Evaluation of fistula rates in three cleft palate techniques without relaxing incisions

Evaluation of postoperative outcomes in palatoplasty with three soft palate cleft repairs

The aim of this study was to compare the postoperative clinical and functional outcomes of palatoplasty with three soft palate cleft repairs and analyse the factors potentially impacting these outcomes. A retrospective analysis was conducted on a consecutive series of 337 patients who underwent primary cleft palate repair by palatoplasty modified with either Furlow Z-plasty (P-FZP, n = 77), intravelar veloplasty (P-IVV, n = 110), or combined intravelar veloplasty-Furlow Z-plasty (P-IVV-FZP, n = 150). The postoperative outcomes evaluated included wound healing (complete closure/fistula) and velopharyngeal function. Demographic and surgical data were analysed using both univariate and multivariate analysis. There was no significant difference between the groups with regard to the sex distribution, age at repair, cleft width, cleft type, or follow-up duration. However, relaxing incisions were significantly more common with P-FZP (26.0%) and P-IVV (29.1%) compared to P-IVV-FZP (10%) (P = 0.002 and <0.001, respectively). The complete wound closure rate was significantly higher with P-IVV-FZP (97.3%) compared to P-FZP (88.3%) (P = 0.012) and P-IVV (90%) (P = 0.015). The normal velopharyngeal function rate was comparable for P-IVV-FZP (86.7%) and P-FZP (83.1%), and both rates were significantly better than the rate with P-IVV (73.6%) (P = 0.039 and 0.029, respectively). The cleft type and width were identified as factors influencing postoperative outcomes. In conclusion, it may be appropriate to prioritize the palatoplasty with combined intravelar veloplasty-Furlow Z-plasty whenever feasible.

A Novel Missense Variant in the TCOF1 Gene in one Chinese Case With Treacher Collins Syndrome

The purpose of this study is to analyze the clinical characteristics of a Treacher Collins syndrome (TCS) patient carrying a de novo variant of TCOF1, and briefly analyze the correlation between genetic results and clinical features. Also, the pathogenesis and clinical treatment of TCS are reviewed.

A Chinese pedigree with TCS containing 8 members was enrolled. Phenotype of the proband was evaluated by a surgeon, then whole exome sequencing of the proband was performed. Then we verified the proband-derived variants by Sanger sequencing in the pedigree. Correlation between genotype and phenotype was analyzed.

The study was conducted in a stomatological hospital.

A Chinese pedigree with TCS containing 8 members.

To ascertain the genetic variants in the Chinese pedigree with TCS.

Blood samples were collected.

We reported a case of typical TCS with a de novo missense variant (NM_001371623.1:c.38T>G, p.(Leu13Arg)) in exon 1 of TCOF1, who presented asymmetrical facial abnormalities, including downward slanting of the palpebral fissures, sparse eyebrows, lateral tilt of the eyeballs, bilateral external ears deformities, hypoplasia of midface, reduction of the zygomatic body, bilateral orbital invagination, right external auditory canal atresia, mandibular ramus short deformity, cleft palate and the whole face was convex.

This research found a novel variant of TCS in Chinese, expanding the spectrum of TCS pathogenic variants. Genetic results combined with clinical phenotype can make a definite diagnosis and provide genetic counseling for the family.

Proposed clinical model for predicting speech outcomes in patients undergoing Furlow palatoplasty for velopharyngeal insufficiency after primary palatoplasty

