Minimal incision palatoplasty with or without muscle reconstruction in patients with isolated cleft palate-a cephalometric study at 5 and 10 years

Influence of Primary Palatal Surgery on Craniofacial Morphology in Patients with Cleft Palate Only (CPO)-Systematic Review with Meta-Analysis

BACKGROUND

Cleft palate only (CPO) is the second most prevalent cleft type. Both the cleft and palatal scarring may affect craniofacial growth. The aim of this systematic review was to summarize scientific evidence on effect of palatal surgery on craniofacial morphology in CPO.

METHODS

A search was conducted in PubMed, PMC, WoS, Scopus, Embase, using the keywords: "cleft palate" AND ("craniofacial morphology" OR "cephalometric analysis") NOT "lip" with inclusion and exclusion criteria ensuring confident, direct comparison between study groups. The quality assessment was performed with Arrive's scale for radiologic examinations.

RESULTS

Of 713 potential articles, 19 were subjected to qualitative analysis and 17 to meta-analysis, which confirmed reduced SNA in unoperated CPO versus non-cleft individuals. No scientific evidence was found directly assessing the effect of surgery on craniofacial morphology. The negative effect of palatal surgery was seen indirectly: in treated CPO versus non-cleft, the size effect of SNA is bigger than in untreated CPO versus non-cleft. A high heterogeneity came from a few non-European publications.

CONCLUSIONS

CPO is associated with sagittal maxillary deficiency resulting both from the cleft and from primary surgery, disregarding cleft severity in operated CPO patients. Ethnic differences influence craniofacial morphology in CPO. This research received no external funding. Study protocol number in PROSPERO database: CRD42021268957.

Cleft Palate Repair: A History of Techniques and Variations

Orofacial clefting is a common reconstructive surgical condition that often involves the palate. Cleft palate repair has evolved over three centuries from merely achieving anatomical closure to prioritizing speech development and avoiding midface hypoplasia. Despite centuries of advancements, there is still substantial controversy and variable consensus on technique, timing, and sequence of cleft palate repair procedures. Furthermore, evaluating the success of various techniques is hindered by a lack of universal outcome metrics and difficulty maintaining long-term follow-up. This article presents the current controversies of cleft palate repair and details how the history of cleft palate repair has influenced current techniques commonly used worldwide. Our review highlights the need for a global consortium on cleft care to gather expert opinions on current practices and outcomes and to standardize technique classifications. An understanding of global protocols is crucial in an attempt to standardize technique and timing to achieve anatomical closure with optimal velopharyngeal competence, while also minimizing the occurrence of maxillary hypoplasia and palatal fistulae.

Split Buccal Fat Flap in Modified Furlow Palatoplasty: Surgical Technique and Early Result

SUMMARY

Encouraging results have been described for the use of pedicled buccal fat pad flap in primary cleft palate repair. This retrospective study describes the surgical technique and early results of a technical innovation utilizing the split buccal fat flaps in modified Furlow palatoplasty with small double-opposing Z-plasty. This technique introduces buccal fat tissue for coverage of lateral denuded palate surfaces to reduce the bone exposure and scar formation to potentially attenuate maxillary growth interference and for reinforcement of the palatal areas of high tension or with incomplete closure to decrease the risk of postoperative dehiscence and oronasal fistula formation. Consecutive nonsyndromic patients (n = 56) with cleft palate were treated with this method, all of whom demonstrated fast mucosalization of lateral palatal recipient regions within 3 weeks postoperatively and showed no fistula with 12 months' follow-up. Of 19 patients (33.9 percent) who underwent auditory-perceptual assessment, 15 (78.9 percent) had normal resonance. Surgeons could add this alternative surgical maneuver to their armamentarium during the primary palatoplasty, in which coverage of lateral surfaces and reinforcement with fat tissue in the anterior soft palate space are of paramount relevance.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Exploring the Relationship Between Palatal Cleft Type and Width With the Use of Relieving Incisions in Primary Repair

OBJECTIVE

The mainstay of palatal repair in the United Kingdom is the intravelar veloplasty (IVVP). It is not always possible to align the oral mucosa in the midline to achieve tension-free repair. The addition of lateral relieving incisions may aid transposition of the oral mucosa to allow closure. The aim of this study was to explore cleft features that may predispose to a requirement for relieving incisions in order to allow palate closure.

