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Boot M, Winters R. Managing massive palatial defect secondary to palatoplasty failures: an in-depth analysis. Curr Opin Otolaryngol Head Neck Surg 2024; 32:269-277. [PMID: 38393699 DOI: 10.1097/moo.0000000000000968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
PURPOSE OF REVIEW Massive palatal defects resulting from palatoplasty failures arising from cleft palate repair complications present ongoing challenges in clinical practice. The purpose of this review is to provide up-to-date insights into aetiology, risk factors, surgical techniques, and adjunctive therapies, aiming to enhance the understanding of such complex cases, and optimize patient outcomes. RECENT FINDINGS Primary palatoplasty has fistula recurrence rates ranging from 2.4% to 55%. Factors such as cleft width, surgical repair method, and patient characteristics, influence the likelihood of failure. Classifications such as the Pakistan Comprehensive Classification and Richardson's criteria aid in assessing defects. Surgical options range from local flaps and revision palatoplasty to regional flaps (e.g., buccinator myomucosal, facial artery-based flaps, tongue flaps, nasal septal flaps) to free microvascular flaps. Alternative approaches include obturator prostheses, and acellular dermal matrix has been used as an adjuvant to multiple repair techniques. Hyperbaric oxygen therapy has emerged as an adjunctive therapy to enhance tissue healing. SUMMARY This comprehensive review underscores the intricate challenges associated with massive palatal defects resulting from palatoplasty failures. The diverse range of surgical and nonsurgical options emphasizes the importance of patient-centric, individualized approaches. Practitioners, armed with evidence-based insights, can navigate these complexities, offering tailored interventions for improved patient outcomes.
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Affiliation(s)
- Madison Boot
- John Hunter Hospital Department of Otolaryngology - Head & Neck Surgery, New Lambton Heights, NSW, Australia
| | - Ryan Winters
- John Hunter Hospital Department of Otolaryngology - Head & Neck Surgery, New Lambton Heights, NSW, Australia
- Tulane University Department of Otolaryngology - Head & Neck Surgery
- Tulane University Division of Plastic & Reconstructive Surgery, New Orleans, Louisiana, USA
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Yu V, Pham J, Lukomski L, Joseph J, Guo Y. Comorbidity and Operative Time are Stronger Predictors than Age for Palatoplasty Adverse Airway Events, A NSQIP-P Study of 6668 Cases. Cleft Palate Craniofac J 2024; 61:1149-1156. [PMID: 36786023 DOI: 10.1177/10556656231156509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Adverse airway events (AAEs) are rare but devastating complications following palatoplasty. The purpose of this study is to evaluate patient risk factors for their effect on these complications. We hypothesize that prolonged operative time and the presence of multiple medical comorbidities are risk factors for AAEs. DESIGN Retrospective cohort study. SETTING Participant hospitals in the Pediatric American College of Surgeons National Surgical Quality Improvement Program year 2016-2019. PATIENTS Cases of palatoplasty in children under 3 years of age. OUTCOMES Adverse airway events including postoperative reintubation or any requirement of postoperative mechanical ventilation. RESULTS A total of 6668 patients met inclusion criteria. The median operative time was 126 min (IQR 82). AAEs were identified in 107 (1.6%) patients. The incidence of risk factors was found to increase with age and AAEs were more prevalent in younger and older patients. Although patients in the older age groups had significantly higher burden of comorbidities, differences in age were not independently associated with AAEs. Following multivariable logistic regressions, operative times greater than 2 h, ASA class ≥3, >3 medical comorbidities, and black race were found to be significant independent risk factors. CONCLUSIONS In this large, retrospective database study in palatoplasty, increased operative time, ASA classification ≥3, multiple comorbidities, and black race were independently associated with AAEs.
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Affiliation(s)
- Victor Yu
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jason Pham
- Eastern Virginia Medical School, Norfolk, VA, USA
| | | | - Jeremy Joseph
- Division of Plastic and Reconstructive Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Yifan Guo
- Plastic and Oral Maxillofacial Surgery, Children's Hospital of the King's Daughters, Norfolk, VA, USA
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Li Y, Tao H, Yao M, Wu M, Tsauo C, Shi B, Liu R, Li C. Intraoral Scanning Evaluation of Maxillary Arch Changes after Modified Sommerlad Palatoplasty for around Three Years. Plast Reconstr Surg 2024; 153:1169e-1177e. [PMID: 37285204 DOI: 10.1097/prs.0000000000010799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND The purpose of this study was to investigate dental arch changes after modified Sommerlad palatoplasty in patients with cleft palate by intraoral scanning technique in children with early deciduous dentition. METHODS This study included 60 patients with nonsyndromic unilateral complete cleft lip with palate or cleft palate only treated by modified Sommerlad palatoplasty without relaxed excision before 18 months of age and 95 healthy controls without cleft. Three-dimensional images of the maxillary dental arches of all participants at age 3 to 4 years were obtained by intraoral scanning technique. Seven parameters (anterior dental arch width, middle dental arch width, posterior dental arch width, anterior palatal arch width, posterior palatal arch width, anterior dental arch length, and entire dental arch length) were measured. RESULTS Compared with the male group, the posterior palatal arch width distance of controls in the female group decreased significantly ( P = 0.039), and the middle dental arch width, posterior dental arch width, and posterior palatal arch width distance of female patients decreased ( P = 0.013, P = 0.002, P = 0.005, respectively). The anterior dental arch length and entire dental arch length distance of children in the unilateral complete cleft lip with palate group was shorter than those of children with cleft palate only ( P < 0.0001, P < 0.0001, respectively). The patient group showed decreased distance of anterior dental arch width, anterior palatal arch width, anterior dental arch length, and entire dental arch length, and increased distance of posterior dental arch width and posterior palatal arch width compared with the control group ( P = 0.0002, P = 0.002, P < 0.0001, P < 0.0001, P = 0.007, P = 0.027, respectively). CONCLUSION The results indicated that the modified palatoplasty group showed no growth inhibition in the middle or posterior dental arch width, or palatal arch width, but slight but significant inhibition in the length of the anterior and entire dental arch. CLINICAL QUESTION/LEVEL OF EVIDNCE Therapeutic, IV.
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Affiliation(s)
- Yuanyuan Li
- From the State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University
| | - Hongxu Tao
- From the State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University
| | - Meilin Yao
- From the State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University
| | - Min Wu
- From the State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University
| | - Chialing Tsauo
- From the State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University
| | - Bing Shi
- From the State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University
| | - Renkai Liu
- From the State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University
| | - Chenghao Li
- From the State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University
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Jung CW, Seo HJ, Choi YS, Bae YC. Incidence of Velopharyngeal Insufficiency after Primary Cleft Palate Repair: A 27-Year Assessment of One Surgeon's Experience. Arch Plast Surg 2024; 51:284-289. [PMID: 38737842 PMCID: PMC11081726 DOI: 10.1055/a-2263-7857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 01/30/2024] [Indexed: 05/14/2024] Open
Abstract
Background Velopharyngeal insufficiency (VPI) is a major complication of cleft palate repair. The purpose of this study was to evaluate the incidence and predictive factors of VPI after cleft palate repair based on 27 years of one surgeon's experience. Methods Medical records were retrospectively reviewed for 652 patients who underwent cleft palate repair between 1995 and 2021. After exclusion of those with other syndromes or developmental disorders, the study included 374 patients with sufficient follow-up until the age of 4 years, when language evaluation was possible. VPI status was categorized through subjective and objective tests into normal, VPI, and borderline. We analyzed potential differences in VPI incidence by multiple factors. Factors with significance were analyzed to confirm the relationships between subvariables. Results Of the 374 patients, 311 (83.2%) exhibited normal pronunciation, 51 (13.6%) had VPI, and 12 (3.2%) were borderline. Primary cleft palate repair performed after 18 months was associated with a higher incidence of VPI than repair conducted before 18 months ( p = 0.005). The incidence of VPI was higher in cases of submucous cleft palate than in the other types based on the Veau classification ( p = 0.011). However, in the multivariable analysis, only the submucous type showed statistically significant results ( p = 0.026). Conclusion A total of 374 people underwent primary cleft palate repair, and 13.6% of those with VPI required secondary therapy. The incidence of VPI was relatively high among patients with primary cleft palate repair after 18 months and patients with submucous cleft palate.
