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Q&A Chat on IRC with Dr. Canady
Friday, May 29, 1998

Disclaimer: The opinions expressed here represent an academic opinion about the general care and treatment of patients with craniofacial disorders. No attempt was made to practice medicine in any form, nor was there an attempt to treat individual patients. Any opinions or views expressed were general in nature and not specifically addressed at any particular person. If you desire an individual opinion a physical exam will be necessary to render that opinion. If you cannot get adequate help in your location, you may call 319-356-2168 and ask Karen to make an appointment for you.

*Dr. Canady is Dr. Canady; Joanne is Joanne Green who is moderating the chat.

Dr. Canady: Hi

Melissa: Hi Dr. Canady. First, I apologize for the length of my question. I have chatted with you before concerning my 2.5 year old daughter, Hannah - PRS and Sticklers. She has had 2 unsuccessful soft palate closures both of which resulted in dehiscence about one week post op.  We are changing PS. We have visited with 2 so far. Both are very concerned with the shortness of her palate and the amount of scarring from the first 2 surgical a

Dr. Canady: I remember talking with you about this and no question is too long if it is important to you

Melissa: will NOT cause tension on the suture site, but due to the amount of scarring in Hannah's palate, he doesn't think he will be able to gain much length. She does have VPI. From the other PS I have spoken to or visited, they say that the Furlow would not be the best for Hannah due to the amount of scarring and because there IS a lot of tension with the Furlow and the tension is more than likely what caused the dehiscence in the first place. My question... how do you weigh the risks? Do we attempt to gain the needed length with the risk of tension and a 3rd dehiscence using the Furlow or do we go with the VY/Von Langebeck repair with the other surgeon and have less chance of breakdown but gain no length?  OR is it simply the skill of the surgeon doing the repair? That is it. Sorry for the length.

Dr. Canady: First, as usual, I need to put a couple of disclaimers in here to keep the people who get paid to keep me out of trouble happy -- My participation here is for educational purposes only and I am making no attempt to practice medicine. Medicine for an individual can only be practiced with the benefit of a physical exam, which I am unable to do. Any answers to any questions are meant to be general in nature and not to reflect or suggest and particular c

Melissa: I understand

Dr. Canady: individual. If you have specific questions you should contact your physician or if you are unable to find a physician, I would be happy to see you. My office number is 319-354-4570. (Sorry for this, but I think everyone understands why this is necessary...) Now for your question...

Dr. Canady: The Furlow has been shown in some studies to have a higher fistula rate. Probably as important for speech is the repositioning of the levator muscles which can be done in any of the repairs and this area of knowledge has been added to greatly lately by a plastic surgeon from Taiwan. It is the case, though, that even if your child had not had multiple surgeries, most reputable centers still report a 20% rate of secondary surgery for VPI (even with s

Dr. Canady: Some time between age 3 and 4 we usually make the decision in our center as to secondary management. Other options besides surgery include and obturator (which is admittedly difficult to get the kids to wear) or doing a primary pharyngeal flap to import additional tissue into a palate which is scarred but not yet closed. This is a rare option, but it does have its place in very selected cases.  It is really a judgment call in the OR in my opinion, a feel for the amount of "play" in the tissues. Does that make any sense?

Melissa: What if the levator muscles are almost completely scarred? And, I want to avoid a flap due to Hannah's PRS and creating OSA. [Obstructive Sleep Apnea]

Melissa: Additional tissue??? Are you referring to using a donor site for tissue such as the forearm?

Dr. Canady: The levator muscles course around a bone called the hamulus (actually a piece of this bone called the "hook" of the hamulus and it would be unusual that it is completely scarred beyond use.  Additional tissue I was referring to was tissue from the pharyngeal flap (ie, this tissue can be used on rare occasions to close the center portion of the soft palate. I share your concerns about OSA after p-flap and this is probably more likely in the setting of

Dr. Canady: that in situations such as this you have to have a wide selection of choices that you as a surgeon are comfortable using and you have to spend a lot of time with the family running through the flow chart you are going to use to arrive at the choice you ultimately use...wish it was simpler and cleaner than that, but I don't believe that would be an honest answer...

Melissa: One quick question regarding the hamulus - one PS that we met with suggested fracturing the bones surrounding the soft palate in order to reduce tension. Is this the bone you are talking about? Will that help to reduce tension on the suture sites?

Melissa: So basically the PS will have to wait and see what is really in there and what he has to work with before knowing the best route to take??