This study aimed to validate the predictors of speech outcomes following Furlow palatoplasty in patients with velopharyngeal insufficiency (VPI) after primary palatoplasty and to propose and validate a model to predict the risk of persistent VPI. The study included patients with VPI after primary palatoplasty who underwent Furlow palatoplasty as a secondary surgery. Eleven variables were included: velar length, pharyngeal cavity depth, velopharyngeal gap, velopharyngeal closure pattern, sex, presence of cleft lip, existence of palatal fistula, surgeon, age at primary palatoplasty, age at secondary surgery, and time interval between primary palatoplasty and secondary surgery. Postoperative speech outcomes were assessed at least 1 year after the secondary surgery and classified as velopharyngeal competence (VPC) or VPI. Variables were analyzed using multivariate logistic regression analysis, and the area under the curve (AUC) was used to validate model accuracy. The study sample comprised 101 patients. Of the patients, 62 had VPC and 39 had VPI after secondary surgery. The results showed a younger age at secondary surgery, a smaller velopharyngeal gap, being female, having a coronal velopharyngeal closure pattern and a velopharyngeal closure ratio of 90% or greater produced a greater probability of VPC. Given the constraints of this study, it appears that the Furlow palatoplasty should be prioritized when the clinical model predicts a substantial likelihood of VPC post-surgery.

Evidence-Based Practices in Cleft Palate Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Understand the embryologic origins, cause, and incidence of cleft palate. (2) Review the anatomy and common classifications of cleft palate and associated defects. (3) Describe surgical techniques for palatoplasty and understand their respective indications. (4) Gain an awareness of general perioperative care considerations, timing of repair, and risk factors for and operative mitigation of complications.

SUMMARY

Cleft palate affects 0.1 to 1.1 per 1000 births, with a higher incidence in certain ethnic groups but affecting both sexes equally. Cleft palate may occur in isolation or in combination with cleft lip or in association with other congenital anomalies including various syndromes. The goals of cleft palate repair are to anatomically separate the oral and nasal cavities for normal feeding and improved speech and minimize the risk of oronasal fistulas, velopharyngeal dysfunction, and disruption of facial growth. This review discusses the incidence, causes, and classification of cleft palate; surgical techniques for palatoplasty and perioperative patient management; and complications of palatoplasty.

Prognostic Factors for Speech Outcome among Patients with Submucous Cleft Palate Managed by Furlow Palatoplasty or Posterior Pharyngeal Flap

BACKGROUND

Submucous cleft palate (SMCP) is a particular subtype of cleft deformity for which the optimal surgical timing and technique are still under debate. This study aimed to identify potential prognostic factors for the speech outcome of patients with SMCP and provide evidence for further management strategy optimization.

METHODS

The authors reviewed patients with nonsyndromic SMCP who received either Furlow palatoplasty (FP) or posterior pharyngeal flap (PPF) between 2008 and 2021 in a tertiary hospital-based cleft center. Both univariate and multivariate logistic regression models were used to screen preoperative variables, including cleft type (overt or occult), age at surgery, mobility of velum and pharyngeal wall, velopharyngeal closure ratio, and pattern. The receiver operating characteristic curve was used to determine the cutoff value of the significant predictors for subgroup comparison.

RESULTS

A total of 131 patients were enrolled, with 92 receiving FP and 39 receiving PPF. Age at operation and cleft type were identified as having significant effects on FP outcome. Patients operated on before 9.5 years of age had a significantly higher velopharyngeal competence (VPC) rate than those operated on after that age. The speech outcome among patients with occult SMCP was significantly worse than that of patients with overt SMCP after FP treatment. No preoperative variable was found to be correlated with PPF outcome. PPF yielded a higher VPC rate than did FP among patients operated on after 9.5 years of age.

CONCLUSIONS

The prognosis of patients with SMCP treated with FP is sensitive to age at surgery and cleft type. PPF may be considered for older patients in settings with limited access to multiple surgical procedures, especially when occult SMCP is diagnosed.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Current insights in the preclinical study of palatal wound healing and oronasal fistula after cleft palate repair

Poor palatal wound healing after cleft palate repair could lead to unfavorable prognosis such as oronasal fistula (ONF), which might affect the patient's velopharyngeal function as well as their quality of life. Thus, restoring poor palatal wound healing for avoiding the occurrence of ONF should be considered the key to postoperative care after cleft palate repair. This review provided current insights in the preclinical study of poor palatal wound healing after cleft palate repair. This review comprehensively introduced the animal model establishment for palatal wound healing and related ONF, including the models by mice, rats, piglets, and dogs, and then demonstrated the aspects for investigating poor palatal wound healing and related treatments, including possible signaling pathways that could be involved in the formation of poor palatal wound healing, the related microbiota changes because of the deformity of palatal structure, and the studies for potential therapeutic strategies for palatal wound healing and ONF. The purpose of this review was to show the state of the art in preclinical studies about palatal wound healing after cleft palate repair and to show the promising aspects for better management of palatal wound healing.

