of the adult cleft palate, tension-free 3-layer closure was difficult. Again, aggressive dissection of the soft tissue was required: the nasal and muscular layers were closed without much tension, but oral closure was often under tension, requiring the assistance of dermal biomaterials to bolster the repair.
Patients in the developing world often have limited access to specialized health care, and may not realize that cleft lips and palates can be repaired. As a result, there is an increased incidence of unrepaired clefts in adult-sized individuals in this part of the globe. The American surgeon may encounter these patients during surgical missions. The surgeon should be prepared to repair adult patients with clefts that are significantly enlarged in all 3 dimensions. Closure will require significant soft-tissue dissection as well as the use of biomaterials as needed to repair wide cleft palates.
作者回顾了他们在2006年至2008年期间多次前往孟加拉国农村进行唇腭裂手术任务的经历。大量接受一期腭裂修复术或唇裂修复术的患者已成年或体型如成人。成人期的原发性唇腭裂修复手术通常比在标准年龄（小于2岁）时进行修复更具挑战性。在美国，这类患者很少见，但在前往发展中国家的外科手术任务中，美国外科医生可能会更频繁地治疗这类患者。本报告讨论了作者在孟加拉国农村治疗唇腭裂的经验。
2006年至2008年期间，在三次前往孟加拉国农村的任务中，共治疗了146例唇裂和腭裂患者。其中33例（23%）患者体型如成人，年龄在13至35岁之间。113例（77%）患者年龄在12岁及以下。单侧唇裂采用Millard推进旋转技术修复。双侧唇裂通过Mulliken和Salyer倡导的一期手术进行修复。腭裂采用双指瓣法修复。
总体而言，146例患者中有8例（5.5%）出现了非危及生命的并发症（感染或伤口裂开），需要后续进行修复手术。成年体型的患者由于生长发育，其裂隙尺寸显著增大，同时上颌在横向和前方也有扩展。成人唇裂修复需要进行大量的软组织解剖，以充分闭合裂隙，并确保上唇和鼻翼基部的对称性。然而，该手术有时会导致唇瘢痕位于解剖学上不利的位置。此外，随着成人腭裂横向尺寸的增加，无张力的三层闭合很困难。同样，需要对软组织进行积极解剖：鼻腔和肌肉层在无太大张力的情况下闭合，但口腔闭合往往处于张力之下，需要使用真皮生物材料来加强修复。
发展中国家的患者获得专科医疗保健的机会往往有限，可能没有意识到唇腭裂是可以修复的。因此，在世界这一地区，成年体型个体中未修复的唇腭裂发生率有所增加。美国外科医生在外科手术任务中可能会遇到这些患者。外科医生应做好准备，为裂隙在三维空间均显著增大的成年患者进行修复。闭合手术需要进行大量的软组织解剖，并根据需要使用生物材料来修复宽腭裂。
