surgery

The cleft lips have the same prevalence in the general population as trisomy 21 is about 1 / 700, this frequency varies by race: 3.6 / 1000 among American Indians against 0.3 / 1,000 among blacks.
The cleft lip and palate and maxillofacial bilateral clefts are more common in boys than in girls. There is a bilateral cleft slots for 4 unilateral, when isolated. The cleft lip associated with cleft palate in 70% of unilateral clefts and 85% of bilateral clefts.
These are not exceptional anomalies associated with malformation in a context less than 10% of cases of cleft lip, this rate increases if the slot is bilateral, it is 15 to 50% if the palate is cleft. These malformations are most often isolated, rarely inherited.
Outside the contexts malformation, prenatal diagnosis of major interest to the slot to prepare parents and carers at home and the child’s disability.

Positive cleft lip diagnosis
Unilateral cleft lip alone
The lip: break Cupid’s bow, the slot is lateralized, usually closely related to the still lower edge of the lip, nostril up to the threshold that may be involved. The nose is more or less deformed, the nostril is slightly flattened on the side of the slot, the partition is slightly deflected. If the threshold is not affected nostril, one can note a decrease in the thickness of soft tissue on the side of the slot.
The maxillary dental alveoli are tidy, the cavity of the lateral incisor on the side of the slot may be a little set back.

Alveolar cleft lip, unilateral.
Lip: the slot is wider, with a thick rim median, under the nose prominent sagittal section.
The nose is definitely bent, the nostril on the side of the slot is enlarged and flattened, the tip is deflected toward the slot, and the wall is oblique. The maxilla: the alveolar cleft between the groups, with opening of the maxillary arch side of the slot.

Cleft lip and palate maxillary unilateral.

Lip: the slot is wide.
The nose is deformed. The maxillary bone slot is even clearer that the amniotic fluid passes the nasal cavity in the mouth, noting the defect at a mouth opening and if the slot is wide, the tongue gets into the nasal cavity during swallowing movements. Cleft palate can be objectified on a cutting plane axial oblique.
Only the bony cleft palate can be visualized by ultrasound.
Symmetric bilateral cleft lip
Lip: the slots are symmetrical with respect to the nostrils, with a median bud is not bone, prominent in the nose, the septum is in short, the nose is small, flattened, the partition is not deflected, the nostrils are small.
The maxilla: no disturbance in the tooth sockets

Alveolar cleft lip and bilateral and symmetrical

Lip: the slots are wider, the median process is very prominent, sometimes exceeding the tip of the nose, it has a component containing the bone cells of the central incisor germs.
The nose is flat, the nostrils are difficult to distinguish, in deck stretched forward slots.
The maxillary bone defect is the median, broad, since the cells of the central incisors are in the median labial bud.
Cleft lip and palate maxillary bilateral and symmetrical
Lip and nose abnormalities are identical, the deviated septum is not perfectly visible and because its lower edge is in contact with the tongue when the mouth is closed, it is emphasized by the amniotic fluid in the mouth opening.

Asymmetric bilateral cleft
It can be isolated from a labial side and lip-jaw-palate of the other. It looks like a unilateral cleft, only the careful study of the lip can see cleft lip contralateral.

Corresponds to agenesis of the premaxilla

There is one opening the mouth and nose, 4 shoots lip and nasal primitive form the edges of the single cavity. On a sagittal median, there’s no relief no nasal nasal bone.

Isolated cleft palate

The ultrasound is more often faulted.
The only sign of Appeal may be a discrete retrognathia sometimes a simple shift of the lower lip on a sagittal section plane. The study of tongue position during swallowing movements shows a high position and back of the tongue.

Contribution of 3D ultrasound

Surfacing technique provides a better limit the height of the slot relative to the threshold nostril. The study of the block volume is an undeniable contribution in cleft palate, to objectify them and appreciate their importance and depth.

