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This one is about: AOL Chat with Dr. Carstens, July 30, 1997

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America Online Chat with  Dr. Carstens
July 30, 1997

Each month, Dr. Carsten (Dr. Carstens) has generously agreed to come online and answer people's questions. Below is the log of the chat.

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Dr. Carstens: Hello to everyone in the room. Joanne will you start out?

Joanne: It is nice to have you with us again, Dr. Carstens. Kat will ask our first question.

Kat: Hi Dr. Carstens. I am just wondering if you can tell me if being cleft-affected makes one more prone to having sinus infections?

Dr. Carstens: I can't give you statistics but the clinical answer is yes. The reasons for this are complex. Clefts are accompanied by a contra-lateral (opposite side) deviation of the septum (the central cartilage of the nose. In response to this the CLEFT SIDE TURBINATE gets larger. The lower turbinate is its own bone and belongs on the lateral wall of the nose. The function of the three turbinates is to humidify the air going through the nose. The lower one often grows so large as to almost touch the septum. For this reason nasal breathing is often blocked unexpectedly on the cleft side. At any rate the opening of the maxillary sinus (the one behind the cheek) was constructed by God too high. It drains off the top of the sinus and into the nose. The opening of this sinus can be blocked by allergies or affected by turbinate size. Therefore one has a mechanical predisposition to inadequate sinus drainage. One can also postulate that the cleft-sided sinuses may have anatomic deformation. How's that for a mouthful?

Kat: Oh, thank you so much.

Joanne: Thank you, Dr. Carstens. Kristi has our next question.

Kristi: My question relates to pharyngoplasty. How successful is it after a pharyngeal flap?

Dr. Carstens: Are you referring to a sphincter pharyngoplasty done to improve the results of a previously placed pharyngeal flap?

Kristi: Yes.

Dr. Carstens: Okay. Pharyngeal flaps "fail" if they are too small so that too much air gets around them. This happens either by stingy design or by excessive postop shrinkage. At any rate if this be the case the pharynx can be "tightened" with a pharyngoplasty. Several authors have commented recently on such "salvage" procedures. The results are good to fair but all such data (since it pertains to speech) is very hard to quantitate. I personally think that the first step in VPI (velopharyngeal insufficiency) ie nasal escape is to make sure that the palate is as long as possible before going on to the flaps. Is that helpful?

Kristi: Yes thank you Dr. Carstens :-)

Joanne: Thank you, Dr. Judy has a question for you now.

Judy: How long after a hard and soft palate is closed before you can tell if a fistula has formed and what are the symptoms?

Dr. Carstens: Good question. I have one so I have given it a good deal of thought. Fistulae don't happen by chance. They result from either a failure of the two layer closure heal. Pardon me, there is no either. But healing by be an anatomic design that doesn't make a good seal or by a breakdown of the tissues. Either there was enough tissue put into the center but not in the right configuration or there was not enough tissue in the center.

The latter situation corresponds to TENSION or inadequate blood supply. Every surgeon has had this happen. This is what makes palate repair NOT A RACE but a very meticulous process. The fistula rate I have commented on before. Once they form they require a major effort to close. The symptoms for the small ones are probably hard to pick up. The kids can't tell us. If they are large enough to be seen post op chances are they will get larger with time.

Tissues expand with facial growth. If tissues are not joined in the midline, as growth occurs the defect becomes more noticeable. Symptoms in talking kids probably relate to liquid coming out the nose. Large fistulae of course lead to nasality. Okay I'll stop.

Joanne: Thank you, Dr. Carstens. Sharon has a question for you now.

Sharon: My question is dealing with options that a Pierre Robin Sequence child has when there is still some nasality present but that the child has had previous sleep disorders including mild apnea and snoring. What options beside the flap are there if any?

Dr. Carstens: How old is your child?  How serious is the problem?

Sharon: She is 10 her apnea, snoring has been more or less alleviated by an adnoidectomy and tonsillectomy. The nasality is not super severe but present.

Dr. Carstens: Surgeons are physicians first and operators second. Sometimes the best thing to do is to sit on one's hands and let the child grow. It will come out in the wash. Your child still has significant growth expected in the midface and mandible. When the benefits of surgery become more subtle it becomes incumbent on the surgeon to sort out the risk/benefit ratio. As long as she sleeps okay and doesn't have problems with staying awake, desaturation or growth disturbance...sit on it.

Joanne: Thank you for your answer, Dr. Melissa has a question for you now.

Melissa: When do you recommend that the children see the dentist and or oral surgeon?

