An Outcome Study of a 2-Flap Pushback Palatoplasty Used in the Treatment of Wide Cleft Palates

Medial incision approach in modified small double-opposing Z-plasty for Veau II cleft repair

An encouraging outcome was described for the use of modified Furlow small double-opposing Z-plasty (sDOZ) using the medial incision (MIsDOZ) approach in repair of Veau type I cleft palate. This retrospective study assessed early results of using extended indication criterion of MIsDOZ for the management of consecutive non-syndromic patients with Veau II cleft palate treated by a single surgeon. Bardach two-flap plus sDOZ (two-flap approach) or medial incision approach with a tension-driven stepwise application of lateral palatal incisions (soft palate only, von Langenbeck type, or two-flap type) were applied. Surgical (age, cleft width, operative time, hospital stay, and complication)- and auditory-perceptual assessment-related data were collected. Two-flap approach (n = 21) demonstrated a significantly (p < 0.001) increased operative time (132.8 ± 12.2 versus 114.8 ± 19.9 min, respectively) and higher use of lateral incisions (100% versus 44.4%) than medial incision approach (n = 27), with no significant (p > 0.05) difference for age at surgery (13.0 ± 6.1 versus 13.6 ± 5.8 months), cleft width (8.5 ± 4.1 versus 8.7 ± 3.8 mm), hospital stay (1.0 ± 0 versus 1.0 ± 0 day), and complication (0% versus 0%) and hypernasality (9.5% versus 7.4%) rates. In conclusion, the medial incision approach for Veau II cleft repair resulted in reduced need for lateral palatal incision with no increase of complication or hypernasality rates.

25-year Follow-up of Primary Tibial Periosteal Graft for Hard Palate Repair in Cleft Lip and Palate: Outcomes, Concerns and Controversies

OBJECTIVE

This study evaluates long-term outcomes in adults with Unilateral and Bilateral Cleft Lip and Palate (UCLP/BCLP) treated during the period 1992 to 1995 with tibial periosteal graft in primary repair.

DESIGN

Retrospective study.

SETTING

Department of Plastic and Maxillofacial Surgery, Children's Hospital Bambino Gesù (Italy).

PATIENTS

The study included 52 patients with non-syndromic BCLP/UCLP who met the inclusion criteria.

INTERVENTIONS

All patients underwent a standardized surgical protocol using a tibial periosteal graft as primary repair of the hard palate.

MAIN OUTCOME MEASURE(S)

Long-term outcomes on maxillary growth, residual oronasal fistula, and leg length discrepancy.

RESULTS

About <2% of patients showed oral-nasal communication. Mean value of maxillary depth was 86° ± 4.5°. The lower value for maxillary retrusion was 76.8° in relation to the Frankfurt plane. At the x-ray control, 12.2% of patients showed leg discrepancy with a difference of always <2 cm.

CONCLUSIONS

The rate of maxillary retrusion obtained was the same if compared to other techniques. Tibial periosteal graft reduces the risk of fistula and the need for reintervention after secondary bone graft. The study did not observe negative impacts on leg growth after 25 years.

Anatomical Study of Domain Rescue of Palatal Length in Patients With a Wide Cleft Palate: Buccal Flap Reconstruction in Primary Palatoplasty

BACKGROUND

This study characterizes the potential loss of velar length in patients with a wide cleft and rescue of this loss of domain by local flap reconstruction, providing anatomic evidence in support of primary lengthening of the soft palate during palatoplasty.

METHODS

A retrospective review was conducted of all patients with a cleft palate at least 10mm in width, who underwent primary palatoplasty with a buccal flap prior to 18 months of age over a 2-year period. All patients underwent primary palatoplasty with horizontal transection of the nasal mucosa, which was performed after nasal mucosa repair, but prior to muscular reconstruction. The resulting palatal lengthening was measured and the mucosal defect was reconstructed with a buccal flap.