Slots and malformation syndrome

The association is not unique, a thorough review is needed. Into cracks or bilateral median, the association with brain abnormalities is common; they are anomalies of the midline: holoprosencephaly, median cleft for, agenesis of the corpus callosum bilateral.  Slots for a systematic search for disease amniotic bands, imposes a fine and meticulous study of the ends, in this case the slots are often large and decaying with a loss of substance complicating considerably the possibilities for surgical repair.
The associations are the most common malformations:
Heart in 3-7% of cases
Esophageal atresia: 5%
Cervical vertebral anomalies: 13%
Small size is 4 times more frequent than in the general population
Chromosomal abnormalities: 8%

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a) A slot in the lip
The mouth is composed of two lips, upper (under the nose) and lower.
Only the upper lip is affected and is separated into two parts or the right side of the nose or the left side (unilateral cleft lip right or left) or in some cases on each side of the nose, thereby, the nostrils are flattened ( bilateral cleft lip).

b) Cleft palate
The inside of the mouth consists of a cap (called a palace) and a floor within which the tongue. The roof of the mouth that is to say the palace extends back and forth from the incisors. It is first bone, extended posteriorly by a flexible membrane and mobile terminated by a uvula (called the velum). This membrane allows close communication with the nose.
So either the hard palate or soft palate are split (cleft palate total) or whether the soft palate only.

All these defects can exist in isolation or completely. There are:

• Unilateral cleft lip left or right without cleft palate,
• Bilateral cleft lip palate without division,
• Cleft lip with G or D division of hard and soft palate,
• Bilateral cleft lip with division of hard and soft palate,
• Slots of the soft palate (without division of the lip)
• Of submucosal cleft palate that spot only by the division of the uvula because the hard palate is split, or else by an abnormality of speech from 4 years.

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Generally, the cleft lip is a lack of fusion of embryonic tissue of the face leading to a loss of substance of the upper lip. Similarly, the cleft palate is an absence of the substance of the arch leading to oral communications between the nose and mouth.

Indeed, cleft lip and / or cleft palate are common malformations of the face that appear early in embryonic development. The cleft lip is more common than cleft palate. In 80% of cases, cleft lip is unilateral and occurs two times more left than right.

However, prevention of folic acid supplementation during pregnancy whether food or drug would reduce by nearly one third the risk of occurrence of this type of malformation. To address these defects, we can do cleft lip and palate surgery. Indeed, surgery is needed to repair the cleft lip and palate.

As for plastic surgery, it can intervene to reduce the scars left by the operation and give the face a “normal”. In addition, sessions at the therapist will sometimes be necessary at the onset of language in order to mitigate potential problems of phonation (voice production and spoken language).

Similarly, orthodontic treatments are also needed to correct a possible malocclusion. Malocclusion is present mainly in those with cleft palate and those with cleft lip with involvement of alveolar bone.

In addition, monitoring by a psychologist is recommended so that the child accepts their differences and be prepared for operations as well as in cases of disability associated. In sum, it is worth noting that only 3% of slots are related to a genetic mutation. Therefore, it is important to diagnose as specific as possible in case of discovery of a crack.

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Definition: The cleft lip and palate, more commonly known as “cleft lip” is an anomaly for an average of one child in every thousand Europeans. It is against more common among Japanese and more rare among black Americans. Girls are twice as affected as boys.

There are two types of cleft: cleft lip and cleft palate.

Cleft lip, which concerns most often boys, corresponds to an interruption of the lip, often associated with cleft of the maxilla, which is to say a crack between the second incisor and canine. The nostril on the same side of the cleft lip is sometimes enlarged.

Cleft palate, she is more prevalent among girls. It is situated on the palate. This consists of two different parts that we feel in passing the language on the palate: the veil, a membrane behind, and the bone, located in front, behind the teeth. Cleft palate is concerned the veil or the entire palace.

The cleft lip and palate combines both types of slots: lip and palate. It may be one or both sides. In 30% of cases, it is associated with other malformations – cardiac, digestive or the brain.