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Affiliation(s)
- Chan Woo Jung
- Department of Plastic and Reconstructive Surgery, School of Medicine, Busan National University, Busan, Korea
| | - Hyung Joon Seo
- Department of Plastic and Reconstructive Surgery, School of Medicine, Busan National University, Busan, Korea
- Biomedical Research Institute, Busan National University Hospital, Busan, Korea
| | - Ye Seul Choi
- Department of Rehabilitation Medicine, Busan National University Hospital, Busan, Korea
| | - Yong Chan Bae
- Department of Plastic and Reconstructive Surgery, School of Medicine, Busan National University, Busan, Korea
- Biomedical Research Institute, Busan National University Hospital, Busan, Korea
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Rossell-Perry P. Flap Necrosis Associated With Furlow's Palatoplasty. J Craniofac Surg 2023; 34:1301-1303. [PMID: 37101326 DOI: 10.1097/scs.0000000000009323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/09/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Numerous authors have reported their outcomes after using Furlow's palatoplasty for cleft palate repair. However, little attention has been given to the operative complications associated with this technique. The present study was carried out to present cases and analyze the various factors influencing the development of this complication accompanying Furlow's palatoplasty. MATERIALS AND METHODS This is a case report study of patients with cleft palate admitted to our center due to sequelae after primary cleft palate repair using Furlow palatoplasty between 2003 and 2021. Patient information was identified from the Smile Train cleft charity organization, parents' reports, and hospital records (intake forms and operating room registries). RESULTS Five patients were identified as having secondary cleft palate with palatal flap necrosis and associated with Furlow palatoplasty during patient evaluation at our center between 2003 and 2021. The observed prevalence was 1.54%. CONCLUSIONS Palatal flap necrosis is a rare but serious complication after primary Furlow's palatoplasty. The occurrence of this complication can be reduced by careful preoperative planning, and prevention is possible.
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Affiliation(s)
- Percy Rossell-Perry
- Research Professor Health of Science Faculty School of Human Medicine, Peruvian University Union (UpeU) Lima, Peru
- South American Medical (SAMAC) and Research and Innovation (STRIAC) Advisory Councils, Smile Train Foundation, New York City, NY
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Lucamba A, Grillo R, Bessa S, Hernández NMM, Filipe L, Naclério-Homem MDG. The importance of a local cleft mission and its spread. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 124:101382. [PMID: 36649802 DOI: 10.1016/j.jormas.2023.101382] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 12/29/2022] [Accepted: 01/11/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Cleft lip or palate are very usual birth defects. This study aims to discuss a local cleft mission performed in Angola and some specifics on the topic. METHODS This retrospective study assessed the main features of a local cleft mission conducted in September 2022. The mission was carried out at the Hospital Josina Machel in Luanda, Angola. Data was retrieved and analyzed. The Shapiro-Wilkes test and Pearson correlation were used and considered significant only at 95% confidence interval. RESULTS Cleft missions are a difficult task. Logistical and financial problems are exacerbated by the extreme difficulty of recruiting patients, particularly in remote regions, far from major centers. Despite successful widespread, some surgeries have been postponed due to comorbidities, common in Africa. CONCLUSION The organizers of the mission must be aware of the difficulty of attracting patients and must use different media such as television and radio. The internet needs to be used to the maximum and could reach a higher number of prospects.
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Affiliation(s)
- Agnelo Lucamba
- Department of Oral & Maxillofacial Surgery, Hospital Josina Machel, Luanda, Angola
| | - Ricardo Grillo
- Department of Oral & Maxillofacial Surgery, Traumatology and Prosthesis - Faculty of Dentistry of the University of São Paulo, Brazil; Department of Oral & Maxillofacial Surgery, Faculdade Patos de Minas, Brasília, Brazil.
| | - Suzana Bessa
- Department of Anesthesia, Hospital Josina Machel, Luanda, Angola
| | | | - Luzolo Filipe
- Department of Oral & Maxillofacial Surgery, Huambo Provincial Hospital, Huambo, Angola
| | - Maria da Graça Naclério-Homem
- Department of Oral & Maxillofacial Surgery, Traumatology and Prosthesis - Faculty of Dentistry of the University of São Paulo, Brazil
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Peyvasteh M, Askarpour S, Moradi N, Mansouri A. Comparison of the Outcomes of Surgical Repair of Cleft Palate Performed by Modified Von Langenbeck and Bardach (Two-Flap Palatoplasty) Methods. World J Plast Surg 2023; 12:94-99. [PMID: 38226189 PMCID: PMC10788101 DOI: 10.61186/wjps.12.3.94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/07/2023] [Indexed: 01/17/2024] Open
Abstract
Background Cleft lip and cleft palate are one of the most common congenital craniofacial abnormalities in the skull and face. We aimed to investigate the prevalence of complications after primary cleft palate repair surgery, performed on patients referred to a children's hospital, and to use the information and results obtained from it to reduce the complications and improve the results of these surgeries. Methods In this cross-sectional-analytical study, using a census sampling method, the medical records of 94 consecutive cleft palate patients treated in Abuzar Hospital in Ahvaz, southern Iran, in the years 2019 to 2021 were studied. The rate of postoperative complications during the first week in terms of wound opening and flap necrosis and one month later in terms of fistula formation after surgery were also extracted from the files. Results Ninety-four patients with congenital cleft palate (57.4% male and 42.6% female) were enrolled. The gap width in all studied patients was 14 ± 5 mm. The frequency of complications of surgical wound opening, flap necrosis, oronasal fistula and hypernasality in von Langenbeck group was 9.5%, 0.15% and 28.1% respectively, and in Bardach group was 9.5 %, 15% and 33.3% respectively. Conclusion There were no significant differences between the two surgical methods in terms of postoperative complications. Besides, what is important in choosing a surgical method is the patient's clinical condition, the surgeon's experience and skill, and his choice.
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Affiliation(s)
- Mehran Peyvasteh
- Department of Surgery, Ahvaz Jundishapur, University of Medical Sciences, Ahvaz, Iran
| | - Shahnam Askarpour
- Department of Surgery, Ahvaz Jundishapur, University of Medical Sciences, Ahvaz, Iran
| | - Negin Moradi
- Department of Speech Therapy, Ahvaz Jundishapur, University of Medical Sciences, Ahvaz, Iran
| | - Adel Mansouri
- Department of Surgery, Ahvaz Jundishapur, University of Medical Sciences, Ahvaz, Iran
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Wheeler JS, Sanders M. Late Bleeding Following Cleft Palate Repair: An Under-Reported Finding? J Craniofac Surg 2021; 33:607-609. [PMID: 34519712 DOI: 10.1097/scs.0000000000008135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT The objective of this article is to assess the incidence of late bleeding following cleft palate repair (palatoplasty) in children. This is a retrospective review of a prospectively maintained database of patients treated for Cleft Lip and Palate in a tertiary academic pediatric hospital setting over 2 hospitals (Middlemore and Starship Hospitals) under the same multidisciplinary team of the Auckland Regional Cleft and Craniofacial Service, New Zealand. All patients with a diagnosis of Cleft Lip and/or Palate undergoing primary cleft palate repair over an 11 year period until March 2020 were included in the study. Our results found there were 482 patients with a new diagnosis of Cleft Lip and/or Palate from Jan 2009 through to March 2020. Three hundred sixty-six of those patients underwent primary palatoplasty at an average age of 10.5 months (range 8-18 months). The sub-types of cleft palate diagnoses were one-third Veau I, one-third Veau II, and the remaining one-third were Veau III, IV, and submucous cleft palate. One-third were syndromic. A total of 6 patients were re-admitted to hospital after discharge from their primary admission with bleeding from the cleft palate surgical site. Of the 6 patients re-admitted, 5 needed blood transfusions and 4 required an urgent return to the operating room. The authors found the rate of late bleeding following primary cleft palate repair in our unit is 1:61 operations or 1.6%. Late bleeding following cleft palate surgery is not well reported in the literature.
