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Sakran KA, Huang H, Al-Moraissi E, Elayah SA, Younis H, Li Y, Shi B. Evaluation of postoperative outcomes in palatoplasty with three soft palate cleft repairs. Int J Oral Maxillofac Surg 2024; 53:677-685. [PMID: 38331640 DOI: 10.1016/j.ijom.2024.01.012] [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] [Received: 06/01/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/10/2024]
Abstract
The aim of this study was to compare the postoperative clinical and functional outcomes of palatoplasty with three soft palate cleft repairs and analyse the factors potentially impacting these outcomes. A retrospective analysis was conducted on a consecutive series of 337 patients who underwent primary cleft palate repair by palatoplasty modified with either Furlow Z-plasty (P-FZP, n = 77), intravelar veloplasty (P-IVV, n = 110), or combined intravelar veloplasty-Furlow Z-plasty (P-IVV-FZP, n = 150). The postoperative outcomes evaluated included wound healing (complete closure/fistula) and velopharyngeal function. Demographic and surgical data were analysed using both univariate and multivariate analysis. There was no significant difference between the groups with regard to the sex distribution, age at repair, cleft width, cleft type, or follow-up duration. However, relaxing incisions were significantly more common with P-FZP (26.0%) and P-IVV (29.1%) compared to P-IVV-FZP (10%) (P = 0.002 and <0.001, respectively). The complete wound closure rate was significantly higher with P-IVV-FZP (97.3%) compared to P-FZP (88.3%) (P = 0.012) and P-IVV (90%) (P = 0.015). The normal velopharyngeal function rate was comparable for P-IVV-FZP (86.7%) and P-FZP (83.1%), and both rates were significantly better than the rate with P-IVV (73.6%) (P = 0.039 and 0.029, respectively). The cleft type and width were identified as factors influencing postoperative outcomes. In conclusion, it may be appropriate to prioritize the palatoplasty with combined intravelar veloplasty-Furlow Z-plasty whenever feasible.
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Affiliation(s)
- K A Sakran
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China; Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - H Huang
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - E Al-Moraissi
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Thamar University, Thamar, Yemen
| | - S A Elayah
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China; Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - H Younis
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Y Li
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China.
| | - B Shi
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
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Hattori Y, Lo CC, Chen YJ, Saito T, Chou PY, Lu TC, Chang CS, Lo LJ. Comparison of modified Furlow palatoplasty using small double-opposing Z-plasty and conventional Furlow palatoplasty: A long-term outcome study. J Plast Reconstr Aesthet Surg 2024; 93:261-268. [PMID: 38723512 DOI: 10.1016/j.bjps.2024.04.058] [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] [Received: 10/20/2023] [Revised: 04/02/2024] [Accepted: 04/21/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND The aim of palatoplasty is to create a functional palate to achieve normal speech, while minimizing post-operative complications. This study aimed to compare the long-term outcomes of modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ) and conventional Furlow palatoplasty (conventional-DOZ) performed in a single center. METHODS A retrospective review of consecutive patients who underwent Furlow palatoplasty between May 2007 and March 2014 was executed. Non-syndromic patients subjected to palatoplasty prior to 24 months of age and followed-up until at least 9 years of age were included. RESULTS A total of 196 small-DOZ and 280 conventional-DOZ palatoplasty patients were included in this study. Overall, 14 patients (2.9%) developed oronasal fistula, and 40 patients (8.4%) received velopharyngeal insufficiency (VPI) surgery. In comparisons, oronasal fistula rate was significantly higher in conventional-DOZ (0.5% vs. 4.6%, p = 0.01), and the VPI prevalence was not significantly different (9.2% vs. 7.9%, p = 0.62). Patients who developed fistula had a significantly higher likelihood of developing VPI than patients without oronasal fistula (50.0% vs. 7.1%, respectively; p < 0.01), with an odds ratio of 13.0. CONCLUSION Both modalities of palatoplasty yielded commendable velopharyngeal function in the long-term follow-up. The small-DOZ with reduced tension lowered the risk of oronasal fistula.