The origin of these abnormalities was in the pregnancy when the fetus’s face grows. Between 35e and 40e day of pregnancy, two parts, called buds, coalesce: the maxillary bud which is the lower face, and the naso-frontal bud forms the nose and forehead.

The causes and consequences

These two buds should merge to get a harmonious face. If this is not the case, a slot more or less formed. Ultrasound can see the anomaly in the sixth month.

In 11% of cases, maternal smoking is involved and 5%, the consumption of alcohol. But mostly, we did not find any event, even if the risk of cracking increases if there is already an anomaly in a close relative.

In addition to the aesthetic displeasure, it may be difficult to talk and eat. To prevent food from passing into the nose, the newborn is fed with a special nipple, and a palace artificial resin, is asked to remove the communication between the mouth and nose.

Tabuse committee

The surgeon must act quickly. If only the lip is affected, the operation takes place in the first three months of life. Slots for more complex, it is possible from the sixth month. One or more operations are needed to close the palate, the veil and the lip.

But the food and cosmetic problems are not the only consequences of cleft lip and cleft palate. The hearing is sometimes disrupted and a balance must take place quickly.

The language learning is also disrupted, so a followed by a speech therapist is essential, in addition to surgery. Balances are held every six months, between the ages of 1 and 3 years, because it is a key period in the development of speech. Until adolescence, consultations do at least once every year.

Exercises with the mouth or physical therapy are also needed because some letters are difficult to pronounce.

Finally, the teeth can cause problems. A slot may hinder the development of the jaws because the palace is too narrow. The position of the teeth may be abnormal, when a missing incisor. Orthodontics plays an essential role through the apparatus.

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The threshold is the basis of the nostril nose is formed by the lip. Therefore caused cleft lip deformity of the nose and justifies speaking of cleft lip and nostril.

The lips surgery during the primary surgery if it fixes what threshold, corrects many of the deformities of the nose and deserves the name chéilo-primary rhinoplasty i.e. repair of the lip and nose. Distortions that persist despite primary repair may be a gesture of secondary surgery. Surgery of the nose will have two objectives: functional and aesthetic.

Chéilo-rhinoplasty primary

This is the first operation after birth, when the repair of the lip.
All repairs are acting on the lip of the nose, rhinoplasty addition of the term indicates the importance that it attaches to the muscle repair in the correction of the nose.
In this action basal functional repositioning, some surgeons add gestures dissection and repositioning more or less extensive on the cartilages of the tip of the nose (alar) and the partition and set up temporary means of restraint: Point Mac Coomb and derivatives.

Rhinoplasty Aesthetic

The term aesthetics should be replaced here by restorative technically but we use it to be understood as denoting the sake of normalcy and even beauty to the patient.
It occurs around adolescence, when demand Morphological will appear. This lip cosmetic surgery will differ depending on the case. It can be a:

* Correction of isolated tip of nose
* Comprehensive rhinoplasty with modification of the dorsum, alar cartilage repositioning for cosmetic improvement of the nasal tip, and this almost always includes surgery septoplasty (Repositioning of the nasal septum) in the interests morphological straighten a crooked nose, but also in a functional purpose (improvement of respiratory flow and symmetrization).

The Rhinoplasty Functional

It is considered, in part wrongly, by many doctors that the rhinoplasty must be made as late as possible. When a child is not breathing through your nose, That it breathes through the mouth due to a deviation of the nose and nasal septum: Recovery nose surgery and septum (Septo-rhinoplasty) is required under pain of severe functional disorders exacerbating an imbalance of facial growth.

The Rhino-Cheiloplasty

When at the time of rhinoplasty, there are still imperfections of the lip, the combination of a revision (the latter with the act of correction of the various elements of the nose) to get as good a balance as possible.

According to multidisciplinary team of Paediatric Surgery Hospital St Vincent de Paul and Robert Debre in Paris:

It is now accepted that the primary repair of the cartilage of the ala of the nose (alar cartilage) is not a drag on growth, quite the contrary, is not allowed to become permanent deformation with time. This requires placing a nasal conformer (Small silicone tube) holding the position of the nostril during the healing time, ideally 6 weeks.

