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Palatal fistulas after primary repair of clefts of the secondary palate
Abstract
Our aim was to assess whether severity of cleft, age at the time of repair, and the operating surgeon's experience contributed to the development of fistulas in patients with clefts of the secondary palate. We studied 814 children born between 1960 and 1999 with clefts of the secondary palate who had had their primary operation at the Department of Plastic Surgery, Rikshospitalet University Hospital, Oslo, Norway. Data were collected retrospectively from the archives of the Oslo Cleft Team. Palatal fistulas developed in 36 patients (4%), among whom 17 patients required correction (2% of the total). The incidence of fistulas was not related to sex. Patients with clefts of the hard and soft palate developed fistulas more often than patients with clefts of the soft palate only (8% compared with 1%, p<0.001). Patients with submucous cleft palates developed fistulas significantly more often than patients with clefts of the soft palate only (5% compared with 1%, p=0.02). Among patients with clefts of the hard and soft palate, the incidence of fistulas increased significantly with increasing age at the time of palatal closure (p=0.005). The incidence decreased significantly the more experienced the operating surgeon was for treating clefts of the hard and soft palate (p<0.001) but not for submucous clefts. Among patients with clefts of the hard and soft palate who had the palate closed at 14 months of age or later, the incidence of fistulas decreased from 21% when the operating surgeon had little experience to 0 when the surgeon had much experience. The incidence of fistulas was related to severity of cleft, age at palatal closure, and the operating surgeon's experience.
... A cleft palate fistula can result as a failure of healing or a breakdown in the primary surgical repair of the palate. [3] Several factors may influence the occurrence of fistulas, including type of cleft palate, [3][4][5] type of cleft repair, [6] cleft width, [6][7][8] and age at the time of palatal closure [4,6] and surgical experience. [9] The aim of the study was to assess the influence of experience of the young surgeon on the occurrence of fistulas following palatoplasty. ...
... A cleft palate fistula can result as a failure of healing or a breakdown in the primary surgical repair of the palate. [3] Several factors may influence the occurrence of fistulas, including type of cleft palate, [3][4][5] type of cleft repair, [6] cleft width, [6][7][8] and age at the time of palatal closure [4,6] and surgical experience. [9] The aim of the study was to assess the influence of experience of the young surgeon on the occurrence of fistulas following palatoplasty. ...
... It is assumed that surgical experience improves over time. There are some studies [4,5] supporting this and other studies [15,16] contradicting this assumption. Lu et al., [5] for instance, demonstrated that the cleft surgeon has a fistula rate of 2% and the resident (under supervision) of 11%. ...
Objectives
The aim of the study was to assess the influence of the experience of the surgeon on the occurrence of fistulas and breakdowns following palatoplasty.
Materials and Methods
A retrospective review on the outcomes of palatoplasty done by a young surgeon in his initial 3 years of operating cleft palate was done. Cleft palate repair was performed using the Pinto's modification of Wardill–Kilner palatoplasty, Veau-Wardill-Kilner V-Y Pushback in both the techniques radical levator muscle dissection was carried out. Data were collected for age, sex, date of birth, syndrome, cleft palate type, type of repair, cleft width, length of soft palate, quality and quantity of muscle, fistula occurrence, and location of fistula.
Results
Retrospective analysis was done on the outcomes of palatoplasty performed by a young surgeon in his initial 3 years at Charles pinto center for cleft lip palate and craniofacial on 220 cleft palate children which included all variants and dimensions of cleft palates. Postoperatively, the incidence of palatal fistulas occurred in 12 patients, three patients had bifid uvula, however, out of 12 patients who had fistulas only four needed fistula closure and one required a uvula re-repair; the rest healed well.
Conclusion
We believe there is a learning curve in performing cleft palate repair. Our technique and principles followed in palatoplasty appear to have a low or zero fistula rate even in the initial period of learning. Furthermore, effective mentorship and guidance help in reducing errors and providing a better outcome.
... The incidence of palatal fistula following cleft palate repair was reported to be 0%-60% historically and 3%-35% in recent studies [8][9][10][11][12]. Furthermore, many factors, including the surgical technique, timing of surgery, extent of cleft, presence of cleft lip, surgeon's experience, and associated syndromes, are known to increase the risk of palatal fistula [12,13]. ...
... Previous studies have reported a wide range of fistula rates after cleft palate repair, ranging from 0% to 60% [8][9][10][11][12]. We report a 3.1% incidence of palate fistulas, which is lower than that recently reported in the literature. ...
... The mean age at cleft palate repair in the group of patients who underwent cleft palate repair after 18 months was 34 months, and submucosal cleft palate was the most prevalent type (64/133). While some studies have argued that the incidence of fistula is directly proportional to the patient's age at operation [10,11,20], other studies have reported that there was no significant difference in fistula formation between patients younger than 18 months and The odds ratio is the ratio of the odds of failure for the second procedure to that of the first. Values above 1.00 favor the first procedure, whereas values below 1.00 favor the second procedure. ...
Background:
Cleft lip and cleft palate are the most frequent congenital craniofacial deformities, with an incidence of approximately 1 per 700 people. Postoperative palatal fistula is one of the most significant long-term complications. This study investigated the incidence of postoperative palatal fistula and its predictive factors based on 25 years of experience at our hospital.
Methods:
We retrospectively reviewed 636 consecutive palatal repairs performed between January 1996 and October 2020 by a single surgeon. Data from patients' medical records regarding cleft palate repair were analyzed. The preoperative extent of the cleft was evaluated using the Veau classification system, and the cleft palate repair technique was chosen according to the extent of the cleft. SPSS version 25.0 was used for all statistical analyses, and exploratory univariate associations were investigated using the t-test.
Results:
Fistulas occurred in 20 of the 636 patients; thus, the incidence of palatal fistula was 3.1%. The most common fistula location was the hard palate (9/20, 45%), followed by the junction of the hard and soft palate (6/20, 30%) and the soft palate (5/20, 25%). The cleft palate repair technique significantly predicted the incidence of palatal fistula following cleft palate repair (P=0.042). Fistula incidence was significantly higher in patients who underwent surgery using the Furlow double-opposing Z-plasty technique (12.1%) than in cases where the Busan modification (3.0%) or two-flap technique (2.0%) was used.
Conclusions:
The overall incidence of palatal fistulas was 3.1% in this study. Moreover, the technique of cleft palate repair predicted fistula incidence.
... The occurrence of fistulae, as noted in published reports, varies widely, ranging from 3.4% to 15% [4,18]. Several predisposing factors may affect fistula development, including age at the time of the palatoplasty [15], cleft type [7,20,21], surgical technique [22][23][24] and the experience of surgeon [14,20,22], although findings from other studies do not support the aforementioned effect of age of palatoplasty [25,26] and cleft type [22] respectively. Studies show that there is no effect of gender on fistula development [20,26]. ...
... The occurrence of fistulae, as noted in published reports, varies widely, ranging from 3.4% to 15% [4,18]. Several predisposing factors may affect fistula development, including age at the time of the palatoplasty [15], cleft type [7,20,21], surgical technique [22][23][24] and the experience of surgeon [14,20,22], although findings from other studies do not support the aforementioned effect of age of palatoplasty [25,26] and cleft type [22] respectively. Studies show that there is no effect of gender on fistula development [20,26]. ...
... Several predisposing factors may affect fistula development, including age at the time of the palatoplasty [15], cleft type [7,20,21], surgical technique [22][23][24] and the experience of surgeon [14,20,22], although findings from other studies do not support the aforementioned effect of age of palatoplasty [25,26] and cleft type [22] respectively. Studies show that there is no effect of gender on fistula development [20,26]. The Iranian based Isfahan Cleft Care Team was established in 2005 for the purpose of providing interdisciplinary management of patients with cleft lip and palate. ...
... This finding corresponds with the range of previously published studies, although the formation of palatal fistula after primary cleft closure has been noted to be variable (Table V), ranging from 4.0% to 45%. 1,4,5,[7][8][9][10][11]13,14,17,[19][20][21][22][23][24][25][26] In our study, gender did not significantly affect the rate of fistula formation, which was a finding also supported by studies published by Emory et al., 10 Muzaffar et al., 11 and Lu et al. 5 Amaratunga 14 reported that palatal fistulas seem to occur more commonly in males. ...
... Amaratunga 14 found that patients with BCLP had palatal fistulas more often than those with other cleft types. Andersson et al. 17 observed that patients with HSCP were significantly more likely to develop a fistula than those with other cleft types. ...
... 5,8 Previous studies have reported that the most common site for fistula formation was at the junction between the hard and soft palate. 5,14,17 In the present study, palatal fistulas developed most often at the soft palate, then the hard palate, followed by the junction of the soft and hard palate. ...
... Cleft palate repair is a surgery done in order to attain proper closure of the nasal floor, muscle tissue and oral mucosa. 1 Failure in regaining the proper structural integrity results in cleft palate fistula which can be either due to the residual non repaired cleft or the breakdown of the original repaired palate. 2 The approach to palatal fistula depends on the symptoms associated, the site and dimensions of the fistula. The most common symptoms are speech distortions caused by nasal emissions; poor oral hygiene caused by food and fluid seepage into the nasal cavity resulting in nasal lining inflammation. ...
... The incidence of palatal fistula can range from 0-35% with the average overall incidence of 8.6%. [1][2][3][4][5][6][7][8][9] The risk factors of palatal fistula repair ranges from the type of cleft defect, its dimensions, the surgeon's experience and the timing and technique of repair used for the procedure. ...
One of the expected outcomes of palate repair is to achieve complete partition between nasal and oral cavity in addition to good speech. Any failure of achieving complete structural integrity of palate is labelled as an oronasal (palatal) fistula with persistent passage between oral and nasal cavity, it can occur at the anterior, posterior or mid palatal region
The aim of the study is to assess prevalence of palatal fistula, cause of palatal fistula, location of palatal fistula and to derive a more relevant surgical technique.
A retro-prospective study was conducted in operated cleft patients who showed presence of palatal fistula between the age group of 9 months to 7 years. The data collected included age, sex and type of cleft defecttype, width of cleft palatetype of surgery performed, size of fistula, location of fistula, duration of fistula formationpostoperatively
8 palatal fistula were included. The fistula was located mostly at the anterior palatal region (50%) and secondly at the mid palatal region (38%). The occurrence of fistula in operated cleft lip and palate cases was noted mostly after V-Y pushback palatoplasty followed by Von Langenbeck
Among the surgical techniques used for palatoplasty, the Von Langenbeck is proven to be superior than V-Y pushback palatoplasty in accordance with the occurrence of palatal fistula. The anterior palate fistulas were the most common type in the study.