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Affiliation(s)
- Yoshitsugu Hattori
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Chin Lo
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Jen Chen
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Takafumi Saito
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Pang-Yun Chou
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Ting-Chen Lu
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chun-Shin Chang
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Lun-Jou Lo
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan.
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Phillips JB, Galarza LI, Sink MC, Goza SD, Brown MI, Hopper SJ, Brown KW, Fernstrum CJ, Hoppe IC, Humphries LS. Longitudinal Speech and Fistula Outcomes Following Primary Cleft Palate Repair at a Single Institution. Ann Plast Surg 2024; 92:S404-S407. [PMID: 38857004 DOI: 10.1097/sap.0000000000003957] [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: 06/11/2024]
Abstract
INTRODUCTION Fistula formation and velopharyngeal insufficiency (VPI) are complications of cleft palate repair that often require surgical correction. The goal of the present study was to examine a single institution's experience with cleft palate repair with respect to fistula formation and need for surgery to correct velopharyngeal dysfunction. METHODS Institutional review board approval was obtained. Patient demographics and operative details over a 10-year period were collected. Primary outcomes measured were development of fistula and need for surgery to correct VPI. Chi-square tests and independent t tests were utilized to determine significance (0.05). RESULTS Following exclusion of patients without enough information for analysis, 242 patients were included in the study. Fistulas were reported in 21.5% of patients, and surgery to correct velopharyngeal dysfunction was needed in 10.7% of patients. Two-stage palate repair was associated with need for surgery to correct VPI (P = 0.014). Furlow palatoplasty was associated with decreased rate of fistula formation (P = 0.002) and decreased need for surgery to correct VPI (P = 0.014). CONCLUSION This study reiterates much of the literature regarding differing cleft palate repair techniques. A 2-stage palate repair is often touted as having less growth restriction, but the present study suggests this may yield an increased need for surgery to correct VPI. Prior studies of Furlow palatoplasty have demonstrated an association with higher rates of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be due to the use of the Children's Hospital of Philadelphia modification. This study suggests clinically superior outcomes of the Furlow palatoplasty over other techniques.
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Affiliation(s)
- John B Phillips
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | | | - Matthew C Sink
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Shelby D Goza
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Madyson I Brown
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Samuel J Hopper
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
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Jing B, Yang C, Tsauo C, Low DW, Tao H, Shi B, Zheng Q, Li C. Evaluation of Secondary Alveolar Bone Grafting for Unilateral Complete Cleft Alveolus: A Retrospective Cone Beam Computed Tomography-Based Study. Facial Plast Surg Aesthet Med 2024. [PMID: 38621184 DOI: 10.1089/fpsam.2023.0257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Background: In patients with cleft lip and palate (CLP), secondary alveolar bone grafting (SABG) with particulate cancellous bone marrow (PCBM) is recommended. Objective: To compare bone graft outcomes in patients with unilateral CLP, when SABG is completed before or after canine tooth eruption (ACE or BCE), as measured by cone beam computed tomography (CBCT). Methods: Patients were allocated into two cohorts, ACE and BCE. The outcomes were evaluated using CBCT, followed by univariate and multifactorial analyses. Results: A total of 468 patients (age 11.61 ± 4.03 years; male/female 288/180) were analyzed, including 282 in the BCE group (9.41 ± 1.59 years, 175/107) and 186 in the ACE group (14.95 ± 4.31 years, 113/73). Although 5-level assessment revealed no significant difference in clinical success rate (>4 points) between the BCE and ACE groups (53.90% vs. 47.85%, p = 0.20), BCE group showed significantly higher rate of bone bridges formation (73.05% vs. 62.90%, p = 0.02), which can be attributed to variations in orthodontic participation and follow-up time. Independent predictors of graft failure were wide cleft, severe oronasal fistula, no palatal bone wall, and insufficient PCBM filling (p < 0.01). Conclusions: SABG should be performed before canine eruption with more aggressive PCBM filling and oral fistula management.
