Flap Necrosis after Palatoplasty in Patients with Cleft Palate

Managing massive palatial defect secondary to palatoplasty failures: an in-depth analysis

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.

Comorbidity and Operative Time are Stronger Predictors than Age for Palatoplasty Adverse Airway Events, A NSQIP-P Study of 6668 Cases

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.

Eco-friendly synthesis of mesoporous bioactive glass ceramics and functionalization for drug delivery and hard tissue engineering applications

Hard tissue regenerative mesoporous bioactive glass (MBG) has traditionally been synthesized using costly and toxic alkoxysilane agents and harsh conditions. In this study, MBG was synthesized using the cheaper reagent SiO2by using a co-precipitation approach. The surface properties of MBG ceramic were tailored by functionalizing with amino and carboxylic groups, aiming to develop an efficient drug delivery system for treating bone infections occurring during or after reconstruction surgeries. The amino groups were introduced through a salinization reaction, while the carboxylate groups were added via a chain elongation reaction. The MBG, MBG-NH2, and MBG-NH-COOH were analyzed by using various techniques: x-ray diffraction (XRD), Fourier transform infrared spectroscopy (FTIR), Brunauer-Emmett-Teller (BET), scanning electron microscopy and energy-dispersive x-ray spectroscopy. The XRD results confirmed the successful preparation of MBG, and the FTIR results indicated successful functionalization. BET analysis revealed that the prepared samples were mesoporous, and functionalization tuned their surface area and surface properties. Cefixime, an antibiotic, was loaded onto MBG, MBG-NH2, and MBG-NH-COOH to test their drug-carrying capacity. Comparatively, MBG-NH-COOH showed good drug loading and sustained release behavior. The release of the drug followed the Fickian diffusion mechanism. All prepared samples displayed favorable biocompatibility at higher concentration in the Alamar blue assay with MC3T3 cells and exhibited the good potential for hard tissue regeneration, as carbonated hydroxyapatite formed on their surfaces in simulated body fluid.

Modified Medial Incision Small Double-Opposing Z-Plasty for Treating Veau Type I Cleft Palate: Is the Early Result Reproducible?

OBJECTIVE

An inspiring early result with no oronasal fistula formation was recently described for a modified medial incision small double-opposing Z-plasty (MIsDOZ) for treating Veau type I cleft palate. This study describes an early single-surgeon experience in applying this newly proposed surgical approach.

DESIGN

Retrospective single-surgeon study.

PATIENTS

Consecutive nonsyndromic patients (n  =  27) with Veau I cleft palate.

INTERVENTIONS

Topographic anatomical-guided MIsDOZ palatoplasty with pyramidal space dissection (releasing of the ligamentous fibers in the greater palatine neurovascular bundle and pyramidal process region, in-fracture of the pterygoid hamulus, and widening of space of Ernst) performed by a novice surgeon (RD).

MEAN OUTCOME MEASURES

Age at surgery, the presence of cleft lip, palatal cleft width, use of lateral relaxing incision, and 6-month complication rate (bleeding, dehiscence, fistula, and flap necrosis). A published senior surgeon-based outcome dataset (n  =  24) was retrieved for comparison purposes.

RESULTS

Twenty-two (81.5%) and 5 (18.5%) patients received the medial incision only technique and lateral incision technique, respectively (P  =  .002). Age, presence of cleft lip, and cleft width were not associated (all P > .05) with the use of lateral incision. Comparative analysis between the novice surgeon- and senior surgeon-based datasets revealed no significant differences for sex (females: 74.1% vs 62.5%; P  =  .546), age (10.2  ±  1.7 vs 9.6  ±  1.2 months; P  =  .143), rate of lateral incision (18.5% vs 4.2%; P  =  .195), and postoperative complication rate (0% vs 0%).

CONCLUSION

This modified DOZ palatoplasty proved to be a reproducible procedure for Veau I cleft palate closure, with reduced need for lateral incision and with no early complication.

The use of surgical template for palatal fistula repair in cleft palate using tongue flap: 3 case report

INTRODUCTION AND IMPORTANCE

The occurrence of a palatal fistula after surgical correction in a cleft palate patient is the most common complication in cleft palate surgery. This condition might be due to poor tissue quality and vascularity, an error in the surgical technique, the size of the defect, the age of the patient, and infection.

CASE PRESENTATION

Three patients with fistula in the anterior and mid-palate regions asked for correction. In past history, all cases had received multiple surgical corrections, and the result showed with recurrent fistula.