... Interestingly, 28 of these 33 children also required speechcorrecting surgery either as a single procedure (n¼10) or simultaneously with the pharyngoplasty (n ¼ 18). The total incidence of fistulas was higher than that in a previous study (2%) of ICP (Andersson et al. 2008) operated by the Langenbeck and Sommerlad techniques. However, the incidence of operated fistulas in our study was significantly related to the technique of palatal repair. ...
... The incidence of operated fistulas was also related to the severity of the cleft, but not to gender. These findings are in agreement with earlier reports (Heliövaara et al., 1993;Muzaffar et al., 2001;Andersson et al., 2008;Phua and de Chalain, 2008;Landheer et al., 2010;Lu et al., 2010). ...
While bilateral cleft lip and palate (BCLP) constitutes a clinical challenge for the whole cleft team, the ideal surgical protocol remains obscure. This study presents the long-term burden of care in terms of secondary surgeries, defined as fistula repair and speech-correcting surgeries (SCS), in a single center. Outcomes of two surgical protocols utilized over the years were also compared.
A retrospective single-center analysis of 81 non-syndromic children with complete BCLP born between 1990 and 2010. Two surgical protocols comprising single-stage and two-stage (delayed hard palate closure) procedures were compared. Outcome was analyzed at the time of alveolar bone grafting (ABG) and post-ABG.
Altogether 54 children (66.7%) had underwent secondary surgery by the time of bilateral ABG. At this point, 38.3% (n = 31) of patients had received SCS and 49.4% (n = 40) had undergone fistula repair. The corresponding incidences at the end of follow-up were 46.9% (n = 38) and 53.1% (n = 43). No significant difference emerged in SCS incidence between the 2 protocols; however, prior to ABG the single-stage protocol had a significantly lower need for fistula repair. Regarding the location of fistulas, some differences were observed, with the single-stage procedure more associated with anterior fistulas.
BCLP has a high surgical burden of care in terms of secondary surgeries, defined as SCS and fistula repair. In our experience, the single-stage protocol, particularly the two-flap technique, offers better results in the management of BCLP than the two-stage approach with a short delay in hard palate closure.
... Several factors may influence the occurrence of fistulas, including the type of cleft palate, 39 cleft width, 40,41 type of cleft repair, 41 age at palatal closure, 39,41 and surgical experience. Results of the retrospective studies by Breugem et al show that the use of a vomer flap reduced cleft width by 30%, subsequently reducing the risk of fistula development. ...
... Several factors may influence the occurrence of fistulas, including the type of cleft palate, 39 cleft width, 40,41 type of cleft repair, 41 age at palatal closure, 39,41 and surgical experience. Results of the retrospective studies by Breugem et al show that the use of a vomer flap reduced cleft width by 30%, subsequently reducing the risk of fistula development. ...
Background and aims:
Between 1997 and 2014, 3 protocols have been used in out cleft unit for primary repair of unilateral cleft lip and palate. During the Scandcleft randomized controlled trial closing the soft palate and lip at 4 months and the hard palate at 12 months (Protocol 1) was compared with closing the entire palate at 12 months (Protocol 2). Protocol 3 comprises closure of the lip and hard palate with a vomer flap at 4 months and the soft palate at 10 months. The purpose of this study was to compare subsequent velopharyngeal competence at age of 3 and 5 years.
Patients and methods:
The study consisted of 160 non-syndromatic patients with a unilateral cleft lip and palate. Protocol 3 was retrospectively compared with Protocols 1 and 2 within the previously published Scandcleft study.
Results:
At 3 years of age, normal or borderline competent velopharyngeal function was found in 68% of patients in Protocol 1, 74% of patients in Protocol 2, and 72% of patients in Protocol 3. At 5 years of age, the corresponding figures were 84%, 82%, and 92%. 21% of patients in Protocol 1, 4% in Protocol 2, and 23% in Protocol 3 had palatal reoperations before the age of 5 years.
Conclusion:
No significant differences emerged in velopharyngeal competence at age 3 years between the 3 protocols. Palatal reoperations were performed earlier in patient groups 1 and 3, explaining the difference in the velopharyngeal competence rate at the 5-year time-point.
... Frequency of palatal fistula at our institution is high compared to reports in literature [1][2][3][4][5][6][7][8][9][13][14][15][16] and loss to follow up, difference in population characteristics could be responsible for this discrepancy. Loss to follow up could have resulted in artificially higher fistula rates if some of the patients lost actually had no fistulas. ...
... According to Parwaz et al., the risk of fistula formation increases as palatal index increases to 0.48 [6]. Wide clefts are prone to tension on closure and are related with more technical difficulties to close than narrow clefts which explains why patients with wide clefts are more likely to develop fistulas [16]. Two-stage palate repair was associated with increased fistula formation in our study (Table 3). ...
Objective:
To determine frequency of palatal fistula following primary cleft palate repair and the associated factors as a measure of cleft palate repair outcome and its challenges at a cleft centre in Uganda.
Results:
Between May and December 2016, 54 children with cleft palate were followed up at Comprehensive Rehabilitation services of Uganda (CoRSU) hospital, from time of primary cleft palate repair until at least 3 months postoperative to determine whether they developed palatal fistula or not. Frequency of palatal fistula was 35%. Factors associated with increased fistula formation were cleft width wider than 12 mm (p = 0.006), palatal index greater than 0.4 (p = 0.046), presence of malnutrition at initial outpatient assessment (p = 0.0057) and at time of surgery (p = 0.008), two-stage palate repair (p = 0.005) and postoperative infection (p = 0.003). Severe clefting (palatal index greater than 0.4) was seen in 74% of patients and malnutrition (Low weight for age) seen in 48% of patients. Palatal fistula rates at our institution were high compared to reports in literature. The high proportions of severe clefting and malnutrition observed in our population that was also poor and unable to afford feeding supplements increased likelihood of fistula formation and posed challenges to achieving low fistula rates in our setting.
... Interestingly, 28 of these 33 children also required speechcorrecting surgery either as a single procedure (n¼10) or simultaneously with the pharyngoplasty (n ¼ 18). The total incidence of fistulas was higher than that in a previous study (2%) of ICP (Andersson et al. 2008) operated by the Langenbeck and Sommerlad techniques. However, the incidence of operated fistulas in our study was significantly related to the technique of palatal repair. ...
... The incidence of operated fistulas was also related to the severity of the cleft, but not to gender. These findings are in agreement with earlier reports (Heliövaara et al., 1993;Muzaffar et al., 2001;Andersson et al., 2008;Phua and de Chalain, 2008;Landheer et al., 2010;Lu et al., 2010). ...
Objective:
Speech-correcting surgeries (pharyngoplasty) are performed to correct velopharyngeal insufficiency (VPI). This study aimed to analyze the need for speech-correcting surgery in children with isolated cleft palate (ICP) and to determine differences among cleft extent, gender, and primary technique used. In addition, we assessed the timing and number of secondary procedures performed and the incidence of operated fistulas.
Design:
Retrospective medical chart review study from hospital archives and electronic records.
Participants:
These comprised the 423 consecutive nonsyndromic children (157 males and 266 females) with ICP treated at the Cleft Palate and Craniofacial Center of Helsinki University Hospital during 1990 to 2016.
Results:
The total incidence of VPI surgery was 33.3% and the fistula repair rate, 7.8%. Children with cleft of both the hard and soft palate (n = 300) had a VPI secondary surgery rate of 37.3% (fistula repair rate 10.7%), whereas children with only cleft of the soft palate (n = 123) had a corresponding rate of 23.6% (fistula repair rate 0.8%). Gender and primary palatoplasty technique were not considered significant factors in need for VPI surgery. The majority of VPI surgeries were performed before school age. One fifth of patients receiving speech-correcting surgery had more than one subsequent procedure.
Conclusion:
The need for speech-correcting surgery and fistula repair was related to the severity of the cleft. Although the majority of the corrective surgeries were done before the age of 7 years, a considerable number were performed at a later stage, necessitating long-term observation.
... A few reports suggest that the cause of fistula is infection. [20] However, infection is unlikely in younger babies, unless they are compromised either immunologically or nutritionally. In older children, infection is seen especially with poor dental and oral hygiene. ...
... In younger children one should repair the anterior palate using the vomer flap with primary lip repair to avoid fistula in alveolar and post-alveolar region. [20] Once fistula occurs in post-alveolar region with flexed premaxilla and shortage of tissue, it is likely to need import of tissue like tongue flap [ Figure 5]. ...
Introduction: The cleft palate repair is commonly performed procedure in plastic surgery practices. In addition, this is also procedure done by trainees to the senior most surgeons. One of common procedure for trainee who are introduced to cleft lip and palate surgeries. Literature is flooded with articles on complication of cleft palate repair and probable factors influencing it till the latest one, which suggest that we are far from getting desirable results in cleft palate repair. Review: The common complications of cleft palate repair are fistulae, velopharyngeal insufficiency and detrimental effect on maxillary growth. Palatal fistula is commonly stated in literature with variable incidence ranging from 3-40% 1 , with an average of 7-10%. Other complications are poor speech outcome and poor growth potential of maxillary bone due to scars following palate repair. Every attempt needs to be made to avoid complications or reduce the rate of complications. This article reviews the factors and pitfalls that are likely to increase the chances of complication following palate repair. Conclusion: As surgeon we are duty bound to reduce the avoidable complication, specially related to judgment and techniques. However, the complication due to inherent deficiency of tissue like hypoplastic soft palate muscles and poor scarring tendencies leading to complications are not avoidable.
... In the first level, abstracts were reviewed for the exclusion criteria (summarized in Table 1). 1,2,5,9,13,17, In the second level screening, all articles filtered through the first level were read in their entirety and the same inclusion and exclusion criteria were applied. Only studies that successfully passed both levels of screening were included in our analysis. ...
... After full review of each selected article, 44 were included in the final analysis ( Fig. 1). There were five randomized controlled trials 35,37,42,48,55 and 39 nonrandomized studies, [1][2][3]5,9,13,17,[21][22][23][24][25][26][27][28][29][30][31][32][33][34]36,[38][39][40][41][43][44][45][46][47][49][50][51][52][53][54]56,57 of which 10 were comparative studies and 29 were noncomparative. The mean Detsky score for the randomized controlled trials was 14, with two studies considered to be of high quality. ...
Background:
The development of an oronasal fistula after primary cleft palate repair has a wide variation reported in the literature. The aim of this review is to identify the reported oronasal fistula incidence to provide a benchmark for surgical practice.
Methods:
A systematic review was undertaken to investigate the incidence of fistula. Multiple meta-analyses were performed to pool proportions of reported fistulae, in each data set corresponding to the continent of origin of the study, type of cleft, and techniques of cleft palate repair used.
Results:
A total of 9294 patients were included from 44 studies. The overall incidence of reported fistula was 8.6 percent (95 percent CI, 6.4 to 11.1 percent). There was no significant difference in the fistula incidence corresponding to the continent of origin of each study or the repair technique used. The incidence of fistula in cleft lip-cleft palate was 17.9 percent, which was significantly higher (p = 0.03) than in cases of cleft palate alone (5.4 percent).