RESULTS

Of the 22 patients included, 3 (13.6%) had a history of Pierre Robin sequence, and 5 (22.7%) had an associated syndrome. No patients had a Veau I cleft, 7 (31.8%) had a Veau II, 12 (54.5%) had a Veau III, and 3 had (13.6%) a Veau IV cleft. All patients had a right buccal flap during primary palatoplasty. The mean cleft width at the posterior nasal spine was 10.6  ±  2.82mm, and mean lengthening of the velum after horizontal transection of the nasal mucosa closure was 10.5  ±  2.23mm. There were 2 (9.1%) fistulas, 1 (4.5%) wound dehiscence, 1 (4.5%) 30-day readmission, and no bleeding complications.

CONCLUSIONS

Patients with a wide cleft palate have a potential loss of 1cm velar length. The buccal flap can rescue the loss of domain in palatal length, and potentially improve palatal excursion.

The Effect of Presurgical Nasoalveolar Molding on Oronasal Fistula Following Primary Palatoplasty

OBJECTIVE

Presurgical nasoalveolar molding (PNAM) is widely used in cleft care protocol. This study investigated the correlation between PNAM and oronasal fistula after primary palatoplasty.

METHODS

A case-controlled study of 80 unilateral and bilateral complete cleft palate patients who underwent cleft palate repair were enrolled. Patients were divided into 2 groups: (1) no PNAM use and (2) PNAM use. The incidence of oronasal fistula and postoperative complications were compared between groups.

RESULTS

Forty patients in each group demonstrated the same baseline characteristics. The PNAM group showed a significantly lower postoperative oronasal fistula rate (15% versus 50%, P=0.003). Palatal cleft width wider than 12.5 mm increases the odds ratio of fistula formation by 1.19-fold (P=0.037), and the PNAM protected against postoperative palatal fistula formation (odds ratio 0.20, P=0.003).

CONCLUSION

Presurgical nasoalveolar molding can reduce postoperative oronasal fistula in wide-gap Veau type III and IV cleft palate.

Systematic Review of Postoperative Velopharyngeal Insufficiency: Incidence and Association With Palatoplasty Timing and Technique

Cleft palate is among the most common congenital disorders worldwide and is correctable through surgical intervention. Sub-optimal surgical results may cause velopharyngeal insufficiency (VPI). When symptomatic, VPI can cause hypernasal or unintelligible speech. The postoperative risk of VPI varies significantly in the literature but may be attributed to differences in study size, cleft type, surgical technique, and operative age. To identify the potential impact of these factors, a systematic review was conducted to examine the risk of VPI after primary palatoplasty, accounting for operative age and surgical technique. A search of PubMed, Embase, and Web of Science was completed for original studies that examined speech outcomes after primary palatoplasty. The search identified 4740 original articles and included 35 studies that reported mean age at palatoplasty and VPI-related outcomes. The studies included 10,795 patients with a weighted mean operative age of 15.7 months (range: 3.1-182.9 mo), and 20% (n=2186) had signs of postoperative VPI. Because of the heterogeneity in reporting of surgical technique across studies, small sample sizes, and a lack of statistical power, an analysis of the VPI risk per procedure type and timing was not possible. A lack of data and variable consensus limits our understanding of optimal timing and techniques to reduce VPI occurrence. This paper presents a call-to-action to generate: (1) high-quality research from thoughtfully designed studies; (2) greater global representation; and (3) global consensus informed by high-quality data, to make recommendations on optimal technique and timing for primary palatoplasty to reduce VPI.

Buccal Fat Pad: Adjunctive Procedure for Lateral Defect Coverage following Primary Palatoplasty

BACKGROUND

The buccal fat flap is an encapsulated mass originating from a specific fat tissue that is easily accessed and richly vascularized. The aim of this study was to report the effect of using the buccal fat flap on the oronasal fistula rate in primary palatoplasty.

METHODS

A case-controlled study of 94 patients who underwent primary cleft palate repair. Patients were divided into two groups: (1) two-flap palatoplasty with buccal fat flap for coverage of lateral hard palate defect and (2) conventional two-flap palatoplasty. The incidence of oronasal fistula and postoperative complications were compared between groups. Multivariate analysis was performed to determine the risk factors of oronasal fistula development.