Dr. Carstens: All children have dental problems, few have oral surgery problems. Oral surgeons have a dental degree but that doesn't mean that they practice pediatric dentistry. I was trained as a general surgeon before plastic surgery but I don't do gall bladders or hernias. Your pediatric dentist or orthodontist or cleft panel will recommend if your child needs oral surgery.

Melissa: I guess I wondered as far as timing for bone graft etc.

Dr. Carstens: Okay I get your question. The decision of when to graft has mostly to do with the eruption sequence. A conference between the specialists can help you determine this. It is often based on the anatomy of the canine tooth...this has such a long root that it is crucial for the orthodontist. Hope that answers your question.

Melissa: Thanks Dr. C!

Joanne: Thank you, Bob has a question for you now.

Bob: Hi, Doc...My question has to do with the older generation as far as plastic surgery. How do you tell when enough is enough? I was born in the 50's and med science has changed a lot. I have a lot of scar tissue, and with the blood supply being what it is, how do I get a good evaluation as to what my options are?

Dr. Carstens: I wish that I could see your face to answer that question.

Bob: Is there some way I can set up an appointment with your office?

Dr. Carstens: All of us C-A people have to wrestle with that question. It is a matter of balance between your anatomy and your soul's desire.

Bob: Is it possible to work with scar tissue on the face?

Dr. Carstens: The answer to that is that I will see any cleft patient, rich or poor, until I drop dead.

Dr. Carstens: There is always something that can be done...sometimes wisdom means knowing when the risks outweigh the benefits. This is a very personal matter.

Bob: Thank you.

Joanne: Thank you. Annette has a question for the doctor now.

Annette: Hi Dr. Carstens! My son had lip repair surgery 8 days ago and it looks great, but it also looks funny. His lip has pulled up quite a bit and the area between the lip and the nose appear flat as well as rounded in spots. How long will it take before all of this settles?

Dr. Carstens: You will seen major resolution of swelling after the first three weeks. HOWEVER collagen (the building block of all scar) is produced by the fibroblast cells from day 5 until day 70 therefore the scar will get red and hard. Don't be scared. This is normal. You can begin light massage at three weeks and heavy massage at 6 weeks. At this time 90% of the collage will have been laid down.

Annette: How long does it take to get an accurate picture of what the scar will be?

Dr. Carstens: The final phase of scar maturation will then ensue. It takes about a year. You won't begin to see the change in the color and thickness of the scar until about month 4 to 6. These are VERY predictable guidelines.

Annette: It just appears to look like nothing now.

Dr. Carstens: Somewhere after the 4th to 6th month on through the first year.

Annette: It is so thin.

Dr. Carstens: You must be patient. God knows how to heal tissues. We surgeons just try to get them into the right position.

Annette: Thank you, I guess I have to remember that. I just want it to be over and "normal".

Dr. Carstens: We all have that desire; remember that your baby IS normal in the soul.

Annette: Thank you, Dr. Carstens.

Joanne: Thank you, Dr Carstens. I have a related question. We are hearing on the list a lot about seeing "extra lip tissue" in our kids after repair, my own son and daughter had very thick lips (both bilateral clefts) but it was explained to me that the extra tissue was there to be used later to build the columnela. But I am hearing now of children having the "extra lip" reduced by surgery - - can you explain to me what causes this "extra lip" affect and when is it a building block, and when is it something to be revised?

Dr. Carstens: Joanne you WOULD ask the $64,000 question. I have been writing and drawing on this non-stop for the past two weeks.

Joanne: Could you summarize??

Dr. Carstens: The philosophical issue determines the surgical procedure. Therefore the QUESTION is where is the columella and where is the philtrum in bilateral clefts. Is there really MISSING tissue or is it there, just hidden.

You have to think of clefts as the 4 D's  1. Division; 2. Deficiency; 3. Displacement; and 4. Distortion. Clefts are like an earthquake. There is a central fault line but we all know that the shock waves travel very far from the epicenter.

Probably the greatest degree of deficiency is a the level of the fault line...ie. the bone and the mucosa (pink oral/nasal tissue) that surrounds the bone. Everything beyond that is progressively less affected. In the bilateral cleft the central tissue is all in the prolabium. This includes both columella and philtrum. The question is how to separate them? And if there is simply now enough to go around, can tissue be brought in from the sides to create a fake columella.

Dr. Carstens: So...if there is enough prolabial tissue then the "unwinding" of the tissue as described by Dr. Cutting at NYU probably makes the most sense. In this repair the philtrum is cut very narrow and there is NO scar between it and the philtrum. Ala other methods of importing tissue from the sides mean creating scar at or near the columellar labial junction. With me?

