Universal Applicability of the Furlow Palatoplasty: Resident as Primary Surgeon in a Consecutive, Nonselective Series

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.

Intraoperative Microvascular Complications in Autologous Breast Reconstruction: The Effects of Resident Training on Microsurgical Outcomes

BACKGROUND

 Academic medical centers with large volumes of autologous breast reconstruction afford residents hand-on educational experience in microsurgical techniques. We present our experience with autologous reconstruction (deep inferior epigastric perforators, profunda artery perforator, lumbar artery perforator, bipedicled, and stacked) where a supervised trainee completed the microvascular anastomosis.

METHODS

 Retrospective chart review was performed on 413 flaps (190 patients) with microvascular anastomoses performed by postgraduate year (PGY)-4, PGY-5, PGY-6, PGY-7 (microsurgery fellow), or attending physician (AP). Comorbidities, intra-operative complications, revisions, operative time, ischemia time, return to operating room (OR), and flap losses were compared between training levels.

RESULTS

 Age and all comorbidities were equivalent between groups. Total operative time was highest for the AP group. Flap ischemia time, return to OR, and intraoperative complication were equivalent between groups. Percentage of flaps requiring at least one revision of the original anastomosis was significantly higher in PGY-4 and AP than in microsurgical fellows: PGY-4 (16%), PGY-5 (12%), PGY-6 (7%), PGY-7 (2.1%), and AP (16%), p = 0.041. Rates of flap loss were equivalent between groups, with overall flap loss between all groups 2/413 (<1%).

CONCLUSION

 With regard to flap loss and microsurgical vessel compromise, lower PGYs did not significantly worsen surgical outcomes for patients. AP had the longest total operative time, likely due to flap selection bias. PGY-4 and AP groups had higher rates of revision of original anastomosis compared with PGY-7, though ultimately these differences did not impact overall operative time, complication rate, or flap losses. Hands-on supervised microsurgical education appears to be both safe for patients, and also an effective way of building technical proficiency in plastic surgery residents.

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.

On the Frequency of Oronasal Fistulation After Primary Cleft Palate Repair

Objective:

The aims of the study were to assess the postoperative oronasal fistula rate after 1-stage and 2-stage cleft palate repair and identify risk factors associated with its development.

Design:

Systematic review.

Setting:

Various primary cleft and craniofacial centers in the world.

Patients, Participants:

Syndromic and nonsyndromic cleft lip, alveolus, and palate patients who had undergone primary cleft palate surgery.

Intervention:

Assessment of oronasal fistula frequency and correlation with staging, timing, and technique of repair, gender, and Veau type. The results obtained in this systematic review were compared with those in previous reports.

Outcome:

The main outcome is represented by the occurrence of the oronasal fistula after 1-stage versus 2-stage palatoplasty.

Results:

The mean fistula percentage was 9.94%. In the Veau I, II, III, and IV groups, the respective fistula rates were 2%, 7.3%, 8.3%, and 12.5%. Oronasal fistula locations based on the Pittsburgh Fistula Classification System were soft palate (type II), 16.2%; soft palate–hard palate junction (type III), 29.3%; and hard palate (type IV), 37.3%. There were no statistically significant differences between 1-stage and 2-stage palatoplasty, syndromic and nonsyndromic, or male and female patients. Primary palatoplasty timing was not a significant predictor.

Conclusion:

Some disparities arose when comparing studies, mainly regarding location and types of clefting prone to oronasal fistulation. Interestingly, the fistula rate does not differ between 1- and 2-stage closure, and timing of the repair does not play a role.