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Affiliation(s)
- Jonathan S Wheeler
- Auckland Regional Cleft and Craniofacial Service, Departments of Plastic and Reconstructive Surgery and Oral Health, Middlemore Hospital University of Auckland, Auckland, New Zealand
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Roode GJ, Bütow KW, Naidoo S. Microbial contamination profile change over a 4-year period in nonoperated cleft soft palate. J Appl Microbiol 2021; 132:665-674. [PMID: 34180558 DOI: 10.1111/jam.15193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 05/16/2021] [Accepted: 06/10/2021] [Indexed: 11/29/2022]
Abstract
AIMS Surgical site infection is a major concern in cleft soft palate. Knowledge of the type, number and antimicrobial resistance of pathogens present preoperatively contribute to treatment success. The aim of this study is to determine whether or not the microbial contamination (diversity) preoperatively has changed since 2015. METHODS AND RESULTS Swabs were taken from the surgical site in 103 consecutive patients who presented for primary repair of the soft palate cleft. These were sent for microscopy, culture and sensitivity testing. Swabs were taken before disinfecting the site. Results were tabled and compared with two previous studies from the same facility. Out of 103 patients, 100 patients showed positive cultures with 42 different pathogenic micro-organisms identified. Most dominant pathogen was Klebsiella pneumoniae, 45.6%, increased by 28% from the previous two studies, with 93.6% of these pathogens resistant to one or more antimicrobials. Most of the other identified pathogens showed an alarming increase in occurrence, with a wide resistance to antimicrobials. CONCLUSIONS The increase in number and diversity of microbial contamination as well as their resistance to antimicrobials is a real concern. Ways of preventing postoperative infection in a natural way need to be explored. SIGNIFICANCE Surgeons need to be aware of constant changes in micro-organisms.
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Affiliation(s)
| | - Kurt-Wilhelm Bütow
- Maxillo-Facial and Oral Surgical Practice, Life-Wilgers Hospital, Lynnwood Ridge, South Africa
| | - Sharan Naidoo
- Maxillo-Facial and Oral Surgical Practice, Mediclinic Midstream Hospital, Lyttelton, South Africa.,Department of Maxillofacial and Oral surgery, Facial Deformity Clinic, University of Pretoria, Pretoria, South Africa
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Effect of Cleft Palate Repair Timing on Inpatient Complication Rate: Review of a National Database. J Craniofac Surg 2021; 32:466-468. [PMID: 33704961 DOI: 10.1097/scs.0000000000007069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Timing of cleft palate repair is controversial. We aim to assess whether timing of cleft palate repair affects rates of inpatient complications, length of stay (LOS), and cost of stay. METHODS The Healthcare Cost and Utilization Project Kids' Inpatient Database 2009 was queried for all admissions with a primary diagnosis of cleft palate during which cleft palate repair was performed as a primary procedure. Age 6 months or less was termed "early" repair, while age >6 months was termed "standard" repair. Patients age >3 years old, inpatient stays >30 days, and those stays in which a cleft lip repair was performed were excluded. Logistic regressions were used to model the probability of complications. Generalized linear models and a natural log link function were used for LOS and hospital charges, using SAS 9.4. RESULTS We included 223 early and 1482 standard repair patients. Early repairs were exclusively performed in urban hospitals (P < 0.001). Eighty-nine patients experienced a total of 100 complications, including respiratory failure (N = 53), airway obstruction (N = 18), and oropharyngeal hemorrhage (N = 13). We found no significant difference in complication rate or total hospital charges in the 2 groups. The earlier repair group had a slightly longer LOS (P = 0.048). CONCLUSION Over 85% of United States cleft palate repairs are performed after 6 months of age. All early repairs were performed at urban hospitals, and had slightly longer LOS. There was a 5.1% overall complication rate. Available data revealed no significant difference in complication rates between early repair and standard repair groups. LEVEL OF EVIDENCE 3b.
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Early Postoperative Complications in Primary Cleft Lip and Palate Repair: A Retrospective Analysis of 328 Cases. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.831955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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de Araújo LL, Alonso N, Fukushiro AP. Treatment of Cleft Lip and Palate in the Amazon Region in Brazil: Speech Results and Sociodemographic Aspects. Cleft Palate Craniofac J 2021; 59:595-602. [PMID: 34032142 DOI: 10.1177/10556656211017791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the speech outcomes in individuals with cleft lip and palate (CLP) from the Amazon region and determine their correlation with sociodemographic factors. DESIGN Cross-sectional, prospective, single-blind study. SETTING Tertiary care institute in Manaus, Amazonas, Brazil. PATIENTS Four hundred twenty individuals with CLP, aged 4 to 57 years. MAIN OUTCOME MEASURES The samples were judged by 3 speech pathologists experienced in the speech assessment of individuals with CLP. Hypernasality was scored using a 4-point scale, being 1 = absent, 2 = mild, 3 = moderate, and 4 = severe, and the active speech symptoms were classified as absent or present. The final score for each speech symptom was reached by consensus among the 3 examiners Descriptive analysis of sociodemographic data included origin, socioeconomic status, type of cleft, surgical technique employed, the age they underwent primary and secondary palatoplasty, and palatal fistula. RESULTS Absence of hypernasality was observed in 41% of the individuals, 18% had mild, 28% moderate, and 13% severe hypernasality. Active speech symptoms were observed in 57% of the individuals. Significant correlations were found between speech outcomes and the variables such as origin, socioeconomic status, age at primary and secondary palatoplasty, and presence of fistula. CONCLUSIONS Most individuals with repaired CLP from the Amazon region presented speech disorders, characterized by hypernasality and active errors. Patients living outside the state capital, of low socioeconomic level, underwent palatoplasty late and with presence of palatal fistula tended to have the worst speech outcomes.
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Affiliation(s)
- Laryssa Lopes de Araújo
- Yaçuri da Amazônia Institute, Manaus, Brazil.,Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, Brazil
| | - Nivaldo Alonso
- Department of Plastic Surgery, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, Brazil
| | - Ana Paula Fukushiro
- Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, Brazil.,Speech-Language Pathology Department, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
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Stein JR, Mantilla-Rivas E, Aivaz M, Rana MS, Mamidi IS, Ichiuji BA, Manrique M, Rogers GF, Finkel JC, Oh AK. Safety and Efficacy of Single-Dose Ketorolac for Postoperative Pain Management After Primary Palatoplasty: A Prospective Cohort Study With Historical Controls. Cleft Palate Craniofac J 2021; 59:505-512. [PMID: 33942669 DOI: 10.1177/10556656211012864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To analyze safety and efficacy of single-dose ketorolac after primary palatoplasty (PP). DESIGN Consecutive cohort of patients undergoing PP, comparing to historical controls. Setting: A large academic children's hospital. PATIENTS, PARTICIPANTS A consecutive cohort of 111 patients undergoing PP (study n = 47) compared to historical controls (n = 64). INTERVENTIONS All patients received intraoperative acetaminophen, dexmedetomidine, and opioids while the study group received an additional single dose of ketorolac (0.5 mg/kg) at the conclusion of PP. MAIN OUTCOME MEASURES Safety of ketorolac was measured by significant bleeding complications and need for supplementary oxygen. Efficacy was assessed through bleeding, Face Legs Activity Cry Consolability (FLACC) scale, and opioid dose. RESULTS Length of stay was similar for both groups (control group 38.5 hours [95% CI: 3.6-43.3] versus study group 37.6 hours [95% CI: 31.3-44.0], P = .84). There were no significant differences in all postoperative FLACC scales. The mean dose of opioid rescue medication measured as morphine milligram equivalents did not differ between groups (P = .56). Significant postoperative hemorrhage was not observed. CONCLUSIONS This is the first prospective study to evaluate the safety and efficacy of single-dose ketorolac after PP. Although lack of standardization between study and historical control groups may have precluded observation of an analgesic benefit, analysis demonstrated a single dose of ketorolac after PP is safe. Further investigations with more patients and different postoperative regimens may clarify the role of ketorolac in improving pain after PP.