Dr. Canady: That technique was popular some years ago, but is less used now. It can free up some length in the closure, but I think now a lot of people now are concerned about how changing the course/tension on levator affects its ability to move and produce proper speech. Your PS has an advantage over me in that he has done an exam and I would suppose that he already has a plan (or at least several options). Since I haven't actually seen the palate, I have t

Dr. Canady: done

Melissa: Ok, thank you so much. I appreciate you taking the time to answer. Sorry for the length.

Dr. Canady: No problem. Good luck and know that I have seen kids who have had several palate closure attempts that have ultimately turned out fine.

Joanne: Thanks. I have a question for you.

Dr. Canady: ok, Joanne.

Joanne: Both of my boys have had bone graft. For both, bone was taken from the hip. I was under the impression that it would take weeks to get over - the scar would be huge and they would always feel the discomfort. None of that is true. They have a one inch scar, they were up and around right away and totally over it in a week or so. So, what made the difference? How is it done differently than before?

Dr. Canady: Actually, I am not sure where all that started, but our experience has been similar -- that generally the kids bounce back pretty well. I published a study a few years ago with one of our oral surgeons (Dr. Deb Zietler) about exactly this subject. We looked at 50 consecutive patients (no hiding anybody) and essentially all of them were back at their pre-op activities by 2 weeks post op -- that means running, etc -- all the stuff we didn't want them to do again...!!!

Joanne: LOL- yes. I found the hardest part of it all was keeping them down

Dr. Canady: We try to do less muscle dissection than we did before and that must make some difference. It is amazing, though, because if somebody did that to me now, I would need round the clock nursing for about a year -- it is hard enough to get out of bed as it is...

Joanne: Thanks. I never know how to answer people when they ask about it except to share our experience. Thanks, Dr. Canady. Lori has a question for you now.

Dr. Canady: I can send you a copy of that reprint if you like -- I don't have access to the reference where I am right now.

Joanne: I would - yes.

Dr. Canady: Hi Lori

Lori: Hi! Spencer will have his lip repaired with your team on June 23rd, in case you don't remember us.

Dr. Canady: I remember you guys and I am looking forward to seeing you again in June.

Lori: He will be 16 weeks old at that time. You suggested his palate repair be done at about 10 months. That falls exactly at Christmas time. Is there any way you'd consider doing it earlier or is later better?

Dr. Canady: I'm pretty flexible about timing in general because I don't honestly believe that there is one "best" time for either the lip repair or the palate repair. There are pluses and minuses at each time and the dates that I use are basically a compromise between getting things done in time for the kids to develop function and trying to minimize the secondary effects of scar on the growth of the face. We can work out a time either way that will work.

Lori: Great! For insurance purposes, it would be wonderful to get it done this year, but of course we want what's best for Spence!

Dr. Canady: It's funny, but when I go to places like the Philippines, you see normal maxilo-mandibular relationships in cleft affected kids that you just don't see here because they never had surgery and they never had the effects of scar. And of course I don't mean funny in a humorous way, but it is just so different than you see in the US.

Lori: Spencer is eating runny cereal at bedtime. Will he have to go without post lip repair?

Dr. Canady: No, we'll be able to work something out post op so he is happy.

Lori: Okay. Do we bring our own MJ squeeze bottles and Ross nipples to the hospital?

Dr. Canady: Probably a good idea. I am a believer in using the same bottles as much as possible because it seems like the kids get used to them and we just seem to have less problems. Not a lot of science to back that up, but it is my opinion.

Joanne: Thanks, Doctor Canady... Chris has a question for you now.

Chris: Hi Dr Canady, I'm Chris from Australia.  I have a 2 1/2 y.o. daughter born with bilat. cleft lip (incomplete) and palate. Her repair of both deformities was done at the same time at about 3 1/2 months. What is your opinion about timing of lip and palate repair? Early or late? Together or separate procedures?

Dr. Canady: Hi Chris from Australia. As I was saying, there are pros and cons to repairs at any age. The approach in our center is to do them as separate operations and to do the lip at age 3 - 4 months or later and the palate at 10-14 months. This represents a compromise of function vs. growth and I certainly realize that there are a lot of opinions about this. I would emphasize that all of these are "opinions (including my own)" because there are studies that support and refute jus
Dr. Canady: repair.

Chris: thanks :)

Dr. Canady: You're welcome.

Joanne: Thanks, Melissa has another quick question for you now.

Melissa: Hannah again - PRS and Sticklers - 2 unsuccessful cleft surgeries - I have been reading studies about surgeons using free tissue transfers for cleft repairs that continually breakdown. They mention sites such as the forearm and "dorsalis pedis - first dorsal metatarsal artery free flap" as a means of repair. 1st - what is the success rate using these tissue transfers as means of closure and for speech outcome and 2nd - where is the "dorsali"?

