Fistula in Cleft Lip and Palate Patients—A Systematic Scoping Review

Buccal Fat Pad in Primary and Secondary Cleft Palate Repair: A Systematic Review of the Literature

OBJECTIVE

To review the evidence supporting the use of buccal fat pad (BFP) in primary and secondary cleft palate repair and its short- and long- term clinical outcomes.

DESIGN

Systematic review conducted by 2 independent reviewers following PRISMA guidelines.

SETTING: NONE PARTICIPANTS

Articles were identified from three databases (Pubmed/Medline, Embase and Web of Science). Search terms included "cleft palate", "palatoplasty", "palate repair", "buccal fat pad".

INTERVENTIONS

Use of BFP in primary and secondary cleft palatoplasty.

MAIN OUTCOME MEASURES

Primary outcomes were immediate postoperative complications, postoperative fistula, and maxillary growth. Secondary outcomes were palatal length, speech, and donor site morbidity.

RESULTS

Ninety-one reports were retrieved after excluding duplicates. Twenty-three studies were included (13 case series and 10 comparative studies). Overall level of evidence was low. Randomized and non-randomized studies had a high risk of bias. In primary palatoplasty, BFP was more frequently used filling lateral relaxing incisions(57.4%), or in the hard-soft palate junction and covering mucosal defects(30.1%). In these patients, post operative fistula incidence was 2.8%. Two studies found wider transverse maxillary dimensions after BFP use. No higher incidence of bleeding, infection, dehiscence, or flap necrosis was reported. In secondary palatoplasty, no recurrent fistulas were reported for patients undergoing BFP for fistula repair.

CONCLUSIONS

BFP appears to be associated with a favorable impact in fistula prevention and management, as well as in transverse maxillary growth. However, there is a high heterogeneity among studies, high risk of bias and overall low quality of evidence. More high-quality research with long-term follow-up is warranted.

Gender-Affirming Surgery in Adolescents and Young Adults: A Review of Ethical and Surgical Considerations

BACKGROUND

The number of transgender adolescents seeking gender-affirming surgery (GAS) in increasing. Surgical care of the adolescent transgender patient is associated with several unique technical, legal, and ethical factors. The authors present a review of the current literature on gender-affirming surgery for individuals under the age of legal majority and propose directions for future research.

METHODS

A scoping review of recent literature was performed to assess evidence on gender-affirming surgery in individuals under the age of legal majority. Articles were included that examined either ethical or technical factors unique to pediatric GAS. Study characteristics and conclusions were analyzed in conjunction with expert opinion.

RESULTS

Twelve articles were identified that met inclusion criteria. Ten of these articles discussed ethical challenges in adolescent GAS, seven discussed legal challenges, and five discussed technical challenges. Ethical discussions focused on the principles of beneficence, nonmaleficence, and autonomy. Legal discussions centered on informed consent and insurance coverage. Technical discussions focused on the effects of puberty blockade on natal tissue.

CONCLUSIONS

Surgical care of the adolescent transgender patient involves important ethical, legal, and technical considerations that must be addressed by the clinical team. As the population of individuals seeking GAS after puberty blockade increases, future research is needed describing functional and psychosocial outcomes in these individuals.

Palatoplasty Using Alveolar Ridge Incisions: A Novel Approach for Addressing Cleft Palate Deformities

Background:

Traditionally, plastic surgeons have performed palatoplasties using mucoperiosteal flaps with lateral incisions that are medial to the alveolar ridge. However, narrow flaps can cause limitations in some cases. To construct larger and wider flaps and minimize exposed bone after closure, we propose a novel technique that entails creating the lateral incisions at the top of the alveolar ridge, instead of the base of the alveolar ridge, to capture more tissue when repairing the hard palate.

Methods:

A retrospective chart review was conducted for patients undergoing cleft palate repair with the aforementioned technique. Information collected included basic demographic and diagnostic factors related to cleft palate deformity and history of previous facial surgeries. Operative report details and postoperative complications were analyzed.

Results:

Nineteen patients with hard palate clefts were included in the analysis, with the majority being women (68%). There was a balanced representation of patients with Veau classifications of II (47%) and III (42%). The majority of patients had an isolated cleft palate (74%) and incomplete deformity (63%), with no other craniofacial deformities. One (5%) had postoperative self-limited oronasal fistula managed conservatively.

Conclusions:

We present a novel approach for repairing cleft palate deformities by extending the lateral incision to the top of the alveolar ridge to create larger mucosal flaps. Further longitudinal studies are needed to evaluate how this unique approach compares to traditional methods—with respect to impact on maxillary growth processes, requirement for subsequent surgeries beyond two years of follow-up, and ultimately normalized speech over time.

Administration of Single-Dose Antibiotic Does Not Decrease Oronasal Fistula Rates After Primary Palatoplasty

OBJECTIVE

Oronasal fistula (ONF) is a known complication after primary palatoplasty (PP). Studies investigating the effect of perioperative antibiotics on fistula rates after PP are limited by inadequate sample size or reliance on self-reporting through national databases. In this study, the authors evaluated the association between single-dose perioperative antibiotics and postoperative fistula rates after PP at a single institution.

DESIGN

A retrospective study.

PARTICIPANTS

Children younger than 2 years who underwent PP from April 2009 to September 2019 were included.

INTERVENTIONS

Patients were divided into 2 categories: Group 1 received a single intraoperative dose of IV antibiotic, while group 2 did not.