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Affiliation(s)
- Bingshuai Jing
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Chao Yang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Chialing Tsauo
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - David W Low
- Division of Plastic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hongxu Tao
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Qian Zheng
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Chenghao Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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Sakran KA, Yin J, Yang R, Elayah SA, Alkebsi K, Zhang S, Wang Y, Shi B, Huang H. Early Cleft Palate Repair by a Modified Technique Without Relaxing Incisions. Cleft Palate Craniofac J 2024; 61:646-653. [PMID: 36300250 DOI: 10.1177/10556656221135288] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
OBJECTIVE This study sought to evaluate a modified palatoplasty technique (MPT) concerning the postoperative outcomes and associated influencing factors. DESIGN A retrospective cohort study. PARTICIPANTS AND SETTING One hundred forty-three consecutive patients with non-syndromic cleft palate, who received MPT before one year of age within an oral and maxillofacial surgery department of a university-affiliated tertiary hospital between 2011-2017, were reviewed. MAIN MEASURES The postoperative wound healing and velopharyngeal function (VPF) were the primary outcome measures. The sex, age at surgery, cleft type, cleft width, palatal width, soft palate length, pharyngeal cavity depth, and operation duration were preselected as influencing factors. Univariate and multivariate analyses were conducted. RESULTS The mean age at surgery was 9 ± 1.31 months (5-11), and the average cleft width was 9.03 ± 2.41 mm (4-15). The rate of incomplete cleft palate was 84.6% while the complete cleft palate was 15.4%. Complete wound healing was reported in 96.5% while the others (3.5%) had persistent oronasal fistula. About 90.2% of cases have shown normal velopharyngeal function whereas the others (9.8%) had sustained velopharyngeal insufficiency. The wound healing appeared to be significantly impacted by cleft width and pharyngeal cavity depth (P = .015 and 0.049, respectively). However, none of the factors had a significant association with VPF. CONCLUSIONS The present modified palatoplasty technique has obtained a low fistula rate and appropriate speech outcome. Therefore, this MPT could be promoted for early repairing cleft palate of different severities.
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Affiliation(s)
- Karim Ahmed Sakran
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Jiayi Yin
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Renjie Yang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Eastern Clinic, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Sadam Ahmed Elayah
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Khaled Alkebsi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Shiming Zhang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yan Wang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Hanyao Huang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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Monte TM, Raposo-Amaral CA, Sabbag A, Gil A, Menezes PT, Raposo-Amaral CE. Speech Outcomes After Palatal Lengthening Via Double Opposing Buccinator Myomucosal Flaps. Ann Plast Surg 2024; 92:395-400. [PMID: 38527345 DOI: 10.1097/sap.0000000000003809] [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: 03/27/2024]
Abstract
BACKGROUND Palatal lengthening is becoming a first-line treatment choice for cleft patients with velopharyngeal insufficiency (VPI). As cleft palate-related surgical outcomes are age dependent, speech outcomes may be similarly affected by patient age at the time of treatment. The primary goal of this study is to determine whether there are age-related speech outcome differences when double opposing buccinator myomucosal flaps are used as part of a palatal lengthening protocol and whether these outcome differences preclude utilization of this technique for specific patient age groups. METHODS A retrospective study was performed on consecutive nonsyndromic patients with VPI who underwent treatment using double opposing buccinator myomucosal flaps at our hospital between 2014 and 2021. Patients who completed the 15-month follow-up were stratified by age. Group A aged between 2 and 7 years (n = 14), group B aged 8 and 18 years (n = 23), and group C aged older than 18 years (n = 25) were included. Standardized perceptual speech evaluations and nasopharyngoscopy were performed. Hypernasality, soft palate mobility, and lateral palatal wall mobility were assessed both preoperatively and at a 15-month postoperative interval. Complications were also recorded. The χ2 test was used for statistical comparison. RESULTS All of the age-stratified patient groups in this study showed significant improvement in hypernasality, soft palate mobility, and lateral wall mobility (P < 0.01), with no statistically significant differences between the different patient age groups. Overall speech success was achieved in 69.4% of patients. Patients in group A achieved 78.6% speech success, patients in group B achieved 78.3% speech success, and patients in group C achieved 56% speech success, with no statistically significant differences being shown regarding speech success between the different patient age groups (P > 0.05). CONCLUSIONS Regardless of age, palatal lengthening via double opposing buccinator myomucosal flaps similarly improves speech outcomes.
