Influence of patient age and experience of the surgeon on early complications after surgical closure of the cleft palate--a retrospective cohort study

Modified Medial Incision Small Double-Opposing Z-Plasty for Treating Veau Type I Cleft Palate: Is the Early Result Reproducible?

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.

Anatomical Study of Domain Rescue of Palatal Length in Patients With a Wide Cleft Palate: Buccal Flap Reconstruction in Primary Palatoplasty

BACKGROUND

This study characterizes the potential loss of velar length in patients with a wide cleft and rescue of this loss of domain by local flap reconstruction, providing anatomic evidence in support of primary lengthening of the soft palate during palatoplasty.

METHODS

A retrospective review was conducted of all patients with a cleft palate at least 10mm in width, who underwent primary palatoplasty with a buccal flap prior to 18 months of age over a 2-year period. All patients underwent primary palatoplasty with horizontal transection of the nasal mucosa, which was performed after nasal mucosa repair, but prior to muscular reconstruction. The resulting palatal lengthening was measured and the mucosal defect was reconstructed with a buccal flap.

RESULTS

Of the 22 patients included, 3 (13.6%) had a history of Pierre Robin sequence, and 5 (22.7%) had an associated syndrome. No patients had a Veau I cleft, 7 (31.8%) had a Veau II, 12 (54.5%) had a Veau III, and 3 had (13.6%) a Veau IV cleft. All patients had a right buccal flap during primary palatoplasty. The mean cleft width at the posterior nasal spine was 10.6  ±  2.82mm, and mean lengthening of the velum after horizontal transection of the nasal mucosa closure was 10.5  ±  2.23mm. There were 2 (9.1%) fistulas, 1 (4.5%) wound dehiscence, 1 (4.5%) 30-day readmission, and no bleeding complications.

CONCLUSIONS

Patients with a wide cleft palate have a potential loss of 1cm velar length. The buccal flap can rescue the loss of domain in palatal length, and potentially improve palatal excursion.

Current Postoperative Feeding Practices Following Surgical Repairs for Infants With Cleft Palate

BACKGROUND

Nearly all surgeons have restrictive postoperative feeding protocols in place after primary cleft lip and cleft palate repairs. There are no standardized recommendations, potentially resulting in widely variable practices among cleft surgeons and teams. The purpose of this study was to examine current postoperative feeding practices for infants with cleft palate after lip and palate repairs.

METHODS

A survey of 50 questions was sent to members of the American Cleft Palate-Craniofacial Association (ACPA). Inclusion criteria included providers from North America that have either currently or previously served on a cleft palate team and reached the surgical question set within the survey.

RESULTS

Sixty-four respondents met inclusion criteria. The majority were in speech-language pathology (47%) or nursing (41%) disciplines, involved in feeding consultations frequently (84%), and working in an outpatient setting (69%). After lip surgery, respondents recommended cleft-adapted bottle feeding (88%), spoon feeding (9%), cup feeding (13%), and syringe/squeeze bottle feeding (23%). The majority of respondents (69%) indicated infants could return to their preoperative feeding modality immediately after lip surgery. After palate surgery, respondents recommended cleft-adapted bottle feeding (55%), typical bottle feeding (3%), spoon feeding (36%), cup feeding (64%), and syringe/squeeze bottle feeding (30%). Infants could use a feeding system that required suction at an average of 20 days postoperatively and return to an age-appropriate diet at an average of 15 days postoperatively.

CONCLUSIONS

The present study describes the wide variation of postoperative feeding guidelines used by cleft teams after lip and palate repairs.

Risk Factors of Fistula Following Primary Palatoplasty

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.

Complications or rather side effects? Quantification of patient satisfaction and complications after orthognathic surgery-a retrospective, cross-sectional long-term analysis

OBJECTIVES

The aim of this clinical analysis was to evaluate intraoperative and early postoperative complications as well as late findings and the overall patient satisfaction following orthognathic surgery.

MATERIALS AND METHODS

In a retrospective, cross-sectional study, 119 patients after orthognathic surgery were included. Surgical approaches were single bilateral sagittal split osteotomy (BSSO (n = 52)), single LeFort-I osteotomy (n = 5) and bimaxillary osteotomy (LeFort-I + BSSO (n = 62)). Intraoperative and early (0-4 weeks postoperative) complications were investigated retrospectively (n = 119), whereas late findings and quality of life were assessed via clinical follow-up and survey (mean: 59 months postoperative) on 48 patients.