RESULT

Forty-seven patients in each group demonstrated the same baseline characteristics. The buccal fat group showed a significant lower postoperative oronasal fistula rate (2.13 percent versus 21.28 percent, p = 0.008) and smaller fistula size (2 mm versus 4 mm, p = 0.049). A cleft width wider than 11.5 mm increased the odds ratio of fistula formation by 8.44-fold (p = 0.047), and the use of buccal fat protected against postoperative palatal fistula formation (OR, 0.08, p = 0.019).

CONCLUSION

The use of buccal fat flaps for lateral hard palatal defect coverage in primary palatoplasty can reduce the rate of postoperative palatal fistula, especially in cases of wide palatal cleft.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Cleft Palate Repair: A History of Techniques and Variations

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

Normal Speech Should be the Expected Outcome in the Adopted Cleft Child

Significantly worse speech outcomes and higher complication rates are reported among internationally adopted cleft patients. We evaluated our cohort to provide more accurate counseling to adoptive parents.

METHODS

We reviewed internationally adopted children with unrepaired cleft palate who had 2-flap palatoplasty with radical intravelarveloplasty from 2003 to 2015 in a single-surgeon, consecutive series.

RESULTS

Seventy-two children adopted with unrepaired cleft palate were identified, 2 with syndromic association. The average age at palatoplasty was 28.1 months. Meaningful speech assessment was available in 58 patients. Successful speech was defined by a competent or borderline-competent velopharyngeal mechanism (Pittsburgh Weighted Speech Score <2). Twenty-five patients (43%) had successful speech outcomes. Twenty-nine patients (50%) were recommended secondary operation for nasality. Nonfistula repair secondary operation was performed using the following: fat grafting (9 patients, 43%), intravelarveloplasty (8 patients, 38%), and sphincter pharyngoplasty (4 patients, 19%). The average Pittsburgh Weighted Speech Score improved 5.8 to 1.3 (P = 1.3E-6); 4.8 to 1.0 (P = 0.0009) with fat grafting alone. After all interventions, normal speech was achieved in 43 (74%) of 58 patients. Palatal fistula (9.2% vs 0.9%, P = 0.001) and velopharyngeal insufficiency (50% vs 6.7%, P = 0.0004) rates were both significantly higher in the internationally adopted cohort than our nonadopted population data. The need for secondary surgery was independent of cleft type (P = 0.89), age (P = 0.78), or presence of a "wide" cleft (P = 1).

CONCLUSIONS

Our results demonstrate higher fistula and secondary surgery rates. Successful speech outcomes were achieved in most patients with minimally invasive secondary procedures.

Release of the Lateral Pharyngeal Mucosa Using a Palatal Elevator

The aim of this paper is to present how to release the nasal mucosa from the hard palate and from the lateral pharyngeal wall using palatal elevator.After mucoperiosteal flap is raised, the nasal mucosa is detached with an instrument pushed laterally behind the palatine vessels to meet the medial pterygoid plate. The palatal elevator is passed around the spine at the posterior medial border of the bony palate and then moved forward in the cleft to separate the nasal mucosa from bone. The palatal elevator is now introduced behind the greater palatine vessels, maintaining contact with the medial pterygoid plate. The elevator is pushed deeply up toward the base of the skull to elevate the lateral pharyngeal mucosa medially. When this mucosa is freed, the elevator can be moved anteriorly to separate the nasal mucosa from nasal side wall and upper surface of the hard palate. After closure of the buccal layer, 2 posterior flaps are joined to the small anterior flap. Finally, an A suture is made to hold the buccal layers together with the nasal mucosa and lateral pharyngeal mucosa to obliterate dead space.Herein, the authors present how to completely free the nasal mucosa from the hard palate and from the lateral pharyngeal wall before medial shifting and suturing. In our series of 60 cases of complete or incomplete cleft palate, fistula rate was low (6.7%), which the authors suggest was due to the low tension of the sutured nasal lining with the released lateral pharyngeal wall.