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Affiliation(s)
- Thais Miguel Monte
- From the Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, Brazil
| | - Cesar A Raposo-Amaral
- From the Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, Brazil
| | | | - André Gil
- From the Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, Brazil
| | - Priscila T Menezes
- From the Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, Brazil
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Rizzo MI, Cajozzo M, Bucci D, Pistoia A, Palmieri A, Rajabtork Zadeh O, Palmieri G, Spuntarelli G, Zama M. 25-year Follow-up of Primary Tibial Periosteal Graft for Hard Palate Repair in Cleft Lip and Palate: Outcomes, Concerns and Controversies. Cleft Palate Craniofac J 2024; 61:476-482. [PMID: 36250335 DOI: 10.1177/10556656221132043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
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.
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Affiliation(s)
- Maria Ida Rizzo
- Plastic and Maxillofacial Surgery Unit, Cleft and Craniofacial Center, Bambino Gesù Children's Hospital, Rome, Italy
| | - Marta Cajozzo
- Plastic and Maxillofacial Surgery Unit, Cleft and Craniofacial Center, Bambino Gesù Children's Hospital, Rome, Italy
| | - Daria Bucci
- Plastic and Maxillofacial Surgery Unit, Cleft and Craniofacial Center, Bambino Gesù Children's Hospital, Rome, Italy
| | - Angelica Pistoia
- Plastic and Maxillofacial Surgery Unit, Cleft and Craniofacial Center, Bambino Gesù Children's Hospital, Rome, Italy
| | - Annapina Palmieri
- Department of Cardiovascular, Endocrine-metabolic Diseases and Aging, National Institute of Health, Rome, Italy
| | - Oriana Rajabtork Zadeh
- Plastic and Maxillofacial Surgery Unit, Cleft and Craniofacial Center, Bambino Gesù Children's Hospital, Rome, Italy
| | - Giancarlo Palmieri
- Plastic and Maxillofacial Surgery Unit, Cleft and Craniofacial Center, Bambino Gesù Children's Hospital, Rome, Italy
| | - Giorgio Spuntarelli
- Plastic and Maxillofacial Surgery Unit, Cleft and Craniofacial Center, Bambino Gesù Children's Hospital, Rome, Italy
| | - Mario Zama
- Plastic and Maxillofacial Surgery Unit, Cleft and Craniofacial Center, Bambino Gesù Children's Hospital, Rome, Italy
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Hattori Y, Tu JCY, Chou PY, Lo LJ. Two-flap technique with interpositional dermofat graft for anterior oronasal fistula closure in patients with cleft: A case series. J Plast Reconstr Aesthet Surg 2024; 90:51-59. [PMID: 38359499 DOI: 10.1016/j.bjps.2024.01.012] [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] [Received: 07/01/2023] [Revised: 11/28/2023] [Accepted: 01/29/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Oronasal fistula at the anterior hard palate is one of the common sequelae after cleft surgery, and the leakage negatively affects the patient's quality of life. Although several surgical techniques have been proposed for reconstruction, it remains challenging because of the scarred regional tissue with a high rate of fistula recurrence. In this study, we present the anterior oronasal fistula repair using a two-flap technique with an interpositional dermofat graft (DFG). METHODS A retrospective review of anterior oronasal fistula repair performed by the senior author between April 2018 and August 2022 at the Craniofacial Center was conducted. Patients who underwent a fistula repair using the technique were further identified and investigated. RESULTS Thirty-four operations were performed using the technique, and 31 fistulas were completely closed, with a success rate of 91.2%. The fistula symptom improved but persisted postoperatively in 3 patients, of whom 2 patients underwent a second fistula repair using the same procedure, resulting in successful closure. Fistula recurrence was significantly correlated with fistula size (p = 0.04). The DFG was simultaneously utilized for nasal dorsum and/or vermillion reconstruction in 28 cases. CONCLUSION The two-flap technique enabled tension-free approximation, and the interpositional DFG facilitated watertight closure of the fistula, resulting in a high success rate of anterior oronasal fistula repair. The fistula closure could be combined with other revisional procedures for cleft-related deformities, where the DFG was simultaneously utilized.