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Affiliation(s)
- Jason R Stein
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Esperanza Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Marudeen Aivaz
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Md Sohel Rana
- Joseph E. Robert, Jr., Center for Surgical Care, Children's National Hospital, Washington, DC, USA
| | - Ishwarya Shradha Mamidi
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Brynne A Ichiuji
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Monica Manrique
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Gary F Rogers
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Julia C Finkel
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Albert K Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
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Abstract
BACKGROUND The optimal age for cleft palate repair continues to be debated, with little discussion of surgical risk related to operative timing. This study of 3088 cleft palate patients analyzed the impact of surgical timing on perioperative and 30-day postoperative outcomes. METHODS Primary cleft palate repairs were identified in the National Surgical Quality Improvement Program database from 2012 to 2015. Data were combed for total postoperative complications, rates of readmission and reoperation, operating room time, and length of stay. Bivariate analyses were performed comparing 3-month periods from months 6 to 18, and months 0 to 5, 18 to 23, 24 to 29, and 30 to 59. RESULTS Despite a higher proportion of isolated soft palate closure, children operated on before 6 months had a higher complication rate than children at other ages (7.1 percent versus 3.2 percent; OR, 2.4; p = 0.04), and higher rates of both readmission (3.6 percent versus 1.4 percent; OR, 3.6; p = 0.02) and reoperation (2.4 percent versus 0.5 percent; OR, 4.7; p = 0.04). There were no differences in short-term outcomes for any other age group younger than 5 years, and no differences in hospital length of stay among any age groups. CONCLUSIONS The authors' findings suggest a relative contraindication to operation before 6 months. As there were no differences between any other age groups, long-term speech optimization should continue to be the primary consideration for operative planning. These findings improve the current rationale for palatoplasty timing, and can aid surgeons and parents in the surgical decision-making process. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Peck CJ, Gowda AU, Khetpal S, Lopez J, Shultz BN, Parsaei Y, Wu RT, Steinbacher DM. Primary Cleft Palate Repair Among Older-Age Children and Adolescents in the United States. J Oral Maxillofac Surg 2021; 79:1339-1343. [PMID: 33610491 DOI: 10.1016/j.joms.2021.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Older age cleft palate (CP) repair in international settings has been associated with increased surgical morbidity. This study assesses the prevalence and risks associated with late-age CP repair (age > 5 years) in the United States. METHODS Primary CP repair patients less than the age of 18 years were identified in the National Surgical Quality Improvement pediatric database from 2012 to 2018. Total postoperative complications, readmissions, reoperations, duration of surgery, and length of stay were recorded. T-tests and χ2 analyses were used to compare variables between age groups 0-5, 6-10, and 11-17. RESULTS A total of 10,022 primary CP procedures were identified from 2012 to 2018, of which 868 (8.6%) received repair at age > 5 years. Hispanic patients constituted a larger proportion of CP repair from ages 11 to 17 years than repair at other ages (P < .001). In comparison with children treated from ages 0 to 5 years, children operated on between ages 6 and 10 or 11 and 17 years experienced no increases in unplanned readmissions, reoperations, or complication rates after surgery. Patients of ages 6-10 years and 11-17 years had decreased operating room time (P < .001) compared with younger patients. Patients of ages 11-17 years also had decreased hospital length of stay (P = .04). CONCLUSIONS Many children in the United States received primary CP repair after the age of 5 years likely due to late treatment of submucosal clefts or delayed care among international immigrants/adoptees. Old age procedures were not associated with increased short-term surgical morbidity in comparison with surgery at earlier time points. The causes and implications of older age primary surgery warrant further study.
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Affiliation(s)
- Connor J Peck
- Medical Student, Department of Surgery, Section of Plastic Surgery, Yale School of Medicine
| | - Arvind U Gowda
- Surgical Resident, Department of Surgery, Section of Plastic Surgery, Yale School of Medicine
| | - Sumun Khetpal
- Medical Student, Department of Surgery, Section of Plastic Surgery, Yale School of Medicine
| | - Joseph Lopez
- Craniofacial Fellow, Department of Surgery, Section of Plastic Surgery, Yale School of Medicine
| | - Blake N Shultz
- Medical Student, Department of Surgery, Section of Plastic Surgery, Yale School of Medicine
| | - Yassmin Parsaei
- Dental Resident, Department of Surgery, Section of Plastic Surgery, Yale School of Medicine; and Dental Resident, Department of Orthodontics, University of Connecticut
| | - Robin T Wu
- Surgical Resident, Department of Orthodontics, University of Connecticut, Resident, Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford Medicine
| | - Derek M Steinbacher
- Chief of Oral and Maxillofacial Surgery, Director of Craniofacial, Professor Plastic and Reconstructive Surgery, Yale New Haven Health.
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Lee KC, Halepas S, Wu BW, Chuang SK. For Patients With Isolated Cleft Palate Does Revision Palatoplasty Have an Increased Risk of Inpatient Complication Compared to Primary Palatal Repair? Cleft Palate Craniofac J 2020; 58:72-77. [PMID: 32799652 DOI: 10.1177/1055665620949121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The purpose of this study was to determine whether revision palatoplasty was associated with increased rates of inpatient complication and wound dehiscence compared to primary palatal repair. MATERIALS AND METHODS This was a retrospective study of patients with isolated cleft palate treated with primary palatoplasty or revision surgery for fistula repair. The records were obtained from the Kids' Inpatient Database between 2000 and 2014. The primary predictor was the type of surgery, classified as either primary or revision palatoplasty. Secondary predictors included demographics and comorbidities. Primary study outcomes were the postoperative complication and dehiscence rates as noted during the hospitalization course. The secondary outcomes related to health care utilization as measured through length of stay (LOS) and hospital charges. RESULTS A total of 5357 total admissions (95.5% primary, 4.5% revision) were included in the final sample. Fistula repairs (odds ratio = 14.37, P < .01) had significantly greater odds of wound dehiscence. The rates of inpatient complication ranged from 3.5% to 3.7%, and there were no significant differences between primary and revision surgery (P = .82). Complications were independently associated with insurance status and congenital anomalies. Complications and wound dehiscence both significantly increased the LOS and the hospital charges. Fistula repairs had a shorter mean LOS (P = .02), however this did not translate into cost savings (P = .60). CONCLUSIONS Although the rates of inpatient complications were not significantly different, revision palatoplasty was associated with a greater odds of wound dehiscence. Failure of a primary repair may portend an increased risk of wound failure with subsequent surgeries.
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Affiliation(s)
- Kevin C Lee
- Division of Oral and Maxillofacial Surgery, 25065NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Steven Halepas
- Division of Oral and Maxillofacial Surgery, 25065NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Brendan W Wu
- Department of Oral and Maxillofacial Surgery, 12297New York University Langone Medical Center and Bellevue Hospital Center, New York, NY, USA
| | - Sung-Kiang Chuang
- Department of Oral and Maxillofacial Surgery, 6572University of Pennsylvania Health System, Philadelphia, PA, USA.,Brockton Oral and Maxillofacial Surgery Inc, Brockton, MA, USA.,Department of Oral and Maxillofacial Surgery, Good Samaritan Medical Center, Brockton, MA, USA
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Restrepo DV, Sato MH, Cardoso FS, da Silva Freitas R. Should Cleft Surgery Always be Performed During the Matutine Time? Analysis of Early and Late Postoperative Complications in a Cleft Center. Cleft Palate Craniofac J 2020; 57:1332-1335. [PMID: 32314597 DOI: 10.1177/1055665620917840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Surgeries performed in the afternoon schedule were discouraged by Smile Train Foundation for patients younger than 2 years. The aim of this study is to present the incidence of complications discriminating time of surgery (morning/afternoon) in a reference center in Curitiba (Brazil) during 2017. DESIGN Retrospective study that evaluated all cleft surgeries that were performed at Assistance Center for Cleft Lip and Palate during 2017. Complications correlated with surgery period (morning/afternoon), type of surgery, and operating surgeon were studied. Statistical analysis was performed to find any association between discrete variables. SETTING Tertiary, institutional. PARTICIPANTS One hundred eighty-seven patients with cleft lip and/or cleft palate/cleft lip and palate, who were evaluated and submitted to surgery in the center and had less than 24 months of age, were included in the study. INTERVENTIONS One hundred twenty-four cheiloplasties and 63 palatoplasties were performed. MAIN OUTCOME MEASURE Incidence of complications. RESULTS From the total of cheiloplasties, the number of complications was 2 (1.6%) and from the total of palatoplasties the number of complications was 11 (17%); 8.1% of surgeries that were performed in the morning had any complication compared to 5.1% of surgeries performed in the afternoon. Statistical analysis of discrete variables with χ2 test showed no correlation between surgery schedule and complications (χ2 = 0.62). CONCLUSION The number of complications was not higher in the afternoon scheduled surgeries. Surgeon expertise had a statistically significant correlation with the absence of complications (χ2 = 20.57).