Conclusions:
Palatal fistulae were more likely to occur in cases of combined cleft lip-cleft palate, compared with cleft palate alone. The authors would recommend the prospective examination and recording of all fistulae to a standardized classification scheme.
Clinical question/level of evidence:
Therapeutic, III.
... They are most commonly located at the junction between the soft and hard palates, or at the junction between the primary and secondary palates [1] . They are more frequent in bilateral than in unilateral clefts [2] , and in combined velopalatal clefts than in velar clefts [3,4] , that is in the more severe anatomic defects. The size of the cleft, the surgical technique and experience of the surgeon, and the age of the patient when operated upon are factors that influence the incidence of these fis- tulas, which varies from 3 to 21% according to different studies [2][3][4][5][6][7][8] . ...
... They are more frequent in bilateral than in unilateral clefts [2] , and in combined velopalatal clefts than in velar clefts [3,4] , that is in the more severe anatomic defects. The size of the cleft, the surgical technique and experience of the surgeon, and the age of the patient when operated upon are factors that influence the incidence of these fis- tulas, which varies from 3 to 21% according to different studies [2][3][4][5][6][7][8] . Depending on their location, their size and their symptomatology, the fistulae might require simple follow-up or surgical intervention. ...
Objectives:
The aim of this prospective study was to measure nasal and oral airflow during speech, before and after obturation.
Patients and methods:
Included were children aged 3-18 years with nonsyndromic clefts and palatal fistulae. The corpus used was: syllable /pi/; a sentence containing stop consonants and a nasal phoneme; and the description of a picture of a scene. Analysis criteria were: percentage of nasality; value of average flow for the explosion; perceived nasality and intelligibility; and tolerance of the proposed device.
Results:
Only 5 children were included due to the observation of an increase in the percentage of nasality after obturation. The value of average flow for the explosion increased in all patients. A decrease in perceived nasality was noted in all but 1 patient. An improvement in intelligibility was observed in 3 out of the 5 children. The tolerance of the device was good.
Conclusion:
While the small number of patients studied does not permit firm conclusions concerning the efficiency of the obturation, the method described, as well as the introduction of 'speed of explosion' of stop consonants, offer new perspectives to prospectively study obturator effects on speech.
... 37,[47][48][49][50][51][52][53] Biological sex was not associated with VPI surgery or fistula repair rate in the following studies but did equate to a greater number of secondary surgery procedures for males in one study. 37,39,52,54 Sitzman et al. documented biological sex was not associated with time to secondary surgery. 7 Our meta-analysis showed no association between biological sex and velopharyngeal outcomes although a large proportion of studies did not include this important patient characteristic. ...
Objective:
Identification of patient factors influencing velopharyngeal function for speech following initial cleft palate repair.
Design:
A literature search of relevant databases from inception until 2018 was performed using medical subject headings and keywords related to cleft palate, palatoplasty and speech assessment. Following three stage screening data extraction was performed.
Setting:
Systematic review and meta-analysis of relevant literature.
Patients/participants:
Three hundred and eighty-three studies met the inclusion criteria, comprising data on 47 658 participants.
Interventions:
Individuals undergoing initial palatoplasty.
Main outcome measures:
Studies including participants undergoing initial cleft palate repair where the frequency of secondary speech surgery and/or velopharyngeal function for speech was recorded.
Results:
Patient factors reported included cleft phenotype (95% studies), biological sex (64%), syndrome diagnosis (44%), hearing loss (28%), developmental delay (16%), Robin Sequence (16%) and 22q11.2 microdeletion syndrome (11%). Meta-analysis provided strong evidence that rates of secondary surgery and velopharyngeal dysfunction varied according to cleft phenotype (Veau I best outcomes, Veau IV worst outcomes), Robin Sequence and syndrome diagnosis. There was no evidence that biological sex was associated with worse outcomes. Many studies were poor quality with minimal follow-up.
Conclusions:
Meta-analysis demonstrated the association of certain patient factors with speech outcome, however the quality of the evidence was low. Uniform, prospective, multi-centre documentation of preoperative characteristics and speech outcomes is required to characterise risk factors for post-palatoplasty velopharyngeal insufficiency for speech.
Systematic review registration:
Registered with PROSPERO CRD42017051624.
... A palatal fistula is a common complication after cleft palate repair, usually occurring in the anterior part of the hard palate, the junction of the hard and soft palate, the palatal sag, and the anterior part of the soft palate (18)(19)(20). A large fistula can lead to a series of problems such as language dysfunction, hearing impairment, poor oral and nasal hygiene, and psychological abnormalities. ...
Purpose
A palatal fistula following the closure of palatal clefts remains a difficult clinical complication. Surgical treatment of fistulas is often complicated, with high recurrence rates. We present our results of fistula closure augmented with GTR, a resorbable membrane designed to promote guided tissue regeneration.
Methods
We reviewed the records of 75 patients operated on between 2008 and 2022 for closure of the palatal fistula. The patients included 24 who underwent fistula closure augmented with GTR and 51 who underwent fistula closure with other techniques. We reviewed the age at surgery, sex, fistula location, and outcome. Operation success was defined as an asymptomatic patient with a healed fistula on clinical examination.
Results
The overall fistula closure rate was 79.1% in the GTR group and 76.5% in the non-GTR group( p = 0.79).
Discussion
The success rate of fistula closure in the GTR group is comparable to that in the non-GTR group in this study. An additional advantage is that this procedure does not require harvesting any autologous tissue and reduces tissue damage in the long term.
... Andersson et al postulated that fistulae develop more often in patients with SMCP and ICP than in those with only soft palate clefts. 9 Phua et al observed higher fistula rates in more severe clefts and 31.8% hypernasality following primary palatoplasty. ...
Background: Cleft palate repair comprises the surgical creation of a congenitally
nonexistent normal anatomy, to establish physiological function by moving tissues
into their normal anatomical positions. In patients with isolated incomplete (IICP)
or submucous (SMCP) cleft palate, the vomer is usually not completely attached
to the palatal plate in the midline. This condition, which is visible through surgical
access radiologically or via endoscope, is often disregarded during hard palate
repair. This can lead to “hypernasality” despite a well-functioning velopharyngeal
mechanism. The general practice of hard palate repair by suturing merely the
nasal layers together separates the oral and nasal cavities. However, without incorporation
of the vomer, it is impossible to build two separate nasal floors on the left
and right sides. We consider that achieving normal speech and separation of the
nasal cavities are mutually dependent and have to be considered equally.
Methods: We described hard palate repair involving the vomer for construction of
both nasal floors. We presented the occlusal relationship, hypernasality, and fistula
rates in 37 patients operated on between January 1, 2017 and June 30, 2018.
Results: One child presented minimal hypernasality; all others had normal resonance/
voice. Fistula rate was zero, and no cross bites were observed.
Conclusions: The implicit connection between the inner nose, resonance/voice,
and prevention of fistulae has not yet been acknowledged. The correct usage of
vomer flaps in IICP and SMCP creating separate nasal floors supports the velopharyngeal
competency, avoids fistula formation, and should be incorporated
regularly, like in other cleft forms.
... Fistulae classified per the proposed classification provides a comprehensive idea of the problem that may be encountered during closure. Several factors may influence the occurrence of fistulas, including the kind of surgical technique employed for palate closure [6][7][8][9] , initial cleft width 10 , early or advanced age at surgery 11,12 , and plastic surgeon's experience. 13 Fistulas may occur anywhere along the palate and are more frequent within the surface and also the transition between hard and palate. ...
Aim: Purpose of our research was to conduct a demographic analysis of palatal fistula in patients arriving in a tertiary care centre. Methodology: Retrospectively all the data was taken before repair of palatal fistula from the year January 2000 to June 2020 in JMMCH & RI, Thrissur were enrolled in the study. Subsequent variables: sex, cleft side, presence of Simonart's band, initial cleft width, intraoperative problems, and postoperative problems were measured. A chi-square test was used as statistical measure to analyse the variables. Results: In age group 0-6 months; the fistula was mostly present in anterior region of hard palatal region (54%), whereas size of the fistula was mostly <0.4mm in 63% cases which was statistically significant (p=0.04). The results were statistically significant in case of patients belonging to 13-24 months (p=0.012) as well as in case of >24 months of age (p=0.045). Conclusion: We recommend a future prospective controlled study to study the factors that lower the incidence of fistula in bigger sample size population.
... Accordingly, cleft palate repair is usually performed in the first year of life before the child starts to speak. A palatal fistula, which occurs in 4 to 25% of cases, is a complication of cleft palate repair [4][5][6][7][8][9][10]. The indications for a fistula repair depend on the related symptoms. ...
Objectives: Despite improved techniques in repair of cleft palate, failure of healing of palatal structures resulting in a palatal fistula is one of the major challenges in the practice of reconstructive surgery. The aim of this study is to evaluate treatment success and failure in patients with palatal fistulas following cleft palate repair. Patients and Methods: Totally 44 patients with a history of cleft palate who underwent surgery for palatal fistula were included in this study undertaken between January 1999 and August 2014. Fistulas were classified as anterior and posterior according to the repair technique and were repaired using one of the following techniques: buccal mucosal flap, tongue flap or mucoperiosteal flap. Results: Success rate for anterior fistulas was 71.42% with tongue flap and 76.92% with mucoperiosteal flap. Success rate for posterior fistulas was 84.62% with mucoperiosteal flap and 75% with buccal mucosal flap. Difference in success rates between the anterior and posterior fistulas was not statistically significant. Conclusion: Our study results suggest the use of mucoperiosteal flaps for both anterior and posterior fistulas smaller than 5mm as the first choice, guided by the principle of replacing absent tissue with similar tissue.
... We assume, however, that the incidence of such events occurring would be low for this common, low-risk procedure. Finally, surgical technique and surgeon experience are predictive factors for postoperative fistula formation [35][36][37][38][39][40][41][42] . While these are critical factors when comparing small treatment cohorts, this large, national database should impart a degree of homogeneity between treatment groups. ...
Background:
Previous attempts to study the effect of prophylactic antibiotics on the outcomes of cleft palate surgery have been hampered by the need for a very large sample size to provide adequate power to discern a potentially small therapeutic effect. This limitation can be overcome by querying large databases created by healthcare governing bodies.
Methods:
Data from the Pediatric Health Information System (PHIS) database was utilized for this analysis. Patients, 6-18 months, who had undergone primary palatoplasty (ICD-9 code 27.62) between 2004 and 2009 were included. Subsequent repair of an oronasal fistula between 2004 and 2015 was identified by ICD-9 procedure code 21.82. Pharmacy billing records were used to determine antibiotic administration. Associations between antibiotic administration and fistula repair were assessed using random-intercept logistic regression adjusting for age, gender, race, and cleft type.