In case of Cleft Lip and Palate associated we are for the use of a Shutter neonatal (Upper plate). The plate (which is now known that it did not, probably, orthopedic or orthodontic role), gives the child the feeling of the integrity of the palate, tongue positioned harmoniously in the oral cavity, but also avoids during feeding, the passage of milk into the nasal cavity, to obtain a satisfying comfort food for the child.

On the other hand, using this plate is very useful to allow breastfeeding, we are very supportive Breastfeeding.

If you want to breastfeed, it is useful to meet lactation consultant(If possible even before birth), and put the child in as soon as possible after birth because it is at this time that he has the potential to suck the most important and he’s okay stimulate lactogenesis. Other assistive devices will be detailed at the Lactation tab.

In case of bilateral cleft, we prefer to operate the 2 sides of the slot during separate interventions to 5 and 7 months in order to optimize the height and mobility of the lip.

If we operate a simple cleft lip in 1 to 2 months time, this age we are recommended by anesthesiologists and neonatologists as safer, in terms of respiratory maturation of the child.
.
If 5 or 7 months treatment called “primary surgical” your child is finished, the ongoing management by the multidisciplinary team.

The soft palate being made, it must stimulate its function during the first year of life and ensure its proper functioning is the role of the SLP. The outbreak of the teeth on a dental arch, which presented a slot may be disturbed, so it is important to be supported by the orthodontist to optimize both the palate and growth also “clean tooth.” These multidisciplinary consultations are held once a year on average.

“To speak well, you have to hear”, so your child will be seen by a ENT that tracks the risk of sero-mucous otitis which may require the installation of aerators trans-tympanic (diabolos) and it is not advisable to ablate adenoids given the risk the stability of the web palate.

If you wish, consult with a Psychologist you may be offered from prenatal diagnosis, it is indeed difficult to be parents of a different child and is very difficult to be oneself a different child and Psychologists are available at any time of treatment.

Finally, sometimes for cracks reaching the alveolus (Gingiva), the contribution is not enough bone to growth and / or lateral incisor is missing. It may be necessary during growth to produce a bone graft to stabilize the bone fragments, allowing the descent of the permanent teeth and, eventually, ask a dental implant where a tooth is missing.

The assistance of a Pediatric dentist (Dentist specific children) is important because these children may have teeth more brittle, care must be less traumatic and more gentle as possible so that dental hygiene is respected and that children work together to care, quality smile depends on it.

Feel free to ask questions, it’s your child, and your participation in all phases of treatment is important; tab Hospital, childcare assistants and nursery nurses will give you useful information about your stay at the hospital that lasts on average 4 to 5 days (the time to get used to baby care and gain weight).

Repeated interventions often hide a much deeper dissatisfaction. But these cases are still rare.

The scene takes place in the medicine cabinet of a chic aesthetic of the capital. One patient lost his temper: “Because I tell you that I really need it! The wrinkles on my brow, I see them again! “The doctor tries to reason with her:” Ma’am, you’re already coming last week, let the product time to act and then it is imperative to space injections several months. – Well then let me laser sessions instead! “Insists the patient. An isolated case? Not sure. “Some actresses would like to see the pike every day,” says Maryse Slous, physician aesthetics in Paris. Without doubt the vision of perfect bodies, silhouettes zero defects exhibited by the media they can lead to this kind of unbridled interventionism. And in waiting rooms, now it is no longer unusual to see a follower of repeated injections, fifties are starting a liposuction of the abdomen and linking with the thighs, buttocks and the arms or women, however beautiful seeking a global transformation, nose, mouth, chest, cheeks…

They are all addicted to cosmetic surgery to much? Not necessarily. “We must distinguish several types of patients,” said Stephane Guichard, plastic surgeon and aesthetic. Some people deal with a specific defect and stop there. Others want to erase many imperfections and come more easily than the first surgery went well. These two categories constitute the bulk of the consultations. They pose no difficulty. And then there is the problem of pathological applications. These are generally patients who repeatedly engage in transactions either because they are chasing an unattainable ideal or because they just repair a botched surgery and they feel unnatural. In these cases, we can talk about real addiction. But it is still rare, “cautions Dr. Guichard.

