Massachusetts Chapter of the American College of Surgeons

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Free-tissue Transfer in the Management of Complex Secondary Cleft Lip and Palate Defects
Landis R. Walsh, BA, Laura C. Nuzzi, BA, John G. Meara, MD, DMD, MBA, Bonnie L. Padwa DMD, MD, Amir H. Taghinia, MD, MPH, MBA, Brian I. Labow, MD
Boston Children's Hospital, Harvard Medical School, Boston, MA

Background:
The majority of cleft lip and palate defects are repaired using conventional techniques without complication. However, complications do arise, necessitating secondary or even tertiary operations. In rare instances, some defects persist even after multiple operations. Treatment in these cases remains understudied and these children face severe limitations to their quality of life. This series reports on the use of free-tissue transfers to reconstruct persistent, complex cleft defects.

Methods:
Records of patients from a single institution who underwent free-flap reconstruction for complex cleft defects between 1/2007-5/2020 were retrospectively reviewed for operative technique, complications, and clinical outcomes. Complications occurring within the first post-operative year were considered “short-term,” whereas those occurring after were considered “long-term.”

Results:
Five patients met inclusion criteria with a median age of 10.3 years (IQR 5.3; range 4-26) at time of operation. Prior to surgery, 80% of patients used a prosthetic obturator. A total of six procedures were included, either radial forearm (67%) or medial femoral condyle (33%) flaps. The median post-operative follow-up time was 86.5 months (IQR 60.75). All flaps survived. The most common short-term complications were transient donor site paresthesia or hyperesthesia (n=3) and superficial donor-site wound dehiscence (n=2). Four procedures (67%) yielded no long-term complications whereas two patients developed recurrent fistulae that required surgical correction.

Conclusion:
Although rare, complex cleft defects may remain refractory to conventional modalities, are a considerable source of morbidity, and may be undertreated. Free-tissue reconstruction yield positive results and provides a useful technique for stable, long-term closure of complex cleft defects.


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