Results:
7160 patients were available for analysis; of these, 6.4% (n=460) had a subsequent repair of an oronasal fistula. Fistula rates were 5.9%, 11.4% and 5.2% among patients given pre-operative antibiotics, only post-operative antibiotics, and no antibiotics respectively (p<0.001). Multivariable analysis results showed that the odds of having an oronasal fistula among patients who were administered pre-op antibiotics did not differ significantly (statistically) from patients who did not receive antibiotics (OR 0.88, 95% CI [0.59-1.31]).
Conclusion:
The treatment goal of primary palatoplasty is the successful repair of the cleft without an oronasal fistula. Administration of preoperative antibiotics did not significantly reduce the odds of subsequent fistula repair within the same PHIS institution following primary palatoplasty.
... Since the majority of our patients (80.5%) had a severe cleft extension (Veau III & IV), it might have affected the higher fistula rate. Anderson et al (2008) reported that the ONF rate was higher in patients with a greater severity of CP (i.e., Veau III & IV) because of a higher tension (18) . To our knowledge, there is no previous data on the association of ONF and Eustachian tube recovery, but if ONF persisted, food reflux into the nasopharynx and irritated the nasal cavity resulting in Eustachian tube openingobstruction followed by Eustachian tube dysfunction (6) . ...
Objective: Evaluate the clinical outcomes regarding the time needed for Eustachian tube recovery and evaluate associated
factors for the recovery in children with cleft palate undergoing primary 2-flap palatoplasty with intravelarveloplasty at
Srinagarind Hospital.
Material and Method: This was a retrospective descriptive study of 82 consecutive non-syndromic cleft palate patients with/
without cleft lip, who underwent primary palatoplasty at Srinagarind Hospital between January 2007 and December 2010.
Demographic data were collected including sex, cleft type, age of palatoplasty, operating surgeon, type of tympanogram,
oronasal fistula, ventilation tube insertion, age of ventilation tube insertion, and number of ventilation tube insertion.
Results: Forty-five boys and 37 girls were included in the study for a total sample of 82 patients. The majority of cleft types was
Veau IIIb (37.8%), followed by Veau IV (21.95%), Veau IIIa (20.73%), Veau I (9.76%), and Veau II (9.76%). Mean age of
palatoplasty was 11.4 months (range, 9-23). There were three plastic surgeons and plastic surgery residents. The average
time for Eustachian tube recovery was 37.5 months. Oronasal fistula was 15.9%. Ventilation tube insertion was 58.5% (one
time: 40.2%, two and three times: 18.3%). Average age of ventilation tube insertion was 16 months (range, 9-64). There was
no statistically significant difference in sex, age of palatoplasty, operating surgeon, ventilation tube insertion, or number of
ventilation tube insertions in Eustacian tube recovery, but there was a statistically significant difference in cleft type, oronasal
fistula, and mean age for ventilation tube insertion in Eustachian tube recovery.
Conclusion: The median recovery time for Eustachian tube function after primary 2-flap palatoplasty with intravelarveloplasty
at Srinagarind Hospital was 37.5 months. Eustachian tube recovery was associated with severity of cleft types, oronasal
fistula formation, and age of ventilation tube insertion.
... 3,4,5 At the same time, other factors are also related to modifications in maxillo-mandibular growth: cleft width, amount of tissue present at birth, individual growth potential, 6 surgical technique employed in the primary repair surgeries, 7 surgical outcome, 8 and the surgeon's ability. 4,9 Some of the frequently reported adverse consequences of primary surgeries have been midface reduction, 4,10 collapse of maxillary arches 11 and presence of cross bite. 12 Currently, the literature lacks information on the individual effects of lip and palate repair surgeries on maxillo-mandibular growth in the first years of life. ...
This study aimed at monitoring the maxillary growth of children with cleft lip/palate in the first two years of life, and to evaluate the effects of primary surgeries on dental arch dimensions. The sample consisted of the three-dimensional digital models of 25 subjects with unilateral complete cleft lip and palate (UCLP) and 29 subjects with isolated cleft palate (CP). Maxillary arch dimensions were measured at 3 months (before lip repair), 1 year (before palate repair), and at 2 years of age. Student’s ttest was used for comparison between the groups. Repeated measures ANOVA followed by Tukey’s test was used to compare different treatment phases in the UCLP group. Paired ttest was used to compare different treatment phases in the CP group. P<0.05 was considered statistically significant. Decreased intercanine distance and anterior arch length were observed after lip repair in UCLP. After palate repair, maxillary dimensions increased significantly, except for the intercanine distance in UCLP and the intertuberosity distance in both groups. At the time of palate repair and at two years of age, the maxillary dimensions were very similar in both groups. It can be concluded that the maxillary arches of children with UCLP and CP changed as a result of primary surgery.
... A sebészeti beavatkozásokat a 4. táblázat foglalja össze [23,29,35,40]. A műtéti szövődmények közé tartozik az oedema, oronasalis fi stula, elzáródott légutak, nyelvischaemia, VPI, ami függ az életkortól és a korrigálandó elváltozás milyenségétől és mértékétől [13,20,41]. A VPI előidézhet beszéd-és nyelési nehézségeket, nasalis regurgitatiót. ...
Absztrakt Az ajak- es szajpadhasadek a veleszuletett rendellenessegek egyik leggyakoribb tipusa. A szerzők celja, hogy osszefoglalo irodalmi ismereteket nyujtsanak a korkepről. A nemzetkozi szakirodalom attekintesen es megvitatasan tul kiemelik a megelőzes lehetősegeit, a genetikai es kornyezeti tenyezők szerepet, az anatomiai es embriologiai jellemzőket, a prae- es a postnatalis diagnozis es kezeles lehetősegeit. Az etiologia multifaktorialis, mind genetikai, mind kornyezeti faktorok egyuttes hatasa sokszinű fenotipusos es klinikai jellemzőkhoz vezet. A praenatalis diagnosztikaban, megelőzesben, genetikai tanacsadas soran es a sebeszi kezelesi strategiaval kapcsolatban a megfelelő multidiszciplinaris ismeretek hianya komoly diagnosztikai hibakhoz vagy tevedesekhez vezethet, ezert kiemelten fontos a klinikai csapatmunka ezekkel az allapotokkal kapcsolatban. A professzionalis csapatmunka es multidiszciplinaris egyuttműkodes garantalja az optimalis ellatast es jobb eletminőseget biztosit a betegek es csalad...
... Dans notre expérience le traitement chirurgical de la fente palatine en hospitalisation courte n'a pas été pourvoyeuse de complications spécifiques et n'a donc pas influencé négativement la qualité de la prise en charge. Aucune complication post-opératoire à court et à moyen terme n'a été retrouvée et le taux de fistules (2 %) est en rapport avec les résultats retrouvés dans la littérature pour ce type de chirurgie [14,15]. ...
The aim of this study was to evaluate our practices by studying the duration of hospitalization and the parental real-life experience after a primary surgery of a cleft palate.
MATERIALS AND METHODS
Monocentric retrospective study by analysis of the patients files and phone interview of the parents whose children were operated for a primary surgery of a cleft palate isolated, or associated with a labial cleft, or included in a syndromic form.
RESULTS
Forty-nine patients (25 B-24 G) were performed by 44 Wardill and five Furlow procedures (average age: 11 months ½) between 2010 and 2012. The average duration of the post-operative stay was 1.5 days. Thirty-three parents were contacted (67%). The return was "very well" or "well done" in 82% of the cases. The pain at home was estimated by the parents as "worthless" or "little intense" in 73% of the cases. For 16% of the parents, the child seemed "uncomfortable". The prescription of analgesic was followed only in 70% of the cases. The duration of hospitalization was considered by the families as "good one" in 70% of the cases, "too long" for 12% and "too short" for 18% in particular because of difficulty in eating or parental anxiety.
CONCLUSION
Even if palatine surgery is considered to be painful, anaesthetic techniques and current analgesic protocols allow to envisage very simple and fast consequences, authorizing an early return of the children at home.
Copyright © 2015 Elsevier Masson SAS. All rights reserved.
... Our analysis also demonstrates that the rate of ONF varies with the type of cleft. Corroborating other studies, we found that the ONF rate was highest for Veau type IV clefts (Cohen et al., 1991;Muzaffar et al., 2001;Andersson et al., 2008;Parwaz et al., 2009;Eberlinc and Kozelj, 2012). The rate of Veau IV clefts was 9.1% in our analysis, which is similar to those of other groups (Phua and de Chalain, 2008;Eberlinc and Kozelj, 2012). ...
Background:
Despite decades of craniofacial surgeons repairing cleft palates, there is no consensus for the rate of fistula formation following surgery. The authors present a meta-analysis of studies that reported on primary cleft palate to determine the rate of oronasal fistula and to identify risk factors for their development.
Methods:
A literature search for the period between 2000 and 2012 was performed. Articles were queried and strict inclusion and exclusion criteria were applied to focus on primary cleft palate repair. A meta-analysis of these data was conducted.
Results:
The meta-analysis included 11 studies, comprising 2505 children. The rate of oronasal fistula development was 4.9% (95% confidence interval, 3.8% to 6.1%). When analyzing a larger cohort, there was a significant relationship between Veau classification and the occurrence of a fistula (P < .001), with fistulae most prevalent in patients with a Veau IV cleft. The most common location for a fistula was at the soft palate-hard palate junction. One study used decellularized dermis in cleft repair with a fistula rate of 3.2%.
Conclusions:
Using 11 studies comprising 2505 children, we find the rate of reported fistula occurrence to be 4.9%. Furthermore, patients with a Veau IV cleft are significantly more likely to develop an oronasal fistula. When fistulae do occur, they do so most often at the soft palate-hard palate junction. A deeper understanding of fistula formation will help cleft palate surgeons improve their outcomes in the operating room and will allow them to effectively communicate expectations with patients' families in the clinic.
Objective
Presurgical nasoalveolar molding (PNAM) is widely used in cleft care protocol. This study investigated the correlation between PNAM and oronasal fistula after primary palatoplasty.
Methods
A case-controlled study of 80 unilateral and bilateral complete cleft palate patients who underwent cleft palate repair were enrolled. Patients were divided into 2 groups: (1) no PNAM use and (2) PNAM use. The incidence of oronasal fistula and postoperative complications were compared between groups.
Results
Forty patients in each group demonstrated the same baseline characteristics. The PNAM group showed a significantly lower postoperative oronasal fistula rate (15% versus 50%, P =0.003). Palatal cleft width wider than 12.5 mm increases the odds ratio of fistula formation by 1.19-fold ( P =0.037), and the PNAM protected against postoperative palatal fistula formation (odds ratio 0.20, P =0.003).
Conclusion
Presurgical nasoalveolar molding can reduce postoperative oronasal fistula in wide-gap Veau type III and IV cleft palate.