Dr. Canady: Hi Melissa. There are reports of using tissue from distant sites for palate closure. This is relatively common in the reconstruction of head and neck cancer patients and much less commonly used in the repair of cleft palates. I personally have no experience using free tissue transfer for the repair of cleft palate and I know of no studies that have looked at speech outcomes for this type of repair. I have done free flaps for other conditions and it is certainl

Dr. Canady: more...
Dr. Canady: The dorsalis pedis donor area is on the top of the foot and has the benefit of being relatively thin, but this donor site is not without its problems -- difficult healing, etc.

Melissa: Ok, thanks. As you can see, we are trying to find out all our options and one that will work for Hannah.

Dr. Canady: Sure. You are great parents and that is your number one job...!!

Melissa: Thank you.

Joanne: Thanks again...now, Katie has a question for you.

Dr. Canady: Hi Katie

Katie: Hi. My daughter is now 7 months old. She was born with a unilateral cleft lip & palate. Her lip repair surgery was at the end of January. She has a good size lump of scar tissue just under her nose. The PS had to "dig out" some stitched that her body was rejecting

Katie: I am doing massage therapy on it, but it still is red and doesn't seem to be going down. PS said she will shoot some cortizone in it when she is under for her palate repair in September.

Dr. Canady: It is true that some sutures act differently in different patients and there is a lot of individual variation in scarring. I have a family who had adopted two cleft affected kids and one has a super scar after his repair and one has a much heavier scar. I used the same technique and the same sutures on both but the result was not exactly the same. Some people believe that massage with vitamin E oil or aloe vera helps and I don't think that hurts. I have also seen good results from 5% Kenalog (a steroid medication) in reducing scar post-op. Doesn't work in everybody, but when it does, it can really make a difference. The best thing though is to give Mother Nature a chance and it is true that wounds in young kids can take up to 18 months or more to reach maturity.

Dr. Canady: Did I get your question right?

Joanne: Dr. Canady -- do you think that perhaps this child's scar is keloiding?

Dr. Canady: Good question...

Katie: If it doesn't go down naturally and with massage, is there anything else that can be done? Also, her nose is still quite a bit flatter on the cleft side. Our PS said there just wasn't enough tissue to make the nostrils even.

Dr. Canady: A lot of people use the term keloid to describe heavy scars -- technically, a hypertrophic scar is a heavy scar within the boundaries of the original wound/incision and a true keloid is a scar that has extended outside the borders of the original wound. Steroid injections are appropriately used in the treatment of both, with hypertrophic scars responding better in my experience. If massage and time don't help, I would probably use the Kenalog and I, too, have injected lips during palate repairs.

Dr. Canady: The nose is probably the most difficult part of the lip repair. Even in people without clefts it is usually the case that the nose is not exactly symmetrical -- go an look at your nostrils in a mirror sometime and I bet that they do not exactly match--but the effects of the cleft on the nose are that the lower lateral cartilage is not the same shape and, importantly, not the same strength as the opposite side. Usually some sort of support or grafting improve the symmetry, but an exact match is rare.

Joanne: Thanks... your next question is from Pat.

Pat: Good evening Dr. Canady, thanks for being here. My daughter has a Tessier facial cleft. We are scheduled for tissue expansion mid-June. I have read that among the complication factors are patients under seven years of age and internal expander ports. In fact, EvaJessie's situation falls into both those categories. Could you please explain the WHY of these? Second question - Would you outline some of the pros and cons of continuity of injections, we are having those done here at home. Thanks.

Dr. Canady: Can you elaborate on continuity of injections for me a little, I'm not sure I understand exactly what you mean...

Pat: How important is it for the same surgeon to be handling all of the process?

Dr. Canady: ok, got it.

Dr. Canady: I think younger kids have more problems with tissue expanders because they don't really understand what is involved with the process and particularly what the consequences are if there are problems, ie, kids will be kids. The internal ports can be a challenge because you have to get them far enough away from the expander so that the expander can expand without covering them and sometimes they turn over or move around and are just tough to find (th

Dr. Canady: help. I personally like to do my own injections because I know where I put the filler port what shape and size it is and if there is a problem with the filling, then it is my fault and I haven't set up one of my colleagues to take the fall. I have had many patients have the filling done by their family doc with excellent success, though. Does that help?

Pat: Okay, yes, thanks, have you ever done expansion of the cheek -- on the face of a five year old?

Dr. Canady: No, honestly, I have not done expansion on a child that young.

Pat: Can this expansion really make a difference to the way she looks?