According to the psychiatrist and psychotherapist Francoise Millet-Bartoli, author of The Beauty tailor, psychology and aesthetic surgery (Odile Jacob), women are more affected than men. Especially the age group 40-60 years, a fragile narcissistic. “It’s a very unsettling time of transition, a period where you lose a lot. Children are leaving, youth fades, the signs of aging settled, divorces are frequent and often unemployment. “Enough to seriously falter all the certainties that we had acquired up here and question his identity.

People with imaginary misfortunes also yield more easily to the frenzy of operation. “Those who suffer from dysmorphophobie focus on physical defects that are nonexistent or minimal, and are constantly correct them,” says Francoise Millet-Bartoli. They are obsessed with any fine line, to the point, for some, no longer show up. In reality, their supposed faults mask a deeper dissatisfaction. Through intervention, these people are looking for a kind of surgical personality “by physically interposed”.
“Everything will be better in my life”

Then loads the surgeon or physician to redirect them to a shrink. For it is not necessarily by changing a part of his body that can improve self-esteem failed. According to the psychiatrist, the repeated interventions also often reveal an underlying depression that patients are unwilling – or unable – to recognize. Still, the surgery and aesthetic medicine can also significantly improve the interpersonal relationships and help build self-confidence.

How, then, to identify applications pathological? Maryse Slous believes that one becomes addicted to cosmetic surgery since it requires injections every two to three months. “In these cases, I direct care to less aggressive electro or pulsed light.” The criterion is to have an application built, insists his part Dr. Guichard. And above all, a person submits to her, not to save a marriage to please his children or friends to copy. ”

For Francoise Millet-Bartoli, patients must ask themselves the question: what do I expect? Surgery is beneficial if it is looking for a healthy glow, rested, to boost morale and confidence. If the request is too vague, “everything will be better in my life,” or too specific, “I want the same nose as Claudia Schiffer,” then we risk the dissatisfaction and the cycle of multiple recidivism.

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For two decades, Eric Selby suffered total blindness and depended on a guide dog, but it was after an artificial retina inserted in his right eye. The ordinary objects can be detected as a curve and the pavement when he ventures away from home.

“Basically it’s flashing lights that have to be interpreted by the brain, but it is incredible that we can see anything,” admitted Selby, a retired engineer from Coventry in central England.

More than a year ago, its 68 years, was inserted an artificial eye implant called Argus II, manufactured by U.S. firm Second Sight, a surgical procedure.

Dutch regulators likely will decide in a few weeks, the shipping company to sell the product in the European Union. It will be the first artificial retina for sale.

The retina works with a tiny video camera and a transmitter embedded in some glasses and a small wireless computer. The computer processes the camera captured scenes and turns them into visual information in the form of electrical impulses sent to the implant.

The device stimulates the remaining healthy cells in the retina, which send the optic nerve.

Visual information then sent to the brain, where it is interpreted as pulses of light that can take the form of an object. Blind patients must learn to interpret the flashes of light. For example, they discuss three points of light as the three vertices of a triangle.

The artificial eye implant is only applicable to people with a specific type of disease in the retina, which still has some good cells. Had to be able to see before and optic nerve must function normally.

One of every 3,000 people suffers from blindness due to this hereditary disease called retinitis pigmentosa and potentially could benefit from the artificial retina.

However, the device has a high price: about $ 100,000. In Britain, the National Health Service pays for new technology sometimes a small number of patients, “said Lyndon da Cruz, one of the doctors who tested the artificial retina at Moorfields Eye Hospital, London.