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Affiliation(s)
- Daniel Velez Restrepo
- Assistance Center for Cleft Lip and Palate (CAIF), Federal University of Paraná, Curitiba, Brazil
| | - Marilson Hideki Sato
- Assistance Center for Cleft Lip and Palate (CAIF), Federal University of Paraná, Curitiba, Brazil
| | | | - Renato da Silva Freitas
- Craniofacial Unit, Assistance Center for Cleft Lip and Palate (CAIF), Federal University of Paraná, Curitiba, Brazil
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Emami A, Hashemzadeh H. Does Primary Vomer Flap Significantly Affect Maxillary Growth? World J Plast Surg 2020; 9:62-66. [PMID: 32190594 PMCID: PMC7068186 DOI: 10.29252/wjps.9.1.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Cleft lip and palate (CLP) is a common congenital anomaly. Efficient surgical management of CLP is challenging in severe cases with wide clefts. Use of primary vomer flap simultaneous with cleft lip repair is effective in some cases, but remains a challenging topic. METHODS This study evaluated 81 non-syndromic CLP patients with extensive palatal cleft and no other underlying condition. Thirty-nine patients (group A) who were infants over 6 months of age underwent primary vomer flap during lip repair to decrease the size of their extensive palatal cleft. The results in this group were compared with group B (n=42) who did not receive primary vomer flap. RESULTS Comparison of the two groups showed that although maxillary growth impairment and maxillary constriction had a higher frequency in group A, the palatal cleft was smaller among them, which enabled easier and more efficient cleft repair in the next step. The difference in maxillary growth impairment was not significant between the two groups. However, the prevalence of some complications such as velopharyngeal incompetence and maxillary growth impairment was slightly higher in group A compared with group B. CONCLUSION Use of primary vomer flap at the time of lip repair can decrease the size of palatal cleft and enhance its later closure. However, since impairment of the maxillary growth was slightly (but insignificantly) higher in the vomer flap group, it should be performed at ages over 6 months of age, as well as in certain cases.
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Affiliation(s)
- Abolhasan Emami
- Department of Plastic Surgery, Iran University of Medical Sciences, Tehran, Iran
| | - Haleh Hashemzadeh
- Department of Orthodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
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Abdollahi Fakhim S, Nouri-Vaskeh M, Fakhriniya MA. Effects of phenytoin spray in prevention of fistula formation following cleft palate repair. J Craniomaxillofac Surg 2019; 47:1887-1890. [PMID: 31812307 DOI: 10.1016/j.jcms.2019.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/13/2019] [Accepted: 11/18/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The effectiveness of topical phenytoin has been reported for the treatment of oral biopsy ulcers, chemotherapy-induced oral mucositis, and chronic periodontitis. This study aimed to investigate the effects of topical phenytoin 2% on the prevention of fistula formation after cleft palate repair. METHOD This randomized clinical trial studied patients with nonsyndromic cleft palate who were referred to a tertiary center and underwent cleft palate repair from March 2010 to February 2015. Patients in the phenytoin group received phenytoin spray 2% for 8 weeks and were compared with an age- and sex-matched control group. RESULTS A total of 160 patients in two phenytoin and control groups (n = 80 for each group) were recruited to the study. The mean ages of patients in the phenytoin and control groups were 11.42 ± 1.30 and 11.08 ± 1.25 months, respectively. The results showed that six patients (7.5%) in the phenytoin group and 15 patients (18.8%) in the control group formed fistulas during the 6-month follow-up period. There was a significant difference in fistula formation between the phenytoin and control groups (p = 0.035). Furthermore, fistula size was significantly smaller in the phenytoin group compared with the control group (p < 0.001). CONCLUSION More frequent use of phenytoin spray can be considered, although there is insufficient information on the long-term side-effects of the chosen drug.
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Affiliation(s)
| | - Masoud Nouri-Vaskeh
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Wound Complications, Additional Ventilation Requirement, Prolonged Stay, and Readmission in Primary Palatoplasty. Plast Reconstr Surg 2019; 144:1150-1157. [DOI: 10.1097/prs.0000000000006163] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE The Veau classification represents the most commonly used system for characterizing cleft palate severity. Conflicting evidence exists as to how increasing Veau classification affects outcomes. This study compared perioperative outcomes between Veau III and IV cleft palate repairs. METHODS The National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was used to identify cleft palate repairs between 2012 and 2016 using CPT codes. Patients with alveolar bone grafts were excluded. Veau III (unilateral) and Veau IV (bilateral) cleft palate repairs were identified using International Classification of Disease code 9 and 10 (ICD-9 and -10 codes. Patient demographics, comorbidities, and adverse events were compared between the cohorts. RESULTS A total of 5026 patients underwent cleft palate repair between 2012 and 2016. Of the 2114 patients with identifiable Veau classification, 1302 had Veau III cleft palates and 812 had Veau IV cleft palates.The Veau IV cleft palate patient population was older (377.8 versus 354.1 days, P < 0.001) and had significantly more comorbidities including a higher incidence of chronic lung disease (P = 0.014), airway abnormalities (P = 0.001), developmental delay (P = 0.018), structural central nervous system deformities (P < 0.001), and nutritional support (P < 0.001). Veau IV cleft palate repairs also had longer operative times (153.2 versus 140.2 minutes, P < 0.001). Despite significant differences in comorbidities and perioperative factors, there were no differences in 30-day complications, readmissions, or reoperation rates between Veau III and IV cleft palate repairs. CONCLUSIONS Patients undergoing Veau IV cleft palate repair have a significantly greater number of comorbidities than Veau III cleft palate repairs. Despite differences in patient populations, 30-day surgical outcomes are comparable between the cohorts.
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22
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Outcomes of Primary Palatoplasty: An Analysis Using the Pediatric Health Information System Database. Plast Reconstr Surg 2019; 143:533-539. [PMID: 30688897 DOI: 10.1097/prs.0000000000005210] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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25
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Vomer Flap: A Golden Tool for the Treatment of Cleft Palate. J Craniofac Surg 2018; 29:e610-e613. [PMID: 29894454 DOI: 10.1097/scs.0000000000004661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Despite the lack of consensus regarding the treatment of labio-palatal clefts, each treatment protocol is the expression of an individual perspective that accumulates the experience of each multidisciplinary group, which all pursue the same goal: to achieve adequate language development with the lowest possible impact on facial growth. To achieve this, a management scheme has been developed, this exploits vomer flaps for the closure of palatal clefts and limits dissections in the palatine segments. Modifications are presented in the design and dissection of vomer flaps, so as to use the largest amount of mucosal tissue available, thus facilitating closure of the different clefts, particularly in Veau Group III clefts.