RESULTS

Bad split (n = 4/114) was the most common intraoperative complication followed by one case of severe bleeding. Regarding early postoperative complications, temporary damage of the inferior alveolar nerve after BSSO was most common (n = 33/114), followed by facial nerve dysfunction (n = 3), failed osteosynthesis (n = 2) and one case of postoperative dyspnoea. Permanent hypaesthesia of the lower lip was the most prevalent (n = 28/45^{(BSSO and LeFort-I + BSSO)}) late finding with varying extent, followed by temporomandibular dysfunction (TMD) (n = 25/48). Skeletal relapse mostly occurred after class II treatment, followed by class III, posterior crossbite and open bite. Overall, the surgery improved the patients' self-perception (85.4%), with 60.4% of patients opting for surgery again.

CONCLUSIONS

Long-term complications after orthognathic surgery occurred more frequently than commonly described in the literature, and analyses of the quality of life show the need for more comprehensive preoperative patient education.

CLINICAL RELEVANCE

Hypaesthesia of the lower lip presented less as complication but rather as side effect following BSSO. As orthognathic surgery is mostly elective, preoperative patient education is of pivotal importance and should include proactive risk stratification.

Incidence of Fistula Formation and Velopharyngeal Insufficiency in Early Versus Standard Cleft Palate Repair

The goals of cleft palate repair are well-established; however, there does exist difference in practice patterns regarding the most appropriate patient age for palatoplasty. The optimal timing is debated and influenced by cleft type, surgical technique, and the surgeon's training. The objective of this study was to compare the rates of post-operative fistula formation and velopharyngeal insufficiency (VPI) in "early" versus "standard" cleft palate repair in a cohort of patients treated at a single craniofacial center.A retrospective chart review identified 525 patients treated for cleft palate from 2000 to 2017 with 216 meeting inclusion criteria. "Early repair" is defined as palatoplasty before 6-months of age (108 patients). "Standard repair" is palatoplasty at or beyond 6-months old (108 patients). Rates of fistula formation were found to be significantly higher in early repairs (Chi-square statistic 9.0536, P value = 0.0026). Development of VPI was not significantly different between the 2 groups (Chi-square statistic 1.2068, P value = 0.27196). As expected, the incidence of post-palatoplasty VPI was significantly higher in patients who had a post-operative fistula when compared to those who healed without fistula formation (Chi-square statistic 4.3627, P value = 0.0367).There is significant debate regarding the optimal timing of cleft repair to maximize speech outcomes and minimize risks. The authors' data show that post-operative fistula formation occurs at a higher rate when performed prior to 6 months old. Furthermore, while the rate of VPI was not significantly affected by age at time of surgery, it was significantly higher in those who experienced a post-operative fistula.

Oronasal Fistula Risk After Palate Repair

OBJECTIVE

To assess risk factors for oronasal fistula, including 2-stage palate repair.

DESIGN

Retrospective analysis.

SETTING

Tertiary children's hospital.

PATIENTS

Patients with non-submucosal cleft palate whose entire cleft repair was completed at the study hospital between 2005 and 2013 with postsurgical follow-up.

INTERVENTIONS

Hierarchical binary logistic regression assessed predictive value of variables for fistula. Variables tested for inclusion were 2 stage repair, Veau classification, sex, age at surgery 1, age at surgery 2, surgeon volume, surgeon, insurance status, socioeconomic status, and syndrome. Variables were added to the model in order of significance and retained if significant at a .05 level.

MAIN OUTCOME MEASURE

Postoperative fistula.

RESULTS

Of 584 palate repairs, 505 (87%) had follow-up, with an overall fistula rate of 10.1% (n = 51). Among single-stage repairs (n = 211), the fistula rate was 6.7%; it was 12.6% in 2-stage repairs (n = 294, P = .03). In the final model utilizing both single-stage and 2-stage patient data, significant predictors of fistula were 2-stage repair (odds ratio [OR]: 2.5, P = .012), surgeon volume, and surgeon. When examining only single-stage patients, higher surgeon volume was protective against fistula. In the model examining 2-stage patients, surgeon and age at hard palate repair were significant; older age at hard palate closure was protective for fistula, with an OR of 0.82 (P = .046) for each additional 6 months in age at repair.