MAIN OUTCOME MEASURE(S)

Outcome measures included ONF formation, length of stay (LOS), and 30-day readmission rates. Multivariable firth logistic regression, quantile regression, and χ² tests were performed.

RESULTS

Of the 424 patients, 215 and 209 patients were in groups 1 and 2, respectively. The overall ONF rate was 1.9% among all patients. Patients in group 1 experienced an ONF rate of 3.3%, while patients in group 2 had an ONF rate of 0.5%. After correcting for confounding variables, the difference in ONF rates was not statistically different (P = .68). Median LOS was 35.7 hours and 35.5 hours (P = .17), while the rate of readmission within 30 days was 4.7% and 2.4% for group 1 and 2, respectively (P = .96).

CONCLUSIONS

Administration of a single-dose perioperative antibiotic did not decrease fistula formation after PP, nor did it affect the patient's LOS or 30-day readmission rate.

Cleft Palate Repair by Otolaryngologist-Head and Neck Surgeons: Risk Factors for Postoperative Fistula

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, 131:1281-1285, 2021.

Aboard the Smile Train: Outcomes of Primary Cleft Palate Repair at a Tertiary Care Center: À bord du Smile Train : les résultats cliniques de réparations de fentes palatines dans un centre de soins tertiaires

Introduction

Cleft palate repair is considered to be a safe procedure, yet still carries a 5% to 30% risk of complications. This study sought to assess the outcomes of this procedure in a high-burden Asian country that partners with the Smile Train to perform cleft surgeries.

Methods

The Aga Khan University medical records database was queried for pediatric patients undergoing cleft surgery between 2014 and 2017. Data were abstracted from the patient medical records, and details of the clinical, demographic factors, and postoperative outcomes were assessed.

Results

Among 142 patients with orofacial clefts, 102 (72%) underwent primary cleft palate repair, one-third (n = 36, 35%) of whom were operated as part of the Smile Train. The median preoperative hemoglobin was 11.4 g/dL (interquartile range: 10.7-12.0 g/dL), whereas the median weight was 8.3 kg (7.7-11.4 kg). Nearly two-thirds (n = 64, 63%) of the cohort underwent preoperative cardiology screening, with only a minority undergoing orthodontic treatment (n = 6, 6%). Approximately 15% (n = 15) of patients experienced a postoperative complication, most often a fistula (n = 11, 73%). On multivariable analysis, with each unit increase in hemoglobin levels, there was a 50% reduction in the odds of experiencing a complication (odds ratio: 0.51, 95% CI: 0.28-0.87). There were no in-patient deaths among the cohort.

Conclusion

The results of the current study provide useful information to key stakeholders including patients, plastic surgeons, and policy makers on the outcomes of cleft palate repair in a developing country.

[Palatal fistula rate after Huaxi Sommerlad-Furlow palatoplasty]

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.

Outcomes of Primary Palatoplasty: An Analysis Using the Pediatric Health Information System Database

BACKGROUND

Previous attempts at reporting oronasal fistula development and secondary speech surgery following cleft palate surgery have been limited to single-center case series. This limitation can be overcome by querying large databases created by health care governing bodies or health care alliances. The authors examined the effect of cleft type and demographic variables on the clinical outcomes.

METHODS

Data from the Pediatric Health Information System database were queried for patients, aged 6 to 18 months, who had undergone primary palatoplasty between 2004 and 2009. Subsequent repair of an oronasal fistula and/or secondary speech surgery between 2004 and 2015 was identified by procedure codes. Logistic regression models were used to assess the associations between cleft type with oronasal fistula and with secondary speech surgery.

RESULTS

Seven thousand three hundred twenty-five patients were identified, and 6.4 percent (n = 468) had a subsequent repair of an oronasal fistula and 18.5 percent (n = 1355) had a secondary speech operation. Adjusted for age, sex, and race, patients with cleft lip and palate have increased odds of oronasal fistula (OR, 5.60; 95 percent CI, 4.44 to 7.07) and secondary speech surgery (OR, 2.32; 95 percent CI, 2.05 to 2.63).

CONCLUSIONS

Using a large, multi-institution billing database, the authors were able to estimate the prevalence of oronasal fistula and surgically treated velopharyngeal insufficiency following primary palatoplasty in the United States. In addition, the authors demonstrated that patients with isolated cleft palate develop fewer oronasal fistulas and require less secondary speech surgery than patients with cleft lip and palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

A Standardized Protocol for the Prospective Follow-Up of Cleft Lip and Palate Patients

OBJECTIVE

To develop a standardized all-encompassing protocol for the assessment of cleft lip and palate patients with clinical and research implications.

METHOD

Electronic database searches were conducted and 13 major cleft centers worldwide were contacted in order to prepare for the development of the protocol. In preparation, the available evidence was reviewed and potential fistula-related risk determinants from 4 different domains were identified.

RESULTS

No standardized protocol for the assessment of cleft patients could be found in any of the electronic database searches that were conducted. Interviews with representatives from several major centers revealed that the majority of centers do not have a standardized comprehensive strategy for the reporting and follow-up of cleft lip and palate patients. The protocol was developed and consisted of the following domains of determinants: (1) the sociodemographic domain, (2) the cleft defect domain, (3) the surgery domain, and (4) the fistula domain.

CONCLUSION

The proposed protocol has the potential to enhance the quality of patient care by ensuring that multiple patient-related aspects are consistently reported. It may also facilitate future multicenter research, which could contribute to the reduction of fistula occurrence in cleft lip and palate patients.