DISCUSSION

Surgical interventions for correction of palatal fistula might be difficult as the surrounding tissue has lost its quality, especially in secondary surgery or after multiple surgical interventions. Flap taken from the tongue can be chosen as an alternative source to close the fistula based on the consideration that the tongue has a favourable position, and located as the nearest tissue directly opposite to the palatal region, and has good vascularity. The aim of this report is to show the advantages of the use a surgical template made from alumina foil to measure the size and shape of the flap in accordance with the form and size of existed fistula. The surgical template was used as a guidance during drawn the design of the flap on the surface of the tongue.

CONCLUSION

The use of surgical templates was very useful as guidance during the marking procedure on the surface of the tongue for designing an individual tongue flap form.

Flap Necrosis Associated With Furlow's Palatoplasty

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.

Cleft Palate Fistula: A Review

Background

The development of postoperative oronasal fistulae (ONF) is a complication that plagues all cleft surgeons to varying degrees. There is extensive literature discussing the incidence, functional impact, and treatment of ONF. The goal of this article is to provide an extensive review of the literature discussing the incidence, causative factors, functional impact, classification systems, and treatment of ONF.

Methods

A literature review was performed using PubMed using the Medical Subject Heading terms "cleft palate" AND "fistula" OR "palatal fistula" OR "oronasal fistula". After review, a total of 356 articles were deemed relevant for this study.

Results

Information regarding ONF care, prevention, and management in patients with cleft palate was collected from the articles included in this review. Treatment of ONF remains a challenging problem as there is not a consensus in the available literature on the best palatoplasty techniques for their prevention and treatment. A myriad of reconstructive options and adjunctive therapies exist, and their use is guided by the size and location of the fistula.

Conclusions

Fistula treatment should be tailored to the specific needs of the patient, and consideration must be given to not only the ONF itself but also the patient's stage of growth and development. Large-scale, multicenter studies are needed in which ONF are described using standardized nomenclature, and improved outcomes reporting is necessary to better define an algorithm for a truly holistic approach to palate surgery and reduce the incidence of palatal fistula.

Exploration of the Influences of Temporary Velum Paralysis on Auditory-Perceptual, Acoustic, and Tomographical Markers

Purpose To better understand hypernasality (HN), we explored the relations between velopharyngeal orifice, auditory perception of HN, and acoustic-spectral measures in an in vivo within-subject design: (a) with a normally functioning velum as the control condition and (b) with a temporarily paralyzed velum as the experimental condition. Method The velum of eight volunteers was injected with ropivacaine hydrochloride (Naropin) in the area of the levator veli palatini and tensor veli palatini muscles to induce temporary velopharyngeal inadequacy (VPI) and HN. Sustained [a] and [i] and oronasal text readings were recorded, and 3D cone-beam computed tomography images of the vocal tract were built before and during velar anesthesia. Differences between conditions and correlations in normal-to-numb differences between velopharyngeal cross-sectional area (VP_area), mean ratings of HN severity, and nine acoustic-spectral measures were determined. Results Three subjects already had some incomplete velopharyngeal closure in the control condition. Temporary motor nerve blockage of the velum (increased VP_area) was accomplished in seven subjects, leading to increased HN and changes in three acoustic-spectral measures. Furthermore, significant correlations only emerged between VP_area, HN, and Model_Kataoka. Conclusions In most of the participants, it was possible to temporarily increase the velopharyngeal orifice to investigate HN while controlling other speech variables and cephalic morphology. Although this study was exploratory and its are findings preliminary, it provided additional evidence for the possible clinical value of Model_Kataoka, A ₃-P ₀, and B _F1 for the objective measurement of VPI or HN.

Facial Artery Musculomucosal Flap in Alveolar Cleft Surgery

INTRODUCTION

Large anterior palatal fistula and special alveolar clefts, such as edentulous atrophic premaxilla and absent premaxilla (premaxillectomy or agenesis), as well as wide unilateral alveolar cleft, are complicated cases in alveolar cleft bone grafting surgery. A superiorly-based buccinator myomucosal flap is suitable in this regard.

MATERIALS AND METHODS

The cleft patients whose large anterior palatal fistula and superiorly based buccinator myomucosal flap had been used for palatal or alveolar reconstruction were recruited in the study. The reconstruction method of the nasal floor, follow-up time, and hospital length of stay were recorded.

RESULTS

A total of 10 patients had been treated by this method. The majority of them were male (6/10), the age range of the patients was 14-25 years. All flaps survived and a case of partial necrosis occurred.

CONCLUSION

As evidenced by the obtained results, a superiorly-based facial artery musculomucosal flap is suitable when the palatal fistula is continuous with the alveolar cleft. Transmaxillary transfer is the other option in patients with closed maxillary arch.