Patients with cleft lip and palate must undergo various surgical interventions at appropriate times to achieve optimal outcomes. While guidelines for the timing of these operations are well known, it has not yet been described if national surgical practice reflects these recommendations. This study evaluates whether orofacial operations are performed in time frames that align with advised timing. Time-to-event analyses were performed using the 2012–2020 Pediatric National Surgical Quality Improvement Program database on the ages at time of orofacial operations. Outliers with an absolute Z-score of 3.29 or greater were excluded. Cleft lip (N=9374) and palate (N=13,735) repairs occurred earliest at mean ages of 200.99±251.12 and 655.08±694.43 days, respectively. Both operations clustered along the later end of recommended timing. 69.0% of lip versus 65.1% of palate repairs were completed within the advised age periods. Cleft lip (N=2850) and palate (N=1641) revisions occurred at a mean age of 7.73±5.02 and 7.00±4.63 years, respectively. Velopharyngeal insufficiency operations (N=3026), not including palate revision, were performed at a delayed mean age of 7.58±3.98 years, with only 27.7% of operations occurring within the recommended time frame. Finally, 75.8% of alveolar bone grafting cases (N=5481) were found to happen within the advised time period, with a mean age of 10.23±2.63 years. This study suggests that, with the exception of VPI procedures, orofacial operations reliably cluster near their recommended age periods. Nevertheless, primary lip repair, palatoplasty, and velopharyngeal insufficiency procedures had a mean age that was delayed based on advised timing.
La fístula oronasal es una complicación de la fístula palatina muy frecuente en los pacientes con este tipo de condiciones físicas, la cual afecta la calidad de vida del paciente y a su vez, produce complejos en cuanto a la estética del mismo, por esto, usualmente se realiza una corrección quirúrgica mediante técnicas establecidas, las cuales a su vez pueden producir efectos adversos o complicaciones tempranas, que afecten la recuperación del paciente y que eviten el éxito de estas intervenciones, por lo cual, en el siguiente artículo de revisión se plantean las principales complicaciones tempranas asociadas a la corrección quirúrgica de las fístulas oronasales.
Objective
An inspiring early result with no oronasal fistula formation was recently described for a modified medial incision small double-opposing Z-plasty (MIsDOZ) for treating Veau type I cleft palate. This study describes an early single-surgeon experience in applying this newly proposed surgical approach.
Design
Retrospective single-surgeon study.
Patients
Consecutive nonsyndromic patients (n = 27) with Veau I cleft palate.
Interventions
Topographic anatomical-guided MIsDOZ palatoplasty with pyramidal space dissection (releasing of the ligamentous fibers in the greater palatine neurovascular bundle and pyramidal process region, in-fracture of the pterygoid hamulus, and widening of space of Ernst) performed by a novice surgeon (RD).
Mean Outcome Measures
Age at surgery, the presence of cleft lip, palatal cleft width, use of lateral relaxing incision, and 6-month complication rate (bleeding, dehiscence, fistula, and flap necrosis). A published senior surgeon-based outcome dataset (n = 24) was retrieved for comparison purposes.
Results
Twenty-two (81.5%) and 5 (18.5%) patients received the medial incision only technique and lateral incision technique, respectively ( P = .002). Age, presence of cleft lip, and cleft width were not associated (all P > .05) with the use of lateral incision. Comparative analysis between the novice surgeon- and senior surgeon-based datasets revealed no significant differences for sex (females: 74.1% vs 62.5%; P = .546), age (10.2 ± 1.7 vs 9.6 ± 1.2 months; P = .143), rate of lateral incision (18.5% vs 4.2%; P = .195), and postoperative complication rate (0% vs 0%).
Conclusion
This modified DOZ palatoplasty proved to be a reproducible procedure for Veau I cleft palate closure, with reduced need for lateral incision and with no early complication.
Objective:. The objective of this study was to quantify the cost-effectiveness and economic value of a reconstructive surgery visiting educator trip program in a resource-constrained setting.
Background:. Reconstructive surgical capacity remains inadequate in low- and middle-income countries, resulting in chronic disability and a significant economic toll. Education and training of the local surgical workforce to sustainably expand capacity have been increasingly encouraged, but economic analyses of these interventions are lacking.
Methods:. Data were analyzed from 12 visiting educator trips and independently-performed surgical procedures at 3 Vietnamese hospitals between 2014 and 2019. A cost-effectiveness analysis was performed using standardized methodology and thresholds to determine cost-effectiveness. Sensitivity analyses were performed with disability weights, discounting, and costs from different perspectives. Economic benefit was estimated using both the human capital method and the value of a statistical life method, and a benefit-cost ratio was computed.
Results:. In the base case analysis, the visiting educator program was very cost-effective at 21·6 million and 61 per DALY averted, with a 113- to 153-fold return on investment for the organization.
Conclusions:. Visiting educator programs, which build local reconstructive surgical capacity in limited-resource environments, can be very cost-effective with significant economic benefit and return on investment. These findings may help guide organizations, donors, and policymakers in resource allocation in global surgery.
Objective
To evaluate and compare the effect of honey or saline mouth bath for wound care on the rate of re-epithelisation of the lateral palatal defects and occurrence of early postoperative complications following palatoplasty.
Methodology
This was a prospective randomized study on participants with non-syndromic cleft palate conducted at a tertiary health institution in Lagos, Nigeria. The test group received oral honey drops for post-operative care for an initial period of two weeks post-surgery, while the control group had regular oral toileting using a warm saline solution. The primary outcome was epithelisation of lateral palatal defect at 2- and 4-weeks post repair. Descriptive and comparative statistics were computed, and the p-value was set at <0.05.
Results
Fifty participants were recruited into the study, 24 in the Test group and 26 in the Control group. The frequency of occurrence of oronasal fistula in the Test group was 4.0% while in the Control group was 10.0%, however, this was not statistically significant. Complete epithelisation of the lateral palatal defect was clinically observed in 66.7% of the participants in the Test group at 2 weeks post-operation, while only 38.5% of participants in the Control group had clinically observed complete epithelisation at the same time point (β = 1.70, p = .035, 95% CI 1.122–26.533). At four weeks, all wounds had epithelised irrespective of the study group.
Conclusion
The application of honey appears to aid earlier epithelization of palatal surgical wounds following cleft palate repair and reduced the incidence of palatal fistula.
Background:
Oronasal fistula (ONF) is a common complication following cleft palate surgery. This study aims to determine the prevalence of ONF and the factors that influence development of ONF following primary palatoplasty.
Materials and methods:
There were 234 patients undergoing primary palatoplasty during 2012 to 2016 included in this cross-sectional study. Patient demographics, surgeon's experience, age at the time of primary palatoplasty, cleft type by Veau classification, cleft width, and operative technique were recorded. The prevalence of fistulae was the primary outcome. Association of age at the time of repair, cleft type, cleft associated with syndromes, cleft width, and surgeon's experience with fistula rate were secondary outcomes.
Results:
There were 234 consecutive patients (128 boys [54.7%] and 106 girls [45.3%]). The mean age at primary palatoplasty was 13 months. Oronasal fistulae occurred in 61 (26.07%) patients. There was a statistically significant association between postoperative oronasal fistulae and the following independent variables: Veau classification (adjusted odds ratio 2.1; 95% confidence interval [CI] = 1.45-3.1, P < 0.01), cleft associated with syndromes (adjusted odds ratio 4.76; 95% CI = 1.48-15.2, P < 0.01) and cleft width more than 11.5 mm (adjusted odds ratio 1.96; 95% CI = 1.00-3.85, P = 0.04).
Conclusion:
The overall number of fistulae was moderate in patients who had undergone primary palatoplasty in our center. Cleft severity as defined by the Veau classification, cleft width, and cleft associated with syndromes were predictive factors for development of postoperative fistulae.
Objectives/Hypothesis
To assess the incidence of palatal fistula after primary repair of the cleft palate among two cohorts of Otolaryngologist‐Head and Neck Surgeons and to identify patient and surgeon characteristics that may predict fistula development.
Study Design
Retrospective case series with chart review.
Methods
Children who underwent primary repair of cleft palate at one of two multidisciplinary cleft centers over a 10 year period were identified. Charts were reviewed for the presence of palatal fistula; chi square test and multivariate logistic regression analysis were performed to determine variables associated with fistula formation.
Results
From 2007 to 2017, 477 patients underwent primary repair of cleft palate by one of 6 Otolaryngologist‐Head and Neck Surgeons. Twenty‐four children had incomplete charts, allowing 453 patients to be included in the final analysis. The pooled mean incidence of palatal fistula was 6.6% (P = .525) and varied significantly by cleft type. Logistic regression analysis controlling for multiple variables, showed that Veau IV classification had the highest risk of fistula (OR = 10.582; P = .004). Repair by a specific surgeon was not a significant risk factor for fistula development (P > .07 for each surgeon).
Conclusions
Among six Otolaryngologist‐Head and Neck Surgeons with fellowship training in cleft palate repair postoperative fistula rates were consistent and compared favorably to standards in the Cleft and Craniofacial surgery literature established by other surgical specialties. Consistent with larger database studies involving multiple surgical specialties, Veau IV classification was the strongest predictor of palatal fistula development, even after adjusting for multiple variables, including differing levels of experience.
Level of Evidence
4 Laryngoscope, 2020
Background:
Improving surgeons' technical performance may reduce their frequency of postoperative complications. The authors conducted a pilot trial to evaluate the feasibility of a surgeon-delivered audit and feedback intervention incorporating peer surgical coaching on technical performance among surgeons performing cleft palate repair, in advance of a future effectiveness trial.
Methods:
A nonrandomized, two-arm, unblinded pilot trial enrolled surgeons performing cleft palate repair. Participants completed a baseline audit of fistula incidence. Participants with a fistula incidence above the median were allocated to an intensive feedback intervention that included selecting a peer surgical coach, observing the coach perform palate repair, reviewing operative video of their own surgical technique with the coach, and proposing and implementing changes in their technique. All others were allocated to simple feedback (receiving audit results). Outcomes assessed were proportion of surgeons completing the baseline audit, disclosing their fistula incidence to peers, and completing the feedback intervention.
Results:
Seven surgeons enrolled in the trial. All seven completed the baseline audit and disclosed their fistula incidence to other participants. The median baseline fistula incidence was 0.4 percent (range, 0 to 10.5 percent). Two surgeons were unable to receive the feedback intervention. Of the five remaining surgeons, two were allocated to intensive feedback and three to simple feedback. All surgeons completed their assigned feedback intervention. Among surgeons receiving intensive feedback, fistula incidence was 5.9 percent at baseline and 0.0 percent following feedback (adjusted OR, 0.98; 95 percent CI, 0.44 to 2.17).