Dr. Canady: Tough for me to say without seeing her -- sounds like a cop-out I know, but it's true. An exam would go a long way toward giving a better answer

Pat: Yes, I understand that. Oh well, good try, though! Thanks again, I'll let someone else on  :-)

Joanne: Thanks... Rhonda has the next question for you.

Rhonda: My daughter had her lip repair 1 month ago and I have heard of people doing lip massage. Is this something I should be doing on a regular basis and will it help reduce the scarring? I have recently heard of a new product named Mederma available in the States. Do you know anything about this and is it a good product to use to reduce the scarring? Or should I use something like vit E? My plastic surgeon also said the scar will get very red over the next

Dr. Canady: Hi Rhonda. I do recommend massage after the first 3 weeks but you should check with the surgeon who did the repair to make sure they are comfortable with that. Mederma has been VERY heavily marketed and I am not personally aware of good studies in the US literature that are good or bad about it. They were marketing it heavily at the American Cleft/Craniofacial Association Meeting in Baltimore last month.

It is interesting that we, as plastic surgeons, don't know more than we do about wound healing and how to manipulate it. We have done work in my lab in the fetal model (less to no scar) and there is some reason to believe that substances called growth factors, particularly transforming growth factors may be one way to impact scarring. This is a ways from being ready for "prime time" but I do believe that in the future we will be able to do a lot more than we can do now.

Rhonda: Thank you

Dr. Canady: You're welcome

Joanne: Thanks...Now Cindy has a couple of questions for you.

Dr. Canady: Hi Cindy

Cindy: Thank you for being here Dr. Canady. My son Branden was born with a bilateral cleft lip and palate. He will be having his palate repair around 13 months of age. Our PS closes bilateral cleft palates by connecting the two sides to the vomer bone. Is this a common practice with bilateral cleft palates, and what are the pros and cons to this? I assume that it would lessen the chances of developing a fistula, but I'm not sure about it as I reall

Dr. Canady: Vomer flaps are fairly commonly used in bilateral cases and I use them quite often to help close the nasal layer. Again, there are probably some trade-offs in terms of facial growth, but I do believe that this is a sound way to close palates when it is necessary.

Cindy: Does this lessen the chances of fistulas?

Dr. Canady: Probably, and in fact, there are some cases where this is necessary to achieve closure at all (ie, if you tried to get the nasal side and oral side closed to each other without using the vomer, you would probably have real problems...)

Cindy: That is what I thought you would say - because many bilateral clefts are very wide. Ok - my second question has to do with bone grafts. My oldest will have hers in a year or so. Our PS uses the skull as the graft site. I have heard many pros to this site. Can you tell me some of the cons of the skull as the graft site?

Dr. Canady: I have used this as a donor on occasion in the past as well. Probably the biggest con is that there is a remote chance of a dural tear (the covering of the brain) and that in younger kids there is not as much cancellous (spongy) bone as there is in the hip. I have had several parents just not like the idea of having the skull operated on, even when I told them the reasons why I thought that was a good idea in that particular case. Biologically, the advantages to "homotropic" bone grafts (ie, bone stays close to where it was taken from -- skull bone does better in the head and neck, etc. This is not cut and dried, but some people believe it more strongly than others. A trade off is that there is also evidence that cancellous bone may do better as a graft in the alveolus and there is more of that in the hip.

Cindy: How young are we talking about when you say younger?

Dr. Canady: Younger is relative...as the skull grows, it develops a diploic space between the hard outer shell and the hard bone of the inner shell. The diploe is where the cancellous or spongy bone is in the skull. Develops at different rates in different kids...

Cindy: Ok - I think you have told me what I wanted to know. I am sure I will know what to ask him when the time comes anyway. Thank you very much for your time.

Joanne: Thank you -- the next question comes from Sandy.

Sandy: I'm mom to Leah who has a bilateral cleft lip & palate. She had her lip repair in Feb. can you explain the patchwork palate repair?

Dr. Canady: I'm not sure what you mean by the patchwork palate repair, sorry.

Sandy: Another cleft-talk mom told me about it. She said it was like a quilt

Joanne: I think I can help with this one.

Dr. Canady: ok

Joanne: The mom described it as -- the palate was very wide and the child was getting older -- they wanted to close it, but there was very little tissue, so the PS did a type of "patchwork" job... and it works very well. That's all the info we got on the list, as I recall.

Dr. Canady: Hmmmmm...really about the only thing I can think of is to use a pharyngeal flap as a center "patch" do you think that was what they were talking about? All the other repairs that I have ever used are some variation of moving tissue from laterally to the center. Using a pharyngeal flap in the primary closure is, as we talked about, pretty rare...at least in my experience.