The Lima Surgical Protocol for Cleft Palate Repair

BACKGROUND

A cleft team experience addressing non-syndromic cleft palate and cleft lip and palate is presented. The purpose of the present study is to compare surgical outcomes using 2 different protocols for cleft palate repair provided by a cleft team in Lima, Perú.

METHODS

This is a comparative study between 2 groups of patients with non-syndromic cleft palate who were operated using different surgical protocols from 1999 to 2014. One hundred twenty-four children with non-syndromic isolated cleft palate and cleft lip and palate treated from 2007 to 2014 using a surgical protocol developed by our cleft team in Lima, Perú were compared with 145 children with cleft palate and cleft lip and palate treated by the same team using different protocol from 1999 to 2007. Data collection was accomplished by evaluation of symptomatic oronasal fistulas, presence of velopharyngeal insufficiency (VPI) and postoperative complications.

RESULTS

Statistical significant differences were observed between the 2 groups regarding the development of flap necrosis in favor of the Lima protocol. No significant difference in palatal fistula and VPI rate between the 2 protocols was found.

CONCLUSIONS

The Lima Surgical Protocol for cleft palate repair is an alternative strategy which uses the strengths of different surgical techniques based on the severity of the cleft. We observed better surgical outcomes using the Lima protocol with regards to postoperative complications in patients with non-syndromic cleft palate.

Perioperative Management in Patients With Cleft Lip and Palate

In cleft care, perioperative treatment strategies like ear nose and throat (ENT) diagnostics as well as postoperative antibiotics, feeding, and duration of inpatient stay are nonstandardized procedures varying between different centers. Likewise, intraoperative choice of suture materials and time of suture removal are performed inconsistently. Therefore, we wanted to collect information on protocols focusing on these topics to summarize and subsume currently approved treatment strategies of centers around the world. We ask members of international cleft centers for their respective treatment strategies and performed descriptive statistics.Absorbable suture material is used for reconstruction of the outer lip skin in 20 of 70 centers. Removal of skin sutures is conducted after 7.0 ± 1.5 days. Suturing of the orbicularis oris muscle, the enoral and nasal mucosa, as well as the palatal musculature is predominantly performed with absorbable suture materials. Intraoperative antibiotic prophylaxis is applied in 82.9% of the participating centers. In contrast, 31.9% of the departments do not apply any antibiotic postoperatively. Postoperative feeding is performed in 27 centers via a nasogastric tube for 4.6 ± 2.3 days on average. Mean length of postoperative inpatient stay is 4.1 ± 2.6 days in children after cleft lip surgery and 4.5 ± 2.7 days after cleft palate surgery. ENT consultation before surgery is routinely conducted in 52.8% of the centers and 82.9% of ENT colleagues investigate middle ear pathologies in the same operation in which cleft repair is performed.Closure of the lip skin is predominantly performed with nonabsorbable suture material followed by a suture removal after 1 week. Intraoperative antibiotic prophylaxis as well as inpatient hospital stay of 4 to 5 days in combination with oral feeding and a preoperative consultation and intraoperative cooperation with the ENT department seems to be well-proven concepts in cleft lip palate patient care. However, this analysis illustrated the variations and differing approaches in perioperative care emphasizing the need to verify perioperative management concepts in cleft surgery-preferably in the context of multicenter studies.

Predictors affecting anterolateral thigh flap in reconstruction of upper extremity

Our study is aim to explore predictors for failure of anterolateral thigh (ALT) flap in the reconstruction of upper extremity.We performed a retrospective study for 509 patients who underwent ALT flap in the reconstruction of upper extremity. Among them, 27 patients suffered from necrosis of ALT flap (necrosis group, NG) and 482 gained survival of this flap (survival group, SG). We collected possible factors including 3 aspects: demographic variables - age, sex, body mass index (BMI), history of hypertension, diabetes, heart disease, smoking and alcohol, trauma mechanism, and postmenopausal; surgical-related variables - surgical duration, blood loss, number of reconstructed veins, flap size, perforator type, diameter of perforator, and vein graft; blooding variables - hemoglobin, D-dimer, white blood cell, red blood cell, and platelet count (PLT). We compared the above data between NG and SG by univariate, multivariate, and Kaplan-Meier method coupled with a log-rank test linear regression analysis.The survival incidence of ALT flap repairing upper extremity was 94.7% (482 of 509). The outcome of univariate analysis showed that age (53.5 ± 9.2), BMI (26.7 ± 4.5), larger flap size (24.3*9.2), D-dimer (0.58 ± 0.10), and PLT (278.1 ± 34.4) in NG were significantly higher than these (44.2 ± 7.9, 22.3 ± 4.2, 19.1*7.9, 0.48 ± 0.08, 236.6 ± 30.5) in SG. However, diameter of perforator (1.07 ± 0.02) in NG was markedly smaller than that (1.12 ± 0.02) in SG. Additionally, female patients, postmenopausal, patients with using venous stapler or 1 reconstructed vein had a higher failure rate. Multivariate and Kaplan-Meier method implied the same results.In summary, many factors were related with failure of ALT in the reconstruction of upper extremity. Postmenopausal, D-dimer, and PLT were the first considered as risk factors for ALT flap repairing upper extremity.