Conclusion:
Surgeon-delivered audit and feedback incorporating peer coaching on technical performance was feasible for surgeons.
Objective:
This study aimed to determine the palatal fistula rate, explore the influencing factors of Huaxi Sommerlad-Furlow (SF) palatoplasty.
Methods:
A retrospective review of 385 consecutive cleft-palate cases was performed to determine the incidence of postoperative fistula and assess the possible contributing factors, such as sex, weight, age, cleft type, operator skills, preoperative white blood cell, preventive antibiotic use, and postoperative temperature.
Results:
Fistulas occurred in 15/385 patients (3.9%). Among them, 1 fistula was located at the junction of the hard and soft palates, 12 fistulas in hard palate, and 2 fistulas in alveolar near the hard palate. No evidence suggested that sex, weight, age, preoperative white blood cell, preventive antibiotic use, and postoperative temperature are associated with fistula formation. The incidences of cleft palate fistulas as encountered by senior professors (3.03%) and associate senior professors (2.23%) were significantly lower than those by attending doctors (14.29%, P<0.05). The incidences of cleft palate fistulas in bilateral completely cleft palate cases (20.6%) were significantly higher than those in hard and soft (3.6%) and unilateral cleft palate cases (2.6%, P<
0.05).
Conclusions:
Huaxi SF palatoplasty can avoid the inhibited maxillary growth without requiring lateral relaxing incision, which poses an acceptable risk of fistula formation. The palatal fistula rate is not related to the sex, weight, age of operation, prophylactic use of antibiotics before operation, infection before operation, temperature after operation and other factors. The occurrence of the fistula is related mainly to cleft type and experience level of the surgeon.
Purpose:
The aim of this study was to evaluate the effect of buccal fat pad (BFP) in the palatoplasty and to investigate the risk factors associated with postoperative palatal fistula formation.
Materials and methods:
Sixty-five cleft palate patients were enrolled for this study. Clinical data regarding sex, age, type of cleft, surgical technique, the ratio of cleft width, and BFP graft were collected. The ratio of cleft width was measured and calculated using preoperative clinical photographs. In 36 patients, the BFP was harvested and grafted on the cleft palate to prevent palatal fistula formation. The patients were followed up, the incidence of fistula formation was investigated, and the risk factors related with the fistula were evaluated.
Results:
Four patients had postoperative palatal fistula and were not BFP grafted during operation. The BFP graft and ratio of cleft width are significant factors in palatal fistula formation (P = .035, .003). There was a significant difference in the ratio of cleft width between the normal and fistula groups (P = .006). In the logistic regression analysis, there was significant association between high ratio of cleft width and palatal fistula formation in the no BFP group (odds ratio; 11.15, P = .036).
Conclusions:
The ratio of cleft width and BFP graft was a significant factor in palatal fistula formation. The BFP graft is a reliable procedure to prevent palatal fistula formation and increase the success of palatoplasty.
We describe a case of the combined use of acellular dermal matrix and pedicled buccal fat pad (BFP) in a wide U-shaped cleft palate repair. Acellular dermal matrix was used as a "patch" repair for the nasal mucosa defect as opposed to the conventional inlay graft. The advantages include reduced cost and a smaller avascular graft load. Lateral relaxing incisions were made to ensure tension-free closure of oromucosa at midline. Lateral oromucosa defect closure with well-vascularized pedicled BFP ensures enhanced healing, less palatal contracture and shortening, and reduced infection. The palate healed with mucosalization at 2 weeks, and no complications were noted at 6 months follow-up.
Objective:
Describe patients born with unilateral cleft lip with or without cleft alveolus (CL±A) in relation to cleft severity and laterality, gender, associated anomalies and syndromes, number and type of lip- and nose operations, and time of alveolar bone graft (ABG) treatment in relation to dental status in cleft area.
Materials and methods:
Patients included 220 children born with unilateral CL±A, born between 1988 and 1997 referred to the Oslo Cleft Lip and Palate Team. The data were collected retrospectively. All patients were followed up until 18 years of age.
Results:
Among all CL±A, 3.6% had recognized syndromes, 6.8% had associated anomalies, and in 89.6% CL±A was the only malformation. CL±A was more common, but not more severe, on the left side. Among the 160 individuals with CL±A without syndromes and associated anomalies, 66.9% had an isolated soft tissue CL, and 33.1% were diagnosed with a CL alveolus (CL+A). Male predominance was observed. Children with CL+A had more severe soft tissue clefts of the lip and underwent more lip and nose surgeries than children born with CL. The time of ABG was found to be at a younger age when the patient had a lateral incisor in the cleft area than when this tooth was missing.
Conclusion:
Findings provide a reference for morphologic variations in CL±A, and insight into the surgical burden of care until the age of 18 years.
Objective:
Adopted children with cleft lip and/or cleft palate form a diverse group of patients. Due to increased age at palatal repair, adopted children have a higher risk of velopharyngeal insuffiency and poor speech outcome. Delayed palate repair may also lead to longer lasting Eustachian tube dysfunction. Decreased function of the Eustachian tube causes otitis media with effusion and recurrent acute otitis media, which can lead to other middle ear problems and hearing loss.
Methods:
One-hundred-and-thirty-two adopted children treated by the Cleft palate team in Wilhelmina Children's Hospital during January 1994 and December 2014 were included. Retrospectively, middle ear findings, the need for ventilation tube insertion and hearing during childhood were assessed. Findings were compared with 132 locally born children with cleft lip and/or cleft palate.
Results:
Adopted children had a mean age of 26.5 months old when they arrived in our country. After the age of two the total number of otitis media with effusion episodes and the need for ventilation tube placement did not significantly differ among adopted and non-adopted children. Adopted children had significantly more tympanic membrane perforations. Hearing threshold levels normalized with increasing age. Although within normal range, adopted children showed significantly higher pure tone averages than locally born children when they were eight to ten years old.
Conclusion:
In general, adopted patients with cleft lip and/or cleft palate did not have more middle ear problems or ventilation tubes during childhood. However, theyhave more tympanic membrane perforations.
Background: Management of cleft palate problems have been improved during last 2 decades. The purpose of palatoplasty is decrease in complications such as palatal fistula. The incidence of cleft palate fistula after palatoplasty reported widely between 0 to more than 76%. This study aimed to evaluate the efficacy of closure of hard palatal fistula using acellular dermal matrix (AlloDerm) graft.
Methods: This cross-sectional study was done during 2015 to 2016 in referral Alzahra hospital in Isfahan, Iran. Patients who had a secondary fistula in any ages referred to cleft palate clinic and signed a consent form to be operated with this method were included. Postoperative recurrence in closed fistula was checked with follow-up appointments at 6 months for all cases.
Findings: Of 30 patients (12 men and 18 women) participated in this study, recurrence of hard palatal fistula was seen in 4 patients.
Conclusion: Closure of cleft palate fistula using acellular dermal matrix is a useful method with high success rate.
Background:
Humanitarian surgical organizations provide palatoplasties for patients without access to surgical care. Few organizations have evaluated the outcomes of these trips. This study evaluates the palatal fistula rate in patients from two cohorts in rural China and one in the United States.
Methods:
This study compared the odds of fistula formation among three cohorts whose palates were repaired between 2005 and 2009. One cohort included 97 Chinese patients operated on by teams from the United States and Canada under the auspices of Resurge International. They were compared to cohorts at Huaxi Stomatology Hospital and the University of California San Francisco (UCSF). Age, fistula presence, and Veau class were compared among cohorts using Chi-square tests. Logistic regression was used to analyze predictors of fistula formation.
Results:
The fistula risk was 35.1% in patients treated by humanitarian teams, 12.8% at Huaxi University Hospital and 2.5% at UCSF (P <0.001). Age and Veau class were associated with fistula formation (Age P = 0.0015; Veau P <0.001). ReSurge and Huaxi patients had 20.2 and 5.6 times the odds of developing a fistula, respectively, compared to UCSF patients (P <0.01, both). A multivariable model controlling for surgical group, age, and gender showed an association between Veau class and the odds of fistula formation.
Conclusions:
Chinese children undergoing palatoplasty by international teams had higher odds of palatal fistula than children treated by Chinese surgeons in established institutions and children treated in the United States. More research is required to identify factors affecting complication rates in low-resource environments.
Aims:
(1) Assess the level of available evidence regarding fistula occurrence in cleft lip and palate patients, (2) identify main research areas in the original studies, (3) evaluate the quality of original studies, and (4) summarize the evidence.
Methods:
Two independent researchers searched the Cochrane Database of Systematic Reviews, Medline, Web of Knowledge, Web of Science and EMBASE, the Grey literature, and the reference lists of main references. The level of evidence was assessed based on study design and according to the Hierarchy of Evidence. The quality assessment was done using the adapted Consolidated Standards of Reporting Trials and Strengthening the Reporting of Observational Studies in Epidemiology checklists and a validity scoring system. Main findings were summarized, and fistula rates were compared between early and more recent articles, also between high-quality and low-quality studies.
Results:
The systematic search and relevance assessment identified a total of 127 sources of evidence. The overall level of evidence was weak because it was dominated by small studies (<30 subjects), retrospective cohort studies, and case series. Main research areas were either: (1) focused on surgeries or (2) focused on risk determinants associated with fistula occurrence. Recent reports were of higher quality than the older ones, but the overall quality in the majority of reports was low. Knowledge synthesis demonstrated a wide range of rates for primary fistula (0-78%). No significant difference was found in the fistula rates of older studies compared with more recent studies or among different quality studies. Multiple risk determinants were studied and age at surgery, surgeon's experience, type and severity of cleft were the most frequently examined risk determinants. However, findings concerning different risk determinants and fistula occurrence were not consistent.
Conclusions:
The research mainly focused on surgeries and fistula-related risk determinants. The available evidence was low level and of poor quality. No consistent pattern between fistula occurrence and any of the risk determinants could be detected. Reported fistula rates did not differ significantly when comparing older studies with more recent studies or when high-quality studies were compared with low-quality studies.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
Objective:
To provide national estimates of the number and cost of primary and revision cleft lip and palate surgeries in the U.S. and to determine patient and hospital characteristics associated with disproportionate use of revision surgery.
Design:
Retrospective cross-sectional study using data obtained from the 2003, 2006, and 2009 Kids' Inpatient Database.
Setting:
Inpatient.
Patients:
Children with CL, CP, or CLP undergoing inpatient cleft lip and/or palate surgery.
Interventions:
Inpatient cleft lip and/or palate surgery.
Main outcome measures:
Orofacial cleft surgery estimates, estimates of primary versus revision surgeries, and estimated inflation-adjusted hospitalization costs.