Analysis of the Intrinsic Predictors of Oronasal Fistula in Primary Cleft Palate Repair Using Intravelar Veloplasty

Introduction:

The purpose of the present study was to investigate various factors of cleft palate and to analyze their effect on fistula occurrence following palatal muscle repair using intravelar veloplasty.

Methods:

A retrospective review of patients who underwent palatoplasty was performed. Primary palatoplasty was performed by a single surgeon in a single center. A total of 165 patients who underwent palatoplasty were enrolled. Primary palatoplasty with levator veli palatini muscle repair using intravelar veloplasty was performed. Three extrinsic factors (age, gender, and body weight) and 6 intrinsic factors (cleft width, ratio of cleft width to intermaxillary tuberosity distance, cleft anterior margin shape, uvula position, cleft lip, and radical intravelar veloplasty) were analyzed.

Results:

Palatal fistula occurred in 11 (6.67%) patients. The occurrence of fistula was significantly correlated with a specific Veau classification, that is, type II ( P = .041). Fistula tended to occur more frequently with a wide cleft palate ( P = .063), and the high-risk cutoff value of the width was 7.75 mm.

Conclusions:

A larger cleft width tended to increase the occurrence of fistula. Close observation and information about the higher risk of fistula formation should be given to patients with a large cleft width who underwent intravelar veloplasty.

Early outcomes of cleft and palatal width following anterior palate repair (vomerine flap) in infants with wide cleft lip and palate

Background

Anterior palatal repair performed during cleft lip repair using a vomerine flap may assist in recruiting additional soft tissue for subsequent completion of palatoplasty, especially in patients with a wide cleft. We present our early results in the hope of triggering a re-evaluation of this technique regarding its advantages for maxillary growth through further studies of patients with a wide cleft.

Methods

A retrospective analysis of patients with complete unilateral and bilateral cleft lip and palate was performed, including cleft and palatal measurements taken during initial surgery (lip repair together with anterior palate repair) and upon completion of palatoplasty.

Results

In total, 14 patients were included in this study, of whom nine (63.3%) had unilateral cleft lip and palate and five (37.5%) had bilateral cleft. All patients had a wide cleft palate. Lip and anterior palate repair was done at a median age of 3 months, while completion of palatoplasty was done at a median age of 10.5 months. Measurements taken upon completion of palatoplasty showed significant cleft width reduction in the mid-palate and intertubercle regions; however, the palatal arch distances at nearby landmarks showed non-significant marginal changes.

Conclusions

Anterior palate repair using a vomerine flap significantly reduced the remaining cleft width, while the palatal width remained. Further research is warranted to explore the long-term effects of this technique in wide cleft patients in terms of facial growth.

Reconstruction of a Huge Residual Palatal Cleft

Closure of large oronasal fistula (ONF) in cleft patients is a challenge for patients and surgeons. The extent of functional impairment has psychologic, social, and developmental consequences. The ONF affects the feeding and speech of patients. Keys to repairing fistulas in this region are a 2-layer, tension-free closure, and an attentive suturing technique. In this article, the details and effectiveness of 2-flap palatoplasty are presented.

The Pushback Pharyngeal Flap: An 18-Year Experience

BACKGROUND

The pharyngeal flap is one of the oldest and most popular techniques for correction of velopharyngeal insufficiency. The authors describe a large series using a technique that combines a pharyngeal flap with a palate pushback to avoid common causes of operative failure while restoring the velopharyngeal mechanism.

METHODS

A retrospective cohort study was performed of patients who underwent a pushback pharyngeal flap by a single surgeon from 2000 to 2017. All patients had a preoperative nasoendoscopy diagnostic of velopharyngeal insufficiency. Operative technique involved elevation of the hard palate mucosa through a retroalveolar incision, passage of the flap through the nasopharyngeal mucosa opening, and inset with sutures through the hard palate mucosa.