Joanne: Maybe -- I've heard of cheek tissue being used -- and of course, we've heard of the tongue flap.

Dr. Canady: You're right, those may be options that were being referred to as well. Again, pretty rare use, at least for me.

Sandy: Thanks Joanne. Can I ask another question?

Joanne: If you had a second question, Sandy -- you can ask that now.

Sandy: Do you usually do palate repair and nose revision at the same time?

Dr. Canady: Not usually. My personal approach is to do a lip revision at the time the child starts school and not much before. I don't personally believe in a lot of early revisions, because I think that the additional scar just causes problems down the road. This is not an opinion that is universally held. I personally feel that there is little harder than the multiply operated nose in a teenager and I try not to put myself in that position any more frequently

Dr. Canady: and not everyone gets a revision then...

Sandy: I should be more specific. When Leah had her lip repair the PS left a flap on each side under her nostril and said he will use this tissue at the time of palate closure to help extend her nose off her face.

Dr. Canady: Yes, that can be done at the time of palate repair, but I usually don't do it that way because if there are airway problems post op and a nasal trumpet or some other tube needs to be inserted, it could disrupt the repair. In all fairness, though, this is rare enough, that it would not be unreasonable to do the two together.

Sandy: Thank you. I was hoping that she wouldn't have more surgery because of doing it this way. She has never had any breathing problems (knock on wood).

Dr. Canady: I am absolutely supportive of doing more than one thing under a given anesthesia if it is medically reasonable.

Joanne: Thanks ... the next question if from Lori again.

Lori: I believe Spencer will only be in the hospital overnight after his lip repair in June. Barring any complications, approximately what time are these little ones released from the hospital the following day? We have that "lovely" six hour drive ahead of us, in case you didn't remember. We also remember the audiologist talking about testing his hearing before we leave, since he'll have ear tubes put in with the lip repair. Would you recommend o

Dr. Canady: The long drive is a double edged sword. I know people like to get on the road as soon as possible, but especially because you live that distance away, I want to make sure that the oral intake is going well before you leave. Probably looking at early afternoon since the audiogram needs to be done...

Lori: Thanks a bunch. See you in three weeks!

Dr. Canady: That way we'll know breakfast and lunch are OK. See you then.

Joanne: Thank you -- we have only two questions remaining on the roster. The next question comes from Chris and Kerri.

Chris: Our PS said he doesn't use "pharyngoplasty" to correct nasal escape/speech problems but uses some other sort of flap procedure - maybe to do with tonsils? What procedures are there for this purpose, and what problems are envisaged with them?

Dr. Canady: Secondary surgery for VPI usually consists of pharyngeal flap, pharyngoplasty, or secondary Z plasty of the soft palate (Furlow). In our center, we decide on an approach based on a pre-operative evaluation using videofluroscopy, videonasendoscopy, (or both), nasometry, and an evaluation by one of our speech therapists.

Dr. Canady: Probably the biggest risk for any of the procedures is reoperation for correction of obstruction (obstructive sleep apnea), or the opposite - lack of total correction of the nasal speech.

Chris: Ok - thanks, that sounds similar to what's in store for our little one :)

Dr. Canady: Good luck and remember that most of the kids really get a lot of benefit from these types of procedures.

Joanne: The last question of the evening is from Deana.

Dr. Canady: Hi Deana.

Deana: Will a bone graph help my daughter with articulation problems? Is it usually a major improvement as my daughter is very hard to understand especially for strangers.

Dr. Canady: Bone grafts can help speech if they close a fistula or if they allow an orthodontist to proceed and improve occlusion. There are certainly articulation problems that have a basis in dentition and in that respect a bone graft may help. Ultimately, the bone graft can help with final dental rehabilitation in the area of the cleft and this may help articulation, too.

Deana: Hmmm... well she just has the little space behind the premaxilla.

Dr. Canady: I would guess that it is in the plan to close that at the time of the graft -- your surgeon would be able to tell you for sure.

Joanne: Thank you, Dr. Canady-- we appreciate the time you spend with us to answer our questions.

Chris: Yes, many thanks :)

Deana: Thank you very much and it was certainly wonderful for you to take the time to answer all our questions and yes it will be closed with the bone graph.

Joanne: As people left, they also left their thanks.

Dr. Canady: You're all welcome. It's fun to chat with everyone and I am glad to know it helps a little.

Joanne: I cannot tell you how valuable this is to our families.

Deana: It helps more than a little and I'm sure you've helped ease minds tonight :^)