Results:
In 2009, there were a total of 2824 and 5431 hospitalizations for cleft lip and palate surgeries, respectively. Revision surgery accounted for 24.2% of cleft lip surgeries and 36.8% of cleft palate surgeries. Children with CLP (OR 1.87, 95% CI: 1.48-2.38), a syndromic diagnosis (OR 1.47, 95% CI: 1.16-1.87), or private insurance (OR 1.71, 95% CI: 1.41-2.09) were more likely to undergo cleft lip revision surgery. Similar risk factors were found for children undergoing cleft palate revision. Mean cost per hospitalization ranged from 8393 in 2009, depending on surgery type, and did not change significantly (in 2009 U.S. $) between 2003 and 2009.
Conclusions:
Interventions to reduce revision surgery by improving results of primary surgery should be targeted in the population of identified high-risk (e.g. syndromic) patients. In addition, the association of health insurance status with revision surgery highlights the need to understand and address the impact of economic disparities on cleft care delivery.
Objectives:
The aim of the study was to assess the influence of the experience of the surgeon on the occurrence of fistulas following palatoplasty.
Materials and methods:
A retrospective review was performed of consecutive children treated between 2006 and 2013 for cleft palate by a single surgeon. Cleft palate repair was performed using the von Langenbeck technique, Furlow palatoplasty, buccal flap or Vomer flap. Data was collected for age, sex, date of birth, syndrome, adoption, cleft palate type, type of repair, cleft width, fistula occurrence and location of fistula.
Results:
A total of 276 operations were performed in 200 children (Veau I, II, III, IV). Mean age at surgery was 21.9 months (range: 6.2 months to 26 years 8.3 months). Postoperatively, palatal fistulas occurred in eight patients (4.0%), however, the incidence was 3.0% in the non-adoption group and 9.7% in the adoption population. In this study there was no statistically significant evidence of a surgical learning curve, and no significant associations between fistula rate and sex, adoption, syndrome, cleft type, cleft width, or type of repair.
Conclusion and clinical relevance:
This study demonstrates a fistula formation rate of 3.0% for the non-adoption population and 9.7% for the adoption population. There was no statistically significant evidence of a learning curve during the first few years of performing cleft palate repair. No other independent risk factors for postoperative fistula formation were identified; however, the benefit of a vomer flap and subsequent reduction in fistula incidence was demonstrated.
The purpose of this study was to determine whether administration of postoperative antibiotics affects the incidence of complications after primary cleft palate repair in a developing area.
This study was a prospective, double-blind, randomized, placebo-controlled trial composed of 518 consecutive patients who underwent primary cleft palate repair at a single institution. Patients were aged 1 to 43 years at the time of surgery (median, 9 years). The patients were divided randomly into two groups. One group received a 5-day regimen of oral amoxicillin (50 mg/kg/day) postoperatively and the other group received placebo medication. Both groups received a single dose of cefuroxime (30 mg/kg) before incision. Patients and providers were blinded to the randomization. Patients were followed postoperatively for early complications (infection and wound breakdown) and for late complications (palatal fistulas).
The incidence of early complications was 13.8 percent among the patients in the placebo group and 8.7 percent among the patients in the antibiotic group (p = 0.175). Fistulas were noted in 17.1 percent in the placebo group and in 10.7 percent in the antibiotic group (p = 0.085). Logistic regression analysis identified visiting surgeons as the only covariate related to early complications (OR, 3.71; p < 0.001). However, the use of placebo (OR, 2.09; p = 0.037), female sex (OR, 2.04; p = 0.047), and Veau III and IV (OR, 3.31; p = 0.004) were observed as factors associated with the incidence of fistulas.
The authors' results indicate that postoperative antibiotic prophylaxis can reduce the incidence of fistulas after primary cleft palate repair in a developing area.
To determine the frequency of oro-nasal fistula in patients undergoing complete cleft palate repair by two flappalatoplasty.
Case series.
Department of Plastic Surgery, Services Hospital, Lahore, from January to December 2013.
Patients admitted to the study place for repair of cleft palate after informed consent obtained were included. Cleft palate was repaired by two-flap palatoplasty, using Bardach technique. Patients were discharged on the second postoperative day and followed-up at third week postoperatively. During follow-up visits, fistulae formation and their sites were recorded on pre-designed proforma.
Among the total 90 patients, 40 patients (44.4%) were male and 50 patients (55.6%) were female. The mean age was 6.4 ± 5.7 years ranging from 9 months to 20 years. At third week follow-up, 5 patients (5.6%) had fistulae formation. Four patients (80%) had anterior fistulae and one patient (20%) had posterior fistula.
With two-flap palatoplasty Bardach procedure for repair of cleft palate, the complication of fistula formation was uncommon at 5.6%, provided the repair was tension free and multi-layered.
Orofacial clefts, including cleft palates (CP), are one of the most common birth defects. CP have a multiplicity of effects on the individual and society in terms of economic costs, loss of productivity, psychosocial effects, and increased morbidity and mortality at all stages of life. Embryological development of the palate is well delineated, with developments in the last decade regarding the biomolecular processes involved. Etiology is complex, involving a number of genetic and environmental factors. Various techniques can be employed for the repair of CP, depending on whether the cleft is of the primary or secondary palate, the width of the cleft, whether lengthening of the palate is necessary, and with regard to concerns of disruption of midfacial growth. All surgical techniques have the goals of restoring functional speech, swallowing, and aesthetics. A multidisciplinary team is necessary for the long-term pre- and postoperative care of CP patients to handle complications, associated anomalies, and to optimize function and quality of life. Birth Defects Research (Part C), 2014. © 2014 Wiley Periodicals, Inc.
The present investigation describes the incidence and variability of the primary cleft condition in all Danish infants born with cleft lip, cleft palate, or both, from 1976 to 1981 and analyzes general somatic growth from birth to age 22 months. Because of excellent sampling conditions in Denmark, the study material is nearly complete. Six hundred and seventy-eight infants with facial clefts were born during the period, corresponding to 1.89 per 1,000 of all newborns. Six hundred and two patients were examined--most of them twice: at 2 months and at 22 months. Material uptake included plaster casts of the upper jaw, cephalometric films in three projections, anthropometric registrations, and information from hospital charts. A detailed grading of the clefts according to severity was carried out. Sex distribution was 61% males and 39% females, of whom 34% had isolated cleft lip, 39% combined cleft lip and palate, and 27% an isolated cleft palate. Left-sided clefts were most frequent. In the combined cleft lip and palate group, 90% exhibited subtotal or total clefts, whereas the clefts were less severe in the isolated cleft lip and isolated cleft palate patients. Birth weight and length showed values close to the average for Danish newborns, but a lag was seen in infants in whom severe palatal cleft was included. The extended method of classification was suggested to select subgroups for special care.
Patients with Treacher Collins syndrome have abnormal vascular supply to the palate, yet it is unknown whether there are increased postoperative healing problems following palatoplasty. This study investigated the correlation between Treacher Collins syndrome and postoperative palatal fistula formation.
Retrospective chart review was performed.
Children undergoing palatoplasty at Children's Hospital Los Angeles from 1987 to 2000 were evaluated. Ten children with Treacher Collins syndrome, 92 children with other syndromes and cleft palate, and 458 nonsyndromic patients with isolated cleft palate were studied.
All children were treated with a one-stage, double-reversing Z-plasty cleft palate repair.
Outcome measures included intraoperative observations of surgical anatomy and postoperative clinic follow-up of fistula formation. Palatal fistula rates between patients with Treacher Collins syndrome, other syndromes, and no syndrome were compared with chi-square analysis.
Children with Treacher Collins syndrome had significantly greater palatal fistula rates (50%) than children with other syndromes (8.7%) or no syndrome (4.1%). Treacher Collins patients demonstrated large palatal fistulas and poor flap vascularity.
Children with Treacher Collins syndrome and cleft palate have significantly higher palatal fistula risk than other children with cleft palate when double-reversing Z-plasty palate repair is performed. Our findings suggest that children with Treacher Collins syndrome and cleft palate may have poor vascularity to palatal flaps created during palatoplasty. Furthermore, we recommend that surgeons performing palatoplasty minimize the dissection of mucoperiosteal flaps around the greater palatine arterial pedicle and utilize closure techniques creating the least vascular disruption of palatal tissue.
The occurrence and treatment of palatal fistulae have been studied in 1108 CLP patients who had their primary operations performed during the years 1954–69. No fistulae were recorded in 263 patients with incomplete cleft of the primary palate only. These patients were excluded, leaving 845 patients for analysis. The Le Mesurier or Millard technique had been used for the primary lip operation, and the von Langenbeck procedure for closure of the palate; in complete clefts, the anterior part of the palate had been closed using Veau's vomer flap operation simultaneously with lip closure. The observation period ranged from 7 to 22 years, during which time each patient was examined at least once and the majority on several occasions by members of the cleft palate team. The overall incidence of fistulae was 18%. Fistulae were recorded in 11.3% of all complete clefts of the primary palate, and in 36.1% of all complete total clefts. In cases of cleft palate only, fistulae were found in 3.5% of the incomplete clefts, and in 20% of the complete clefts. In patients with bilateral complete clefts, closure of both sides of the lip and anterior palate in one operation seemed to have greatly increased the risk of fistula formation. There was a much higher incidence of fistulae in patients operated on during the years 1954–61 than in those treated in the period 1962–69. Fistula symptoms requiring surgical intervention were recorded in 113 patients. Closure of the fistula was achieved in 84.1%. Of 18 patients with a residual fistula. 17 were asymptomatic or had symptoms so slight that they were considered insignificant and not justifying operation.
A retrospective, multivariate statistical analysis of 129 consecutive nonsyndromic patients undergoing cleft palate repair was performed to document the incidence of postoperative fistulas, to determine their cause, and to review methods of surgical management. Nasal-alveolar fistulas and/or anterior palatal fistulas that were intentionally not repaired were excluded from study. Cleft palate fistulas (CPFs) occurred in 30 of 129 patients (23 percent), although nearly a half were 1 to 2 mm in size. Extent of clefting, as estimated by the Veau classification, was significantly more severe in those patients who developed cleft palate fistula. Type of palate closure also influenced the frequency of cleft palate fistula. Forty-three percent of patients undergoing Wardill-type closures developed cleft palate fistula versus 10, 22, and 0 percent for Furlow, von Langenbeck, and Dorrance style closures, respectively. The fistula rate was similar in patients with (30 percent) and without (25 percent) intravelar veloplasty. Age at palate closure did not significantly affect the rate of fistulization; however, the surgeon performing the initial closure did not have an effect. Thirty-seven percent of patients developed recurrent cleft palate fistulas following initial fistula repair. Recurrence of cleft palate fistulas was not influenced by severity of cleft or type of original palate repair. Following end-stage management, a second cleft palate fistula recurrence occurred in 25 percent of patients. Continued open discussion of results of cleft palate repair is recommended.