Double palatal flap for oro-nasal fistula closure

INTRODUCTION

The management of oral fistula to the nose depends on its etiology, its size and its location. Here, we describe a simple technique, inspired by the ones initially developed by Bardach for cleft palates repair. The surgical alternatives are discussed.

TECHNICAL NOTE

The double palatal flap is a simple technique, allowing closure in a single session of a central or centro-lateral palate fistula. The key of this technique is the dissection between nasal and palate mucous layers, providing a sufficient amount of laxity to close the defect without tension.

DISCUSSION

The double palatal flap can cover centro-lateral palate mucosal fistulae. It provides both aesthetic and functional results in a single stage. Reliability, simplicity and quickness are its main advantages. Outcomes are usually simple; Velar insufficiency may occur, that can be corrected by speech therapy.

Cleft Lip and Palate Repair Using a Surgical Microscope

Background

Cleft lip and palate repair requires a deep and small surgical field and is usually performed by surgeons wearing surgical loupes. Surgeons with loupes can obtain a wider surgical view, although headlights are required for the deepest procedures. Surgical microscopes offer comfort and a clear and magnification-adjustable surgical site that can be shared with the whole team, including observers, and easily recorded to further the education of junior surgeons. Magnification adjustments are convenient for precise procedures such as muscle dissection of the soft palate.

Methods

We performed a comparative investigation of 18 cleft operations that utilized either surgical loupes or microscopy. Paper-based questionnaires were completed by staff nurses to evaluate what went well and what could be improved in each procedure. The operating time, complication rate, and scores of the questionnaire responses were statistically analyzed.

Results

The operating time when microscopy was used was not significantly longer than when surgical loupes were utilized. The surgical field was clearly shared with surgical assistants, nurses, anesthesiologists, and students via microscope-linked monitors. Passing surgical equipment was easier when sharing the surgical view, and preoperative microscope preparation did not interfere with the duties of the staff nurses.

Conclusions

Surgical microscopy was demonstrated to be useful during cleft operations.

Effects of Bisphosphonate Administration on Cleft Bone Graft in a Rat Model

OBJECTIVE

Bone grafts in patients with cleft lip and palate can undergo a significant amount of resorption. The aim of this study was to investigate the effects of bisphosphonates (BPs) on the success of bone grafts in rats.

DESIGN

Thirty-five female 15-week-old Fischer F344 Inbred rats were divided into the following experimental groups, each receiving bone grafts to repair an intraoral CSD: (1) Graft/saline: systemic administration of saline and (2) systemic administration of zoledronic acid immediately following surgery (graft/BP/T0), (3) 1 week postoperatively (graft/BP/T1), and (4) 3 weeks postoperatively (graft/BP/T2). As an additional control, the defect was left empty without bone graft.

MAIN OUTCOME MEASURES

Microcomputed tomography and histologic analyses were performed in addition to evaluation of osteoclasts through tartrate-resistant acid phosphatase staining.

RESULTS

Bone volume fraction (bone volume/tissue volume) for the delayed BP treatment groups (graft/BP/T1 = 45.4% ± 8.8%; graft/BP/T2 = 46.1% ± 12.4%) were significantly greater than that for the graft/saline group (31.0% ± 7.9%) and the graft/BP/T0 (27.6% ± 5.9%) 6 weeks postoperatively (P < .05). Hematoxylin and eosin staining confirmed an evident increase in bone volume and fusion of defect margins with existing palatal bone in the graft/BP/T1 and graft/BP/T2 groups. The graft/BP/T0 group showed the lowest bone volume with signs of acute inflammation.

CONCLUSIONS

Delayed BP administration following cleft bone graft surgery led to significant increase in bone volume and integration compared with saline controls. However, BP injection immediately after the surgery did not enhance bone volume, and rather, may negatively affect bone graft incorporation.