In all cases of colorectal cancer surgery is necessary extension study preoperative imaging method such as ultrasound, CT Computed (CT) or sometimes magnetic resonance imaging (MRI), with two objectives: exclude the presence of liver metastases and to know the existence of benign lesions can be confused with those follow-up.

Objectives Preoperative staging

Evaluation preoperative hepatic resection should include: clinical examination liver tests, determination of carcinoembryonic antigen (CEA) chest radiograph in two projections, colonoscopy and a method staging of the liver. When there is suspicion of liver metastases from colorectal cancer by ultrasound or CT, the objectives of the study will exclude preoperative presence of extrahepatic disease and know the number, size and location of metastases, to plan the type of resection appropriate. The use of routine chest CT, chest X-ray normal is not justified because of its low yield and poor specificity (Positive predictive value 36%) In cases of rectum cancer should be a CT of the pelvis and any pelvic injury suspect must be subjected to fine needle aspiration (FNA) for locoregional extension rule.
Errors infraestadificacion are due to the low sensitivity of imaging methods for the diagnosis of peritoneal or nodal disease, as well as hepatic lesions smaller than 1 centimeter or very superficial.

Staging hepatic

Methods clinically useful for staging liver are ultrasound, CT scan (CT) with conventional intravenous contrast bolus or Porto-CT or CT portography (CT scan after intravenous contrast injection through a catheter placed in the superior mesenteric artery by femoral puncture), CT Helical biphasic CT portography, and magnetic resonance imaging (MRI) gadolinium. Today the standard is biphasic helical CT with previously published technical specifications. In general, metastases behave like hypodense lesions with respect to parenchymal normal and fail to capture the contrast in portal or parenchymal phase. 10-15% peripheral enhancement may occur as hemangiomas, calcifications, areas heterogeneous necrotic radiological or unusual behavior.

As already above, at present biphasic helical CT is the method most diagnostic reliability. If there is no TC helical CT with portography may be the method of choice, taking note that it is more useful to exclude new lesions to confirm as those already detected metastases. Gadolinium-enhanced MRI scan is choice in case of doubt about the diagnosis with hemangioma or infiltration focal fat.

Recently, positron emission tomography (PET) has demonstrated its value in the locoregional disease diagnosis, peritoneal or lymph node, but not has improved diagnostic accuracy in the diagnosis of new liver damage. Its main indication is the group Patients at increased risk of peritoneal or liver disease hidden. The group of Blumgart studied this aspect, getting to discriminate 20% of unresectable patients, half due to liver spread the other half by peritoneal or nodal disease previously undetected (In this second group, 72% were resectable liver metastases). There inoperability two predictors: multiple and bilobar lesions with 38% for both. In the latter group can be valuable PET.

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The types of cancer that can spread more easily to the liver include colorectal, pancreatic, gastric and esophageal cancer, breast cancer, lung cancer and melanoma among others. The causes vary and depend on the spread of blood flow and certain characteristics of the different kinds of cancer cells, while cancers of the gastrointestinal tract often spread to the liver because blood flows directly from these organs to the liver, melanoma spreads to the liver through the blood vessels of the body. Symptoms of liver metastases can be: weight loss, pain in the upper right quadrant of the abdomen, jaundice, fever, sweating and nausea order to proceed with their diagnosis, were made the following tests: Test of bilirubin in blood tests liver function tests, CT or MRI, PET and ultrasound of the liver.

Once diagnosed, treatment depends on the primary site of cancer site, extent of spread to the liver, if it has spread to other organs and the patient. When cancer has spread to both the liver and other organs, systemic chemotherapy is used to treat the whole body. If, on the contrary, the spread is only in the liver, chemotherapy is used and attempt surgical removal. Another option is the use of toxic injection or radiofrequency waves to destroy tumors. Prognosis, it depends on where the primary cancer and the extent of spread to the liver. In a few cases, the healing of patients is achieved by surgical removal of metastases. In most cases, the metastatic liver tumor is not curable, although the above treatments can help shrink tumors, improve life expectancy and relieve symptoms.

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