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26
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White MC, Randall K, Ravelojaona VA, Andriamanjato HH, Andean V, Callahan J, Shrime MG, Russ S, Leather AJM, Sevdalis N. Sustainability of using the WHO surgical safety checklist: a mixed-methods longitudinal evaluation following a nationwide blended educational implementation strategy in Madagascar. BMJ Glob Health 2018; 3:e001104. [PMID: 30622746 PMCID: PMC6307586 DOI: 10.1136/bmjgh-2018-001104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/24/2018] [Accepted: 10/28/2018] [Indexed: 01/05/2023] Open
Abstract
Background The WHO Surgical Safety Checklist reduces postoperative complications by up to 50% with the biggest gains in low-income and middle-income countries (LMICs). However in LMICs, checklist use is sporadic and widespread implementation has hitherto been unsuccessful. In 2015/2016, we partnered with the Madagascar Ministry of Health to undertake nationwide implementation of the checklist. We report a longitudinal evaluation of checklist use at 12-18 months postimplementation. Methods Hospitals were identified from the original cohort using purposive sampling. Using a concurrent triangulation mixed-methods design, the primary outcome was self-reported checklist use. Secondary outcomes included use of basic safety processes, assessment of team behaviour, predictors of checklist use, impact on individuals and organisational culture and identification of barriers. Data were collected during 1-day hospital visits using validated questionnaires, WHO Behaviourally Adjusted Rating Scale (WHOBARS) assessment tool and focus groups and analysed using descriptive statistics, multivariate linear regression and thematic analysis. Results 175 individuals from 14 hospitals participated. 74% reported sustained checklist use after 15 months. Mean WHOBARS scores were high, indicating good team engagement. Sustained checklist use was associated with an improved overall understanding of patient safety but not with WHOBARS, hospital size or surgical volume. 87% reported improved understanding of patient safety and 83% increased job satisfaction. Thematic analysis identified improvements in hospital culture (teamwork and communication, preparation and organisation, trust and confidence) and hospital practice (pulse oximetry, timing of antibiotic prophylaxis, introduction of a surgical count). Lack of time in an emergency and obstructive leadership were the greatest implementation barriers. Conclusion 74% of participants reported sustained checklist use 12-18 months following nationwide implementation in Madagascar, with associated improvements in job satisfaction, culture and compliance with safety procedures. Further work is required to examine this implementation model in other countries.
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Affiliation(s)
- Michelle C White
- Centre for Global Health and Health Partnerships, King’s College London, London, UK
- Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - Kirsten Randall
- Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | | | - Hery H Andriamanjato
- Directeur du Partenariat, Ministère de la Santé Publique, Antananarivo, Madagascar
| | - Vanessa Andean
- Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - James Callahan
- Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - Mark G Shrime
- Centre for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Stephanie Russ
- Centre for Implementation Science, King’s College London, London, UK
| | - Andrew J M Leather
- Centre for Global Health and Health Partnerships, King’s College London, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King’s College London, London, UK
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Jodeh DS, Buller M, Rottgers SA. The Impact of Presurgical Infant Orthopedics on Oronasal Fistula Rates Following Cleft Repair: A Meta-Analysis. Cleft Palate Craniofac J 2018; 56:576-585. [DOI: 10.1177/1055665618806104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Diana S. Jodeh
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
| | - Mitchell Buller
- Department of Plastic Surgery, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - S. Alex Rottgers
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
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Ramdial S, Madaree A. The spectrum of intraoral bacteria seen in patients with cleft palates in an African setting. Microbiologyopen 2018; 8:e00679. [PMID: 29949241 PMCID: PMC6460279 DOI: 10.1002/mbo3.679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 05/28/2018] [Accepted: 05/31/2018] [Indexed: 12/02/2022] Open
Abstract
Dehiscence or palatal fistula formation following palatoplasty is a complication that has grave consequences for the patient that include tissue loss, emotional distress to the parents and patient, and further medical costs. Palatal dehiscence or fistula formation is multifactorial following surgery—tension of wound closure, poor patient adherence to postoperative orders and wound infection are the most common causes for this. Oral colonization with pathogenic organisms could play a role in wound healing complications. Identification of intraoral bacteria among patients with cleft palates has thus far not been performed. To identify the spectrum of intraoral bacteria in cleft palate patients in an African setting; a retrospective, chart review was performed at Inkosi Albert Luthuli Central Hospital—a quaternary hospital in Durban, South Africa. All patients with unrepaired cleft palates who underwent palatoplasty in 2015 were included. Fifty‐two patients were included. Preoperative throat/palatal swabs were taken prior to palatoplasty. The various bacteria cultured from the aforementioned swabs were cataloged. Various bacteria were cultured. In total, 23 patients (44.2%) had positive swab cultures. Eighteen cultures (34.6%) had gram‐positive growth only, four cultures (7.7%) had gram‐negative growth only, while one patient (1.9%) cultured both a gram‐positive and a gram‐negative organism. Streptococcus viridans was the most commonly cultured organism (19.2%) while beta‐hemolytic streptococci were cultured from only 4 swabs (7.7%). Our study cataloged the commonly occurring bacteria found in unrepaired cleft palate patients in Africa. Further research into the clinical significance of each bacteria is advised.
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Affiliation(s)
- Shaal Ramdial
- Department of Plastic and Reconstructive Surgery, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, South Africa
| | - Anil Madaree
- Department of Plastic and Reconstructive Surgery, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, South Africa
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Gelfoam Interposition Minimizes Risk of Fistula and Postoperative Bleeding in Modified-Furlow Palatoplasty. J Craniofac Surg 2018; 28:1993-1996. [PMID: 28437266 DOI: 10.1097/scs.0000000000003616] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Failure to accomplish a tension-free, watertight closure predisposes the palatoplasty patient to fistula formation. Perioperative bleeding also places the patient at risk for adverse airway events (AAE). This study introduces the incorporation of a hemostatic gelatin sponge (Gelfoam) into layered palatoplasty to minimize adverse postoperative bleeding and fistula formation. A retrospective chart review was performed to identify subjects who underwent Furlow palatoplasty with insertion of Gelfoam from 2010 to 2015. Exclusion criteria include age >3 years, prior palate surgery, <30-day follow-up, immunosuppressive state, and diagnosis of Treacher-Collins or Apert Syndrome. Demographic data include age, sex, cleft laterality, prior surgeries, Veau classification, Pierre Robin status, and tracheostomy dependence. Primary outcome was fistula formation. Secondary outcomes included perioperative metrics and AAE.One hundred subjects met criteria, 45% female. Average age was 14.6 months. Subjects with syndromes comprised 28%, with 16% diagnosed with Pierre Robin. Two subjects were tracheostomy-dependent. Prior cleft and mandibular procedures were performed in 55%. Isolated palatal defects were seen in 46%, unilateral lip and palate in 41%, and bilateral lip and palate in 13%. The majority of defects were Veau II and III (35% and 34%, respectively). Adverse airway events occurred in 2%, one of which resulted in reintubation. One subject (1%) was found to have a postoperative fistula.The incorporation of Gelfoam in the modified-Furlow palatoplasty results in a low rate of oronasal fistula (1%) and low perioperative risk of AAE. Further prospective comparison of this method to others will be the focus of future work.
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White MC, Randall K, Alcorn D, Greenland R, Glasgo C, Shrime MG. Measurement of patient reported disability using WHODAS 2.0 before and after surgical intervention in Madagascar. BMC Health Serv Res 2018; 18:305. [PMID: 29703195 PMCID: PMC5923000 DOI: 10.1186/s12913-018-3112-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 04/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patient reported outcomes (PRO) measure the quality of care from the patient's perspective. PROs are an important measure of surgical outcome and can be used to calculate health gains after surgical treatment. The World Health Organisation Disability Assessment Schedule (WHODAS) 2.0 is a PRO used to evaluate pre and post-operative disability across a range of surgical specialities. In this study, Mercy Ships, a non-governmental organisation (NGO), used WHODAS 2.0 to evaluate patient reported disability in 401 consecutive patients in Madagascar. We hypothesised that surgical interventions would decrease pre-operative patient reported disability across a range of specialties (maxillofacial, plastic, orthopaedic, general and obstetric fistula surgery). METHOD WHODAS 2.0 was administered preoperatively by face-to-face interview, and at 3 months post-operatively by telephone. Demographic data, American Society of Anesthesiologists (ASA) physical classification score, duration of surgery, length of hospital stay, and in-hospital post-operative complications were collected from a separately maintained patient database. The primary outcome measure was difference in pre- and post-operative WHODAS 2.0 scores. RESULTS No differences were seen between the two groups in preoperative disability (p = 0.25), ASA score (p = 0.46), or duration of surgery (p = 0.85). At 3 months 44% (176/401) of patients were available for telephone for postoperative evaluation. All had a significant reduction in their disability score from 8.4% to 1.0% (p < 0.001), 17 experienced a post-operative complication, but none had residual disability and there were no deaths. The group lost to follow-up were more likely to be female (65% versus 50%, p < 0.05), were younger (mean age 31 versus 35, p < 0.05), had longer hospital stays (10 versus 4 days, p < 0.001), and were more likely to have experienced post-operative complications (p < 0.05). CONCLUSION This study demonstrates that surgical intervention in a LMIC decreases patient reported disability as measured by WHODAS 2.0.