DESIGN

We performed a national multiinstitutional retrospective study using data from the UK Cleft Collective cohort study.

PATIENTS

The study sample consisted of 474 patients who had undergone IVVP at the time of palatal closure across all 16 of the UK cleft units.

RESULTS

We found strong evidence for the requirement for relieving incisions in patients with an increased degree of clefting per the Veau classification (P < .001), increasing palatal soft-edge width (P < .001) and moderate evidence of an associated use in patients with Pierre Robin sequence (P = .015). Insufficient data were available to explore the relationship between intertuberosity distance and the presence of fistula formation with the use of relieving incisions.

CONCLUSIONS

The results of this study identify cleft features that increase the likelihood for requiring lateral relieving incisions to allow palatal closure. The degree to which the addition of relieving incisions to IVVP affects maxillary growth and speech outcomes is unknown. Further study is required to answer this important question.

Facial growth in patients with isolated cleft palate treated with minimal incision technique compared to a normal population-a cephalometric study at 10 and 16 years of age

OBJECTIVE

To evaluate the result of a novel palatoplasty (minimal incision technique) for closure of an isolated cleft palate (ICP) at 10 and 16 years of age, concerning facial growth, compared to a normal population.

SUBJECTS

Treated group: 55 non-syndromic Caucasian children born with an ICP between 1987 and 2001. The children were treated surgically with a one-stage palatoplasty at a mean age of 13 months. Control group: 110 Caucasian children with normal occlusion with no history of clefts or orthodontic intervention.

METHOD

The treated children (25 boys, 30 girls) were matched (gender and age) with the children in the control group. A retrospective evaluation at 10 (mean 10.5) and 16 (mean 16.0) years of age was performed by analysis of lateral cephalograms. Fifteen variables were evaluated. Ninety-nine per cent confidence intervals were calculated. Two-way factorial ANOVA and mixed-model analysis were performed.

RESULTS

Treated patients compared to the control group showed: at 10 years of age, smaller mandible (P = 0.001) and reduced posterior upper and total face heights (P ≤ 0.001); at 10 and 16 years of age, a retrognathic (P ≤ 0.001), smaller (P ≤ 0.006) and with an increased posterior inclination of the maxilla (P < 0.001), as well as a retrognathic mandible (P ≤ 0.006).

CONCLUSION

The craniofacial morphology at 10 and 16 years of age in patients born with an ICP and treated with the minimal incision technique differs compared to the morphology of a normal control group born without a cleft. Retrognathic maxillas and a smaller and posteriorly inclined maxilla were found in the treated group.

Modified double-opposing Z-plasty for patients with Veau I cleft palate: Are lateral relaxing incisions necessary?

Low fistula rate and a satisfactory speech outcome were previously reported by adopting a modified Furlow palatoplasty using small double-opposing Z-plasty (DOZ). The purposes of this study were to (1) describe the technical standardization of further modification of this small DOZ using the medial incision (MIDOZ) approach for Veau I cleft repair; (2) assess the early postoperative outcomes of a single surgeon's experience using this technique; and (3) evaluate the temporal association of this standardization with the necessity of lateral relaxing incisions.A prospective study (n = 24) was performed consecutively to non-syndromic patients with Veau I cleft palate who underwent MIDOZ approach. Patients with similar characteristics who underwent small DOZ were included as a retrospective group (n = 25) to control for the potential effect of the standardization of surgical maneuvers (including the hamulus fracture) on the rate of lateral relaxing incisions. Six-month complication rate was collected.No postoperative complications, such as bleeding, flap necrosis, dehiscence or fistula were observed. The prospective group had a significantly (all P < .05) higher rate of hamulus fractures (n = 48, 100%) and a lower rate of lateral relaxing incisions (n = 1, 2%) than the retrospective group (n = 16, 32%; n = 26, 52%).This technical standardization for performing palatoplasty using MIDOZ approach provided adequate Veau I cleft palate closure, without fistula formation, and with a low need of lateral relaxing incisions.