Comparison of velopharyngeal morphology of two palatoplasty techniques in patients with hard and soft cleft palate

Purpose

The study aims to compare the velopharyngeal morphology of hard and soft cleft palate (HSCP) patients after Furlow and Sommerlad palatoplasty.

Patients and methods

A total of 51 patients (20 cases in Furlow palatoplasty group, 16 cases in Sommerlad palatoplasty group and 15 normal children in the control group) were included in our study. Velopharyngeal function and speech outcomes of patients with HSCP who had either Furlow palatoplasty or Sommerlad palatoplasty for cleft palate repair were evaluated by perceptual speech assessment (PSA), lateral cephalometric radiographs and nasopharyngoscopy. To assess velopharyngeal morphology of patients treated with two techqiques, we analyzed measurements such as velar length, pharyngeal depth, and the Adequate ratio (the ratio of velar length to pharyngeal depth). Furthermore, skeletal landmarks including cranial base, cervical vertebrae, posterior nasal spine which were defined as the pharyngeal triangle were measured. Finally, the position of the point U relative to the pharyngeal triangle were compared.

Results

Velopharyngeal closure (VPC) rate in Furlow palatoplasty group accounted for 90%, while that in Sommerlad palatoplasty group was 81.3%. PSA of the former group was significantly better than that of the latter group (P < 0.05). Velar length, pharyngeal depth and the Adequate ratio (1.37 ± 0.14 vs. 1.41 ± 0.15) were comparable between the Furlow group and control group (P > 0.05), while Sommerlad group had a shorter velar length, deeper pharyngeal depth and a smaller Adequate ratio (1.20 ± 0.18) compared to the above two groups (P < 0.05). Furhermore, the point U of Sommerlad group in the pharyngeal triangle was higher than that of the other two groups.

Conclusions

In the treatment modality of patients with HSCP, both Furlow palatoplasty and Sommerlad palatoplasty seem to be effective. Furlow palatoplasty appears to have velopharyngeal morphology similar to normal control group., while Sommerlad group shows a shorter velar length, deeper pharyngeal depth and a smaller Adequate ratio.

Evaluation of the effect of a resorbable membrane on the closure of palatal fistulas

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.

Continuous circular closure in unilateral cleft lip and plate repair in one surgery

The study aims at assessing wound healing and safety of single-stage two-layers continuous closure in patients with unilateral cleft lip and palate (UCLP). In this retrospective, descriptive cohort study, we assessed wound healing without fistula formation at 1, 3, and 6 months after a single-stage two-layer UCLP repair, in which the midline suture is continuously circular all along the oral and nasal sides. We examined lengths of hospital stay and the incidence of intra- and postoperative adverse events. Furthermore, we compared the cleft width at birth and on the day of surgery, after presurgical orthopaedics. Eleven UCLP patients underwent one cleft surgery between July 2016 and June 2018 at the age of 8-9 months. Full primary healing occurred in all patients without fistulas. Median length of post-operative hospital stay was 5 days (range = 4-9 days). No intra- or postoperative adverse events above Grade I (according to ClassIntra and Clavien-Dindo, respectively) occurred. Median and interquartile range (IQR) of the palatal cleft width decreased significantly from birth to surgery, i.e., from 12.0 mm (10.8-13.6 mm) to 5.0 mm (4.0-7.5 mm) anteriorly and from 14.0 mm (11.5-15.0 mm) to 7.3 mm (6.0-8.5 mm) posteriorly (p = 0.0033 in both cases). Given these preliminary results, the concept of single-stage continuous circular closure in UCLP has potential for further investigation. However, it remains to be proven that there are no relevant adverse effects such as inhibition of maxillary growth. Registered in clinicaltrials.gov:NCT04108416.