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Affiliation(s)
- Michelle C White
- Mercy Ships, Department of Medical Capacity Building, Port of Toamasina, Toamasina, Madagascar. .,Mercy Ships, Department of Medical Capacity Building, Port of Cotonou, Cotonou, Benin. .,Great Ormond Street Hospital, London, UK.
| | - Kirsten Randall
- Mercy Ships, Department of Medical Capacity Building, Port of Toamasina, Toamasina, Madagascar.,Mercy Ships, Department of Medical Capacity Building, Port of Cotonou, Cotonou, Benin
| | - Dennis Alcorn
- Mercy Ships, Department of Medical Capacity Building, Port of Toamasina, Toamasina, Madagascar.,Mercy Ships, Department of Medical Capacity Building, Port of Cotonou, Cotonou, Benin
| | - Rachel Greenland
- Mercy Ships, Department of Medical Capacity Building, Port of Toamasina, Toamasina, Madagascar.,Mercy Ships, Department of Medical Capacity Building, Port of Cotonou, Cotonou, Benin
| | - Christine Glasgo
- Mercy Ships, Department of Medical Capacity Building, Port of Toamasina, Toamasina, Madagascar.,Mercy Ships, Department of Medical Capacity Building, Port of Cotonou, Cotonou, Benin
| | - Mark G Shrime
- Mercy Ships, Department of Medical Capacity Building, Port of Toamasina, Toamasina, Madagascar.,Mercy Ships, Department of Medical Capacity Building, Port of Cotonou, Cotonou, Benin.,Program in Global Surgery and Social Change, Boston, MA, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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Park E, Deshpande G, Schonmeyr B, Restrepo C, Campbell A. Improved Early Cleft Lip and Palate Complications at a Surgery Specialty Center in the Developing World. Cleft Palate Craniofac J 2018; 55:1145-1152. [PMID: 29578806 DOI: 10.1177/1055665618762881] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To evaluate complication rates following cleft lip and cleft palate repairs during the transition from mission-based care to center-based care in a developing region. PATIENTS AND DESIGN We performed a retrospective review of 3419 patients who underwent cleft lip repair and 1728 patients who underwent cleft palate repair in Guwahati, India between December 2010 and February 2014. Of those who underwent cleft lip repair, 654 were treated during a surgical mission and 2765 were treated at a permanent center. Of those who underwent cleft palate repair, 236 were treated during a surgical mission and 1491 were treated at a permanent center. SETTING Two large surgical missions to Guwahati, India, and the Guwahati Comprehensive Cleft Care Center (GCCCC) in Assam, India. MAIN OUTCOME MEASURE Overall complication rates following cleft lip and cleft palate repair. RESULTS Overall complication rates following cleft lip repair were 13.2% for the first mission, 6.7% for the second mission, and 4.0% at GCCCC. Overall complication rates following cleft palate repair were 28.0% for the first mission, 30.0% for the second mission, and 15.8% at GCCCC. Complication rates following cleft palate repair by the subset of surgeons permanently based at GCCCC (7.2%) were lower than visiting surgeons ( P < .05). CONCLUSIONS Our findings support the notion that transitioning from a mission-based model to a permanent facility-based model of cleft care delivery in the developing world can lead to decreased complication rates.
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Affiliation(s)
- Eugene Park
- 1 Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gaurav Deshpande
- 2 Department of Oral and Maxillofacial Surgery, Maaya Cleft and Craniofacial Unit, MGM Dental College and Hospital, Navi Mumbai, India
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Daniels KM, Yang Yu E, Maine RG, Heng Y, Yang L, Shi B, Corlew DS, Hoffman WY, Gregory GA. Palatal Fistula Risk after Primary Palatoplasty. Cleft Palate Craniofac J 2018; 55:807-813. [DOI: 10.1597/16-007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Humanitarian surgical organizations provide palatoplasties for patients without access to surgical care. Few organizations have evaluated the outcomes of these trips. This study evaluates the palatal fistula rate in patients from two cohorts in rural China and one in the United States. Methods: This study compared the odds of fistula formation among three cohorts whose palates were repaired between 2005 and 2009. One cohort included 97 Chinese patients operated on by teams from the United States and Canada under the auspices of Resurge International. They were compared to cohorts at Huaxi Stomatology Hospital and the University of California San Francisco (UCSF). Age, fistula presence, and Veau class were compared among cohorts using Chi-square tests. Logistic regression was used to analyze predictors of fistula formation. Results: The fistula risk was 35.4% in patients treated by humanitarian teams, 12.8% at Huaxi University Hospital and 2.5% at UCSF ( P < 0.001). Age and Veau class were associated with fistula formation (Age P = 0.0015; Veau P < 0.001). ReSurge and Huaxi patients had 20.2 and 5.6 times the odds of developing a fistula, respectively, compared to UCSF patients ( P < 0.01, both). A multivariable model controlling for surgical group, age, and gender showed an association between Veau class and the odds of fistula formation. Conclusions: Chinese children undergoing palatoplasty by international teams had higher odds of palatal fistula than children treated by Chinese surgeons in established institutions and children treated in the United States. More research is required to identify factors affecting complication rates in low-resource environments.
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Postoperative Respiratory Complications After Cleft Palate Closure in Patients With Pierre Robin Sequence. J Craniofac Surg 2017; 28:1950-1954. [DOI: 10.1097/scs.0000000000003995] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Mucoperiosteal Flap Necrosis after Primary Palatoplasty in Patients with Cleft Palate. Arch Plast Surg 2017; 44:217-222. [PMID: 28573096 PMCID: PMC5447531 DOI: 10.5999/aps.2017.44.3.217] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 10/05/2015] [Accepted: 03/11/2017] [Indexed: 11/12/2022] Open
Abstract
Background The prevalence of flap necrosis after palatoplasty in patients with cleft palate. The prevalence of mucoperiosteal flap necrosis after palatoplasty remains unknown, and this complication is rare. This event is highly undesirable for both the patient and the surgeon. We present here a new scale to evaluate the degree of hypoplasia of the palate and identify patients with cleft palate at high risk for the development of this complication. Methods In this case series, a 20-year retrospective analysis (1994–2014) identified patients from our records (medical records and screening day registries) with nonsyndromic cleft palate who underwent operations at 3 centers. All of these patients underwent operations using 2-flap palatoplasty and also underwent a physical examination with photographs and documentation of the presence of palatal flap necrosis after primary palatoplasty. Results Palatal flap necrosis was observed in 4 cases out of 1,174 palatoplasties performed at these centers. The observed prevalence of palatal flap necrosis in these groups was 0.34%. Conclusions The prevalence of flap necrosis can be reduced by careful preoperative planning, and prevention is possible. The scale proposed here may help to prevent this complication; however, further studies are necessary to validate its utility.