Joanne: Yes. Following you.

Dr. Carstens: What I am saying is that what the surgeon does with the prolabium and the lateral tissues will determine what you see. Do you want an opinion?

Joanne: I am very pleased with my sons outcome and my daughter has not had the rhinoplasty yet. Her nose is still very flat and her lip is large.

Dr. Carstens: If the columellar tissue which has been "banked" can be brought unobtrusively into the columella then the lip can be debulked. It also has to do with the way in which the mouth muscles (the orbicularis oris) are brought underneath the skin of the prolabium. It is impossible for me to comment further without seeing a patient.

Joanne: Thank you.

Dr. Carstens: Sorry to get so technical.

Joanne: I believe Sharon has another question for you.

Sharon: Yes just a curiosity type question. I believe that the saliva glands or some of the saliva glands are located under the tongue. Is that correct?

Dr. Carstens: Yes. The largest salivery gland is the parotid gland of the cheek. However there are minor salivary glands on the palate and under the tongue.

Sharon: In my daughter's case It nearly appears to be another tongue. These glands are so large...When she lifts her tongue up it's like a large layer underneath.

Dr. Carstens: I have seen two cases of children born with duplicate tongues. The smaller of these was in each case beneath the normal tongue.

Sharon: I don't think it is a duplicate tongue or at least nobody has said that they are. but she has a lot of saliva...Is it possible that she has enlarged saliva glands there and do they need attention.

Dr. Carstens: Perhaps the papillae (the orifices on each side where the ducts come out) are large. Can't say without an exam...what does your doctor think?

Sharon: I've asked them and no one will really say -- they kind of shrug it off. The only reason I bring it up is that sometimes we need to tell her to swallow so that her speech clears up.

Dr. Carstens: Have you a pediatric plastic surgeon in your area?

Sharon: I also thought it might have to do with the fact that her jaw still not grown out.

Sharon: Her closest one that we are seeing is about 2 1/2 hours away.

Dr. Carstens: Go see the above or good oral surgeon.

Sharon: We are probably going to panel in a couple of months depending on when we can get it.

Dr. Carstens: Remember you can always schedule an appointment yourselves.

Sharon: Yes.

Dr. Carstens: It is okay to have your own doctor.

Joanne: Thank you, Dr. Judy has another question for you now.

Judy: Does the fact that the teeth are coming in the wrong places have anything to do with a baby biting a lot?

Dr. Carstens: On what?

Judy: People. His teeth are coming in the side of the roof of his mouth on one side.

Dr. Carstens: Is your baby teething or are these visitors obnoxious?

Judy: Baby doesn't seem to be teething at the moment, he has always wanted to bite even before teeth were in sight.

Dr. Carstens: Okay, ectopic tooth eruption is EXTREMELY common in all kids and especially in cleft affected kids. I don't think I have much to offer but you could see your pediatric dentist to get a fix on growth and development status.

Judy: One tooth is kind of buried in (gum line not there) front of mouth. Thank you.

Joanne: Rich has a question for you now, Doctor

Dr. Carstens: Thanks for the light moment. I imagined unwanted salespeople fleeing your premises.

Rich: I liked your comment about cleft being the epicenter of a quake which affects other places as well. Our son (unilateral lip only) also had a lacrimal fistula and PDA.

Dr. Carstens: That seems to me a good analogy.

Rich: He has a dimple at the base of his tail bone that the eye doctor was curious about because he said it might be evidence of an imperforate anus. Our pediatrician said that since the dimple definitely ends (i.e. is not a hole), it is not anything to worry about. Have you seen such a thing and what disaster did we miss out on? Have you seen such a thing?

Dr. Carstens: Sacral dimples are not uncommon. They may represent something as simple as a dimple; they may be a manifestation of the common pilonidal cyst, or they may represent a syndrome.

Rich: What is pilonidal cyst?

Dr. Carstens: A good doctor should always look for syndromic associations whether or not... Anyway a pilonidal cyst is an embryologic inclusion of tissue in the sacral area that sometime includes hair buried under the skin. This can get infected in fact and needs excision. General surgeons deal with this problem not infrequently.

Joanne: Well, our time is up and we need to let the Doctor get back to his family now. We want to thank you, Dr. Carstens, for being with us again.

Rich: Thanks for letting us pick your brain!!!!

Joanne: Well, thank you for your time and your expertise tonight.
Sharon: Yes, thank you.
Kristi: Thank you Dr. Carstens :-)
Dr. Carstens: Anyway, good questions tonight...thank you all.
Joanne: Thank you for your patience with us.
Dr. Carstens: Buenas noches.

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