RESULTS

There were 40 patients with a median age of 9.7 years. Preoperative closure patterns were predominately coronal (85.7 percent), with poor posterior wall motion and an average gap size of 27.5 mm. Postoperative complications included flap dehiscence (n = 1), transient dysphagia (n = 2), obstructive sleep apnea (n = 4), and a palatal fistula and/or persistent velopharyngeal insufficiency that required further surgery (n = 6). At an average of 2.5 years postoperatively, 91.7 percent of patients achieved adequate velopharyngeal function, with significant improvements in the majority of speech metrics (p < 0.001).

CONCLUSIONS

The pushback pharyngeal flap is a safe and effective technique for treatment of velopharyngeal insufficiency. Advantages include high, secure inset with prevention of palatal scar contracture and shortening.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Influence of Infant Cleft Dimensions on Velopharyngeal Function in 5-Year-Old Danish Children Born With Unilateral Cleft Lip and Palate

Aim:

To examine the association of cleft severity at infancy and velopharyngeal competence in preschool children with unilateral cleft lip and palate operated with early or delayed hard palate repair.

Design:

Subgroup analysis within a multicenter randomized controlled trial of primary surgery (Scandcleft).

Setting:

Tertiary health care. One surgical center.

Patients and Methods:

One hundred twenty-five infants received cheilo-rhinoplasty and soft palate repair at age 3 to 4 months and were randomized to hard palate closure at age 12 or 36 months. Cleft size and cleft morphology were measured 3 dimensionally on digital models, obtained by laser surface scanning of preoperative plaster models (mean age: 1.8 months).

Main outcome measurements:

Velopharyngeal competence (VPC) and hypernasality assessed from a naming test (VPC-Sum) and connected speech (VPC-Rate). In both scales, higher scores indicated a more severe velopharyngeal insufficiency.

Results:

No difference between surgical groups was shown. A low positive correlation was found between posterior cleft width and VPC-Rate (Spearman = .23; P = .025). The role of the covariate “cleft size at tuberosity level” was confirmed in an ordinal logistic regression model (odds ratio [OR] = 1.17; 95% confidence interval [CI]:1.01-1.35). A low negative correlation was shown between anteroposterior palatal length and VPC-Sum (Spearman = −.27; P = .004) and confirmed by the pooled scores VPC-Pooled (OR = 0.82; 95% CI: 0.69-0.98) and VPC-Dichotomic (OR = 0.82; 95% CI: 0.68-0.99).

Conclusions:

Posterior cleft dimensions can be a modest indicator for the prognosis of velopharyngeal function at age 5 years, when the soft palate is closed first, independently on the timing of hard palate repair. Antero-posterior palatal length seems to protect from velopharyngeal insufficiency and hypernasality. However, the association found was significant but low.

The Impact of Presurgical Infant Orthopedics on Oronasal Fistula Rates Following Cleft Repair: A Meta-Analysis

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.

Cleft Palate Repair: Description of an Approach, Its Evolution, and Analysis of Postoperative Fistulas

BACKGROUND

Fistulas following cleft palate repair impair speech, health, and hygiene and occur in up to 35 percent of cases. The authors detail the evolution of a surgical approach to palatoplasty; assess the rates, causes, and predictive factors of fistulas; and examine the temporal association of modifications to fistula rates.

METHODS

Consecutive patients (n = 146) undergoing palatoplasty during the first 6 years of practice were included. The technique of repair was based on cleft type, and a common surgical approach was used for all repairs.

RESULTS

The fistula rate was 2.4 percent (n = 125) after primary repair and 0 percent (n = 21) after secondary repair. All complications occurred in patients with type III or IV clefts. Cleft width and cleft-to-total palatal width ratio were associated with fistulas, whereas syndromes, age, and adoption were not. Most complications could also be attributed to technical factors. During the first 2 years, modifications were made around specific anatomical features, including periarticular bony hillocks, maxillopalatine suture, velopalatine pits, and tensor insertion. The fistula rate declined by one-half in subsequent years.

CONCLUSIONS

The authors describe a surgical approach to cleft palate repair, its evolution, and surgically relevant anatomy. Fistulas were associated with increasing cleft severity but could also be attributed to technical factors. A reduction in frequency and severity of fistulas was consistent with a learning curve and may in part be associated with modifications to the surgical approach.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.