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Simulateur de suture – chirurgie des fentes vélopalatines. ANN CHIR PLAST ESTH 2017; 62:167-170. [DOI: 10.1016/j.anplas.2016.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/16/2016] [Indexed: 11/20/2022]
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Roode G, Bütow KW, Naidoo S. Preoperative evaluation of micro-organisms in non-operated cleft in soft palate: impact on use of antibiotics. Br J Oral Maxillofac Surg 2017; 55:127-131. [DOI: 10.1016/j.bjoms.2016.09.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 09/20/2016] [Indexed: 11/27/2022]
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Rossell-Perry P, Figallo-Hudtwalcker O, Vargas-Chanduvi R, Calderon-Ayvar Y, Romero-Narvaez C. Risk factors leading to mucoperiosteal flap necrosis after primary palatoplasty in patents with cleft palate. J Plast Surg Hand Surg 2017; 51:348-351. [DOI: 10.1080/2000656x.2016.1270216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Percy Rossell-Perry
- School of Medicine, San Martin de Porres University, Faculty of Human Medicine, Lima, Peru
- Outreach Surgical Center, Lima, Peru
- ReSurge Int, Sunnyvale, CA, USA
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Rossell-Perry P. Flap Necrosis after Palatoplasty in Patients with Cleft Palate. BIOMED RESEARCH INTERNATIONAL 2015; 2015:516375. [PMID: 26273624 PMCID: PMC4529936 DOI: 10.1155/2015/516375] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 12/04/2014] [Indexed: 11/17/2022]
Abstract
Palatal necrosis after palatoplasty in patients with cleft palate is a rare but significant problem encountered by any cleft surgeon. Few studies have addressed this disastrous complication and the prevalence of this problem remains unknown. Failure of a palatal flap may be attributed to different factors like kinking or section of the pedicle, anatomical variations, tension, vascular thrombosis, type of cleft, used surgical technique, surgeon's experience, infection, and malnutrition. Palatal flap necrosis can be prevented through identification of the risk factors and a careful surgical planning should be done before any palatoplasty. Management of severe fistulas observed as a consequence of palatal flap necrosis is a big challenge for any cleft surgeon. Different techniques as facial artery flaps, tongue flaps, and microvascular flaps have been described with this purpose. This review article discusses the current status of this serious complication in patients with cleft palate.
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Affiliation(s)
- Percy Rossell-Perry
- Post Graduate Studies, School of Medicine, San Martin de Porres University, Lima, Peru
- “Outreach Surgical Center Lima PERU” ReSurge International, Schell Street No. 120 Apartment 1503 Miraflores, Lima, Peru
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Prevalence, demographics, and complications of cleft palate surgery. Int J Pediatr Otorhinolaryngol 2015; 79:803-807. [PMID: 25847465 DOI: 10.1016/j.ijporl.2015.02.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/20/2015] [Accepted: 02/25/2015] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Current published data on the demographics of cleft lip and palate is sparse and differs intranationally in reported incidence, demographics, and complication rates, making accurate local data both valuable and useful. We investigate the prevalence, demographics, and complications of cleft palate correction surgery in the inpatient setting over a 15-year period. METHODS A retrospective review of The California Hospital Discharge Data sets of all pediatric patients who underwent cleft palate repair or cleft palate revision from 1997 to 2011. Children's hospitals (CHs) were analyzed as a separate group. For each record, age, gender, ethnicity, length of stay, total charges, principal payer, complications, and disposition were analyzed. RESULTS 10,450 correction surgeries were performed during 1997-2011. This was an annual case-volume of 697 and annual population-adjusted rate of 2.0, neither of which changed over time (p=0.9 and 0.06, respectively). Of all surgeries, 21.5% were revisions, 48.3% were performed in CHs, 56.2% were performed on males, and 65.5% were performed on Caucasians. The median length of stay was 1 day, which did not change over time (p=1.0). The median total charges increased from $9.074 to $35,643 over the studied period (p<0.001). Admission to CHs was associated with shorter stay (1-3 days vs. 1-4 days) and higher total charges ($15,560 vs. $13,242; both p<0.001). Complications occurred in 393 (3.8%) of the surgeries. This percentage did not change over time (p=0.2). The most common complication was fistula/abscess/infection, which occurred in 159 cases (1.5%). Respiratory complications requiring ventilation occurred 66 cases (0.6%). Complications were more common in CHs (4.8% vs. 2.8%; p<0.001). Mortality rate was <0.1%. CONCLUSIONS Our study constitutes the entire surgical cohort within a state, allowing for an accurate representation of the true perioperative complication rate of these procedures. The prevalence, demographics, and outcomes of the cleft palate correction surgery have remained unchanged during 1997-2011. Collectively, our data suggest that primary and secondary palatoplasty present low perioperative risk.
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Binet A, Poli-Merol ML, François-Fiquet C. [Primary surgery for cleft palate and short hospital stay (48 h): Are they compatible?]. ANN CHIR PLAST ESTH 2015; 61:95-100. [PMID: 26006303 DOI: 10.1016/j.anplas.2015.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 04/20/2015] [Indexed: 11/26/2022]
Abstract
UNLABELLED The aim of this study was to evaluate our practices by studying the duration of hospitalization and the parental real-life experience after a primary surgery of a cleft palate. MATERIALS AND METHODS Monocentric retrospective study by analysis of the patients files and phone interview of the parents whose children were operated for a primary surgery of a cleft palate isolated, or associated with a labial cleft, or included in a syndromic form. RESULTS Forty-nine patients (25 B-24 G) were performed by 44 Wardill and five Furlow procedures (average age: 11 months ½) between 2010 and 2012. The average duration of the post-operative stay was 1.5 days. Thirty-three parents were contacted (67%). The return was "very well" or "well done" in 82% of the cases. The pain at home was estimated by the parents as "worthless" or "little intense" in 73% of the cases. For 16% of the parents, the child seemed "uncomfortable". The prescription of analgesic was followed only in 70% of the cases. The duration of hospitalization was considered by the families as "good one" in 70% of the cases, "too long" for 12% and "too short" for 18% in particular because of difficulty in eating or parental anxiety. CONCLUSION Even if palatine surgery is considered to be painful, anaesthetic techniques and current analgesic protocols allow to envisage very simple and fast consequences, authorizing an early return of the children at home.
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Affiliation(s)
- A Binet
- Structure interne de chirurgie pédiatrique, pôle mère-enfant, American Memorial Hospital, CHU de Reims, 47, rue Cognacq-Jay, 51092 Reims, France
| | - M-L Poli-Merol
- Structure interne de chirurgie pédiatrique, pôle mère-enfant, American Memorial Hospital, CHU de Reims, 47, rue Cognacq-Jay, 51092 Reims, France
| | - C François-Fiquet
- Structure interne de chirurgie pédiatrique, pôle mère-enfant, American Memorial Hospital, CHU de Reims, 47, rue Cognacq-Jay, 51092 Reims, France; Structure interne de chirurgie plastique, reconstructrice et esthétique, pôle locomoteur, hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims, France; EA 3801, université de Reims Champagne Ardenne, SFR CAP santé Reims-Amiens, 51100 Reims, France.
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The efficacy of vomer flap for closure of hard palate during primary lip repair. J Plast Reconstr Aesthet Surg 2015; 68:940-5. [PMID: 25971415 DOI: 10.1016/j.bjps.2015.03.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 03/22/2015] [Accepted: 03/30/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIM This study presents the institutional experience of the use of vomer flap for early closure of hard palate during unilateral complete cleft-lip repair. The purpose of this study was to determine the survival rate of the vomer flap and to investigate its effect on the subsequent palatoplasty. PATIENTS AND METHODS This retrospective analysis includes 101 non-syndromic patients with complete unilateral cleft lip who received a vomer flap for the closure of the hard palate during cleft-lip repair. Patients were aged 6 months to 28 years (median 1 year). Success rates of the vomer flaps were assessed clinically and through pre-operative photographs taken at the time of subsequent palate repair. Ninety-two patients returned for second-stage palate repair, and 74 patients with adequate post-operative follow-up information were statistically analysed. RESULTS Of the 101 patients who were operated with primary lip repair and simultaneous vomer flap, only 54 (52.4%) vomer flaps healed completely. Out of 92 patients who returned for subsequent palatoplasty, 71 (77.2%) were operated with the two-flap technique, and 19 (20.7%) received von Langenbeck repairs. Seven (9.1%) patients had a surgical complication. The failure of previous vomer repair and von Langenbeck surgical technique were identified as factors associated with post-operative complications. CONCLUSIONS We conclude that failed vomer flaps increased the risks of complications in the subsequent palate repair. Furthermore, efforts to use von Langenbeck technique rather than the two-flap technique also resulted in increased surgical complications. As a result, we have abandoned the use of the vomer flap with primary lip repair.
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