CONCLUSIONS

Two-stage surgery, surgeon, and surgeon volume were significant predictors of fistula occurrence in all children, and older age at hard palate repair was protective in those with 2-stage repair.

The Impact of Presurgical Infant Orthopedics on Oronasal Fistula Rates Following Cleft Repair: A Meta-Analysis

Background:

Presurgical infant orthopedics (PSIO) techniques were introduced to improve the outcomes achieved when treating children with complete cleft lip and palate. The effect of PSIO on the incidence of postoperative fistulae has never been reliably demonstrated. We conducted a meta-analysis to assess the effectiveness of PSIO in reducing postoperative fistulas in patients with complete cleft lip and palate.

Methods:

A search of the PubMed and Embase databases was performed to identify relevant articles that included primary palate repairs of patients with unilateral or bilateral complete clefts, reported the incidence of postoperative fistulae, and explicitly stated if PSIO was used. Details including author, number of subjects, use of PSIO, and fistula rate were cataloged.

Results:

A review of the PubMed database yielded 1135 unique citations, and Embase yielded 507 articles. Review of these yielded 15 studies, comprising 1241 children, which met inclusion criteria. The overall rate of oronasal fistula development was 7.09%. The average fistula rate for studies using PSIO was 5.93% versus 9.71% in the non-PSIO group. This difference was not statistically significant ( P = .34).

Conclusions:

The use of PSIO prior to cleft lip and palate repair provides multiple benefits related to facial and nasal form and is supported by a body of literature. The effect of PSIO on the incidence of postoperative fistulae has received less attention in the literature. Our meta-analysis of the available literature does not provide evidence to support the premise that the use of PSIO affects the incidence of fistulae after cleft palate repair.

Cleft Palate Repair: Description of an Approach, Its Evolution, and Analysis of Postoperative Fistulas

BACKGROUND

Fistulas following cleft palate repair impair speech, health, and hygiene and occur in up to 35 percent of cases. The authors detail the evolution of a surgical approach to palatoplasty; assess the rates, causes, and predictive factors of fistulas; and examine the temporal association of modifications to fistula rates.

METHODS

Consecutive patients (n = 146) undergoing palatoplasty during the first 6 years of practice were included. The technique of repair was based on cleft type, and a common surgical approach was used for all repairs.

RESULTS

The fistula rate was 2.4 percent (n = 125) after primary repair and 0 percent (n = 21) after secondary repair. All complications occurred in patients with type III or IV clefts. Cleft width and cleft-to-total palatal width ratio were associated with fistulas, whereas syndromes, age, and adoption were not. Most complications could also be attributed to technical factors. During the first 2 years, modifications were made around specific anatomical features, including periarticular bony hillocks, maxillopalatine suture, velopalatine pits, and tensor insertion. The fistula rate declined by one-half in subsequent years.

CONCLUSIONS

The authors describe a surgical approach to cleft palate repair, its evolution, and surgically relevant anatomy. Fistulas were associated with increasing cleft severity but could also be attributed to technical factors. A reduction in frequency and severity of fistulas was consistent with a learning curve and may in part be associated with modifications to the surgical approach.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Effectiveness of tranexamic acid for reducing intraoperative bleeding in palatoplasties: A randomized clinical trial

BACKGROUND

Few data are available regarding blood loss during cleft palate surgery. This study assessed the effect of using tranexamic acid in the reduction of intraoperative bleeding.

METHODS

A double-blind, randomized clinical trial compared intraoperative bleeding and the incidence of oronasal fistulas after palatoplasties in a control group that was given placebo and an intervention group that was given 10 mg/kg tranexamic acid followed by a continuous infusion of 1 mg/kg/h of the same until the end of surgery. Patients who underwent primary palatoplasty with no known or suspected coagulation disorders at our institution during the study period were included in the study.

RESULTS

70 patients were allocated, 66 received the intervention. Blood loss was reduced by 11.9%, without statistical significance. The incidence of fistulas in the intervention and control groups was 12.9% and 18.75%, respectively. The reduction of 5.8% (CI 95%: 12%-23.8%) was not significant.