Oronasal fistulas, a troublesome complication, often occur after cleft palate repair. Seventy-three patients in a series of 346 cases of cleft palate (21%) were found to have fistulas, most located at the junction of hard and soft palate (42%). Langenbeck's method of cleft palate repair resulted in more fistulas than Wardill's method. Fistulas occurred more frequently in bilateral clefts than in the unilateral type. Nasality was found to be the most common symptom in patients with oronasal fistulas. No treatment was needed for 17 patients, 10 were given obturators, and surgical repair was performed in 46. Treatment was totally successful in 56% of the patients and partially so in 34%.
This study reviewed 199 cleft palate repairs resulting in 22 percent fistula formation. Of these, 49 percent were judged to be symptomatic. Of 44 fistulas, 21 required treatment, of which 14 had conventional type surgical closure with an overall success rate of 35 percent. Good surgical technique and good surgical judgment were felt to be important factors both in preventing postoperative fistula and in the success of their repair. Conventional methods of surgical repair of hard palate fistulas were seen to result in a very poor success rate. Orthodontic movement of maxillary segments was seen to contribute to late postoperative fistula formation. Therefore, orthodontic movement should be completed before undertaking surgical repair of anterior palatal fistulas. Finally, the success rate of anterior fistula repair has been dramatically improved by the addition of free periosteal grafts and cancellous bone grafts.
The velo -cardio-facial syndrome is a recently delineated congenital malformation syndrome, probably of autosomal dominant inheritance. Previous reports have concentrated on facial, oropharyngeal, cardiac, speech, language, and psychological features of this fairly common syndrome. To date, no radiographic data have been presented which might help to further delineate the syndrome, nor has there been an explanation of the characteristic facial appearance seen in this syndrome. This current study reports on cephalometric evidence of platybasia (obtuse angulation of the cranial base) in the velo -cardio-facial syndrome. The finding of platybasia adds one more phenotypic feature to the syndrome and also may help to explain the facial features of retrognathia, malar flatness, and prominence of the nasal root.
Between 1962 and 1976, a one-stage surgical procedure was performed on 328 cases of cleft lip and palate or isolated cleft palate. From 1977 to 1986, a two-stage surgical procedure was performed on 192 patients. After one-stage repair, 22 (6.7%) required a pharyngeal flap at the age of 6 years, and 13 (7%) required a flap after two-stage repair. When the patients were 14 years or older, 56 (17%) needed a flap after one-stage repair, and 14 (24%) required a flap after two-stage repair. Two-stage repair at 24 months and 5.2 years resulted in more patients in need of pharyngeal flaps than those who had repair at 12 to 18 months and 3 years. In both groups, at age 10, the incidence of flaps was approximately 20% after closure of isolated cleft palate involving the hard palate, with 11 to 12% in patients with unilateral cleft lip and palate (UCLP) or clefts of the soft palate only, and 14 to 16% in patients with bilateral cleft lip and palate (BCLP). The pharyngeal flap was more often used in girls than in boys, especially in cases with CP only. Approximately 85% of the flaps were carried out before the age of 10 years, and only a few flaps may have been related to involution of the adenoid. The incidence of fistulas was higher after one-stage repair of cleft lip and palate (CLP) (p < .05) and lower in patients with CP only (p < .05), compared with the results after two-stage repair. Pharyngeal flaps were slightly more common after two-stage repair.(ABSTRACT TRUNCATED AT 250 WORDS)
During the period 1958-1985, 230 patients with cleft palate were operated on in the Department of Plastic Surgery, University of Göteborg, Sweden. A modified push-back technique according to Wardill and Kilner was used. The children were operated on at a mean age of 13 months. They were divided into two groups, the first in which the cleft affected the velum only (n = 121) and the other in which it also affected the hard palate (n = 109). Postoperative dehiscences and fistulas occurred in 19 (8%) patients, of which 16 (15%) belonged to the group in which the cleft affected the hard palate. Only three (2%) of the 121 patients with a cleft in the soft palate only developed dehiscences. The total number of patients who had to be reoperated on because of dehiscences were 10 (4%) and palatopharyngeal flaps had to be performed in 25 patients (11%) because of speech problems.
A review was done of the records of 50 patients who had osseous genioplasty performed at the same sitting as face lifting and, in many cases, submental lipectomy over a 20-year period by the senior author. The types of genioplasties were sliding advancement (40), lengthening with interpositional bone graft (7), and reduction (3). In 9 patients, chin implants were removed, generally because of inadequate chin projection or implant erosion. Three patients were operated on under local anesthesia, the remainder under general anesthesia. Associated procedures, done in 46 patients, included rhinoplasty, forehead lifting, blepharoplasty, lateral canthopexy, excision of buccal fat pads, reduction mammaplasty, and abdominoplasty. In 4 patients, associated maxillofacial procedures were performed, including Le Fort I and III osteotomies, two-jaw surgery, mandibular advancement with sagittal splitting, and orbital expansion. The perceived advantages of osseous genioplasty were greater versatility in dealing with problems in other than the sagittal plane, the possibility of greater chin projection, and a tightening of the submental musculature. Complications occurred in 10 patients. These included two hematomas requiring aspiration in the office, a prolapsed submandibular gland requiring later excision, a transient weakness of the marginal mandibular nerve, a transient numbness of the lower lip on one side, four revisions of scars resulting from the face lifting, and one localized wound infection in the parasymphyseal area that resolved with oral antibiotics. The most common complaint, which came from 8 female patients at some time from 1 month to 3 years postoperatively, was that the chin was "too strong." In 6 of these patients, most of whom were operated on early in the series, some of the chin projection was reduced by burring. Osseous genioplasty can be performed safely along with face lifting and submental lipectomy. The degree of advancement necessary in aesthetic surgical patients is generally less than that required in reconstructive patients. Patient satisfaction is great unless the chin is overly advanced.
We retrospectively reviewed 119 consecutive patients who underwent cleft palate repair at the Mayo Clinic to determine the incidence of postoperative fistula formation, to assess possible contributing factors, and to review the methods of surgical management. Fistulas of the secondary palate were included, but nasal-alveolar fistulas and intentionally unrepaired anterior palatal fistulas were excluded. Six patients whose repairs were performed after 2.5 years of age were excluded to ensure a more uniform patient population. Cleft palate fistulas occurred in 13 of the 113 patients (11.5 percent). The median age at repair was 8.2 months, and the median follow-up period was 5.2 years. Several variables were analyzed by means of the log-rank test to determine their significance in postoperative fistula formation. Sex, extent of clefting (as estimated by the Veau classification), and type of palatal closure did not significantly affect the rate of fistula formation. However, patients who had palatal closure at an age younger than 12 months had a lower incidence of fistula formation (7.8 percent) than children whose closures were performed between the ages of 12 and 25 months (19.4 percent) (p = 0.058). The strongest predictor of the occurrence of a cleft palate fistula was the surgeon performing the procedure (p = 0.008). Fistula repair was deemed necessary in 11 of 13 patients, and 91 percent of these fistulas were healed with a single operation. Most of these fistulas were closed by using local flaps and two-layered closures. Cleft palate repair carries a significant but acceptable risk of fistula formation, which can be managed with local flaps. Fistula occurrence is related most to the experience level of the operating surgeon.
The purpose of this study was to examine the palatal fistula rate after repair with the two-flap palatoplasty technique. This is a retrospective review of 119 consecutive cleft-palate repairs performed over a 5-year interval by a single surgeon. The two-flap palatoplasty technique was used to provide tension-free, multilayer repairs. The age of these children at the time of repair ranged from 7 to 84 months (mode, 9 months). The initial follow-up visit occurred 2 to 12 weeks after the repair operation (mean, 4 weeks). The postoperative follow-up duration ranged from 7 to 48 months. This review of 119 cleft-palate repairs revealed a fistula rate of 3.4 percent (four fistulas in 119 repairs). This experience demonstrates the lowest reported palatal fistula complication rate with use of the two-flap palatoplasty technique.
The purpose of this study was to determine the incidence of cleft palatal fistula in a series of nonsyndromic children treated at the authors' institution. This retrospective analysis of 103 patients with cleft palate treated by five surgeons between 1982 and 1995 includes 60 boys and 33 girls, whose median age was 18.4 months at the time of surgery. The median length of follow-up was 4.9 years after primary palatoplasty. Cleft palatal fistula was defined as a failure of healing or a breakdown in the primary surgical repair of the palate. Intentionally unrepaired fistulas of the primary and secondary palate were excluded. Extent of clefting was described according to the Veau classification. Statistical examination of multiple variables was performed using contingency table analysis, multivariate logistic regression, and the Wilcoxon rank sum test. The incidence of cleft palatal fistula in this series was 8.7 percent. All of these fistulas were clinically significant. The rate of fistula recurrence was 33 percent. The incidence of cleft palatal fistula when compared by Veau classification was statistically significant, with nine fistulas occurring in patients with Veau 3 and 4 clefts and no fistulas occurring in patients with Veau 1 and 2 clefts (p = 0.0441). No significant differences between patients with and without fistulas were identified with respect to operating surgeon, patient sex, patient age at palatoplasty, type of palatoplasty, and use of presurgical orthopedics or palatal expansion. All three recurrent fistulas occurred in the anterior palate, two in patients with Veau class 3 clefts and one in a patient with a Veau class 4 cleft. The low rate of clinically significant fistula was attributed to early delayed primary closure, with smaller secondary clefts allowing repair with a minimum of dissection and disruption of vascularity.
To evaluate speech quality and oronasal fistula after primary palate repair using a buccal mucosal flap.
Retrospective study cohort of patients with cleft palate.
Primary care center for treatment of craniofacial congenital anomalies.
One hundred fifty-six nonsyndromic patients underwent palatoplasty with the buccal myomucosal flap by the senior surgeon between 1989 and 2002. The preoperative workup, surgical technique, and other factors that might affect the outcome were identical in every case. Oronasal fistula and variables affecting speech quality were analyzed.
The most common type of cleft was unilateral cleft lip and palate (43.5%). The median follow-up was 5.8 years (0.4 to 21 years), and the median age at repair was 6.2 months. The overall fistula formation was 3.6%, decreasing progressively: 1989 to 1994: 2.9%, 1995 to 2002: 0.7% (p <.05). Velopharyngeal incompetence (VPI) occurred in 8.8% of the patients, decreasing from 5.3% to 3.5% in the last years. VPI and oronasal fistulae were observed mainly in unilateral and bilateral clefts of the lip and palate. Velopharyngeal adequacy occurred in 91.1% of the children, and resonance was normal in 91.1 %. None of the patients had severe hypernasality or hyponasality. Articulation was normal in 97.9% of the children. Speech quality was good in 89% of the patients.
The technique presented has been effective, with the advantages of palatal closure without tension, good muscular reconstruction, lengthening of the nasal layer, and palatal closure without raw areas. The technique, early repair, and surgeon's skills were the most important variables for good outcomes regarding speech and fistula formation.
- Wilhelmi BJ