CONCLUSIONS

The reduction of intraoperative blood loss was lower than expected and not statistically significant; a larger sample is needed to confirm the observed reduction. The drug did not seem to have negative effects on flap viability.

Role of Postoperative Antimicrobials in Cleft Palate Surgery: Prospective, Double-Blind, Randomized, Placebo-Controlled Clinical Study in India

BACKGROUND

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.

METHODS

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).

RESULTS

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.

CONCLUSION

The authors' results indicate that postoperative antibiotic prophylaxis can reduce the incidence of fistulas after primary cleft palate repair in a developing area.

Surgical learning curve in performing palatoplasty: A retrospective study in 200 patients

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.

Fistula incidence after primary cleft palate repair: a systematic review of the literature

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.

Influence of osteotomy procedure and surgical experience on early complications after orthognathic surgery in the mandible

INTRODUCTION

This study evaluated the influence of osteotomy procedure and surgical experience on early complication rates following orthognathic surgery in the mandible.

MATERIALS AND METHODS

In a retrospective study, patients who underwent a mandibular osteotomy (Obwegeser-Dal Pont (ODP) and Hunsuk-Epker (HE)) were included. Incidence of "bad splits", "bleeding episodes", "delayed wound healing", "failed osteosynthesis" and "nerve lesions" at 2 months post-operatively were recorded. Surgical experience was classified as: beginner (<10), intermediate (10-40) and expert (>40). Complications were correlated to the surgical approach and the experience level of the surgeon.

RESULTS

400 patients were included. 200 underwent a bimaxillary approach. 186 patients were operated using the ODP technique, 214 according to HE. Multivariate analysis confirmed significantly more unwanted fractures and bleeding events for ODP when compared to HE (p = 0.28, p = 0.003). Experienced surgeons had more osteosynthesis failures (0.047) and significantly more nerve lesions than the other groups (p = 0.01).

DISCUSSION

The HE osteotomy showed a more reliable fracture mechanism with less relevant bleeding episodes. Differences between the surgeons of varying training status were marginal with exception of a higher rate of osteosynthesis failure and temporary hypoesthesia in the experienced group.

The cost of intraoperative plastic surgery education

PURPOSE

Within the surgical community, it is commonly accepted that the length and cost of a surgical case increase when a resident physician participates. Many accountable care organizations, however, believe the opposite, that is, resident assistance enhances efficiency and diminishes operative time. The purpose of this study is to determine the opportunity cost to the attending surgeon for intraoperative teaching during index plastic surgery cases.

METHODS

A single senior surgeon's experience over a 7-year period was evaluated retrospectively for Current Procedural Terminology codes 40700 (repair of primary, unilateral cleft lip) and 42200 (palatoplasty). Variables collected include operative time, the presence or absence of a physician learner, and postgraduate year level. Statistical analysis was performed with the Kruskal-Wallis test using the S+ programming language. A cost analysis was performed to quantify the effect of longer operative times in terms of relative value units (RVUs) lost.

RESULTS

During the study period, a total of 45 patients had primary, unilateral cleft lip repair; 70 patients had cleft palate repair. Of those cases, 39 (87%) cleft lip repairs and 60 (86%) cleft palate repairs were performed with a resident or fellow present. There was a statistically significant difference in the amount of time required to perform either surgery with a physician learner than without, with operative times being 60% (p = 0.020) longer for cleft lip repair and 65% (p = 0.0016) longer for cleft palate repair. The results were further stratified based on level of training, with craniofacial fellows and plastic surgery residents (independent and integrated) compared separately. Cases where a craniofacial fellow was present required the longest operative times: 103% (p = 0.0012) longer for cleft lip repairs and 104% (p < 0.0001) longer for cleft palate repairs when compared with the senior surgeon operating alone. Using the 2011 physician work RVUs for these surgeries and the 2011 Medicare conversion factor for RVUs to dollars, the opportunity cost is over $275 per case per trainee for any physician learner. When craniofacial fellows are analyzed separately, over $440 is invested in intraoperative teaching per case per fellow.

CONCLUSIONS

Resident involvement in the operating room is crucial to the education of independent surgeons. This involvement, however, comes at a significant opportunity cost to the attending surgeon. As an incentive to retain academic surgeons and uphold a quality academic environment in the OR, compensation should be offered for intraoperative teaching.