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Affiliation(s)
- Yoshitsugu Hattori
- Craniofacial Center, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Junior Chun-Yu Tu
- Craniofacial Center, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Pang-Yun Chou
- Craniofacial Center, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Lun-Jou Lo
- Craniofacial Center, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Dental and Craniofacial Science, Chang Gung University, Taoyuan, Taiwan.
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Houkes RP, Smit JA, Lachkar N, Tse R, Breugem CC. Unraveling a Major Burden of Orofacial Clefts Analyses: Classification of Cleft Palate Fistulas by Cleft Surgeons. Cleft Palate Craniofac J 2024; 61:508-512. [PMID: 36594232 PMCID: PMC10893769 DOI: 10.1177/10556656221149521] [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: 01/04/2023] Open
Abstract
OBJECTIVE The objective of this study was to investigate how cleft surgeons classify palatal fistulas. We focused on three different anatomical locations (ie, hard palate, soft palate, junction hard/soft palate) to analyze agreement/disagreement at various anatomical locations. DESIGN Cross-sectional survey study. PARTICIPANTS Participants in an international webinar that focused on palatal fistula treatment were included. INTERVENTION Participants were presented with a survey pre- and post-webinar. MAIN OUTCOMES Frequency of used classification systems for classifying oronasal fistulas and the inter-rater reliability of the Pittsburgh classification system. RESULTS A total of 141 participants completed the questionnaires prior to the webinar and 109 participants completed the survey after the webinar. In total, four classification systems were used (ie, Pittsburgh, Pakistan Comprehensive Fistula Classification [PCFC], anatomical and 'other'). The Pittsburgh classification was the most commonly used system in all cases. However, Pittsburgh inter-rater reliability was low (κ = 0.136 pre-webinar, and κ = 0.174 post-webinar). Surprisingly, a substantial shift was observed from the anatomical to Pittsburgh classification after the webinar, indicating increased awareness of the usability of the Pittsburgh classification system. CONCLUSIONS This study demonstrates a large heterogeneity with regards to the classification of cleft palate fistulas. Interestingly, a shift was observed from the anatomical to Pittsburgh classification after the webinar. However, the inter-rater reliability for using the Pittsburgh classification was low. Classifying palatal fistulas in a homogenous fashion could enhance comparison of primary palate repair and could improve treatment of palatal fistulas.
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Affiliation(s)
- Ruben P. Houkes
- Dept. of Plastic Surgery, Amsterdam UMC, location University of Amsterdam, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Johannes A. Smit
- Dept. of Plastic Surgery, Amsterdam UMC, location University of Amsterdam, Emma Children's Hospital, Amsterdam, The Netherlands
| | - N. Lachkar
- Dept. of Plastic Surgery, Amsterdam UMC, location University of Amsterdam, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Raymond Tse
- Dept. of Plastic Surgery, Seattle Children's Hospital, Seattle, USA
| | - Corstiaan C. Breugem
- Dept. of Plastic Surgery, Amsterdam UMC, location University of Amsterdam, Emma Children's Hospital, Amsterdam, The Netherlands
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Davies A, Davies A, Main B, Wren Y, Deacon S, Cobb A, McLean N, David D, Chummun S. Association of Perioperative Antibiotics with the Prevention of Postoperative Fistula after Cleft Palate Repair. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5589. [PMID: 38322814 PMCID: PMC10846777 DOI: 10.1097/gox.0000000000005589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/27/2023] [Indexed: 02/08/2024]
Abstract
Background There is debate amongst surgeons regarding the use of antibiotics to prevent fistulae after palatoplasty. Prescribing should be evidence based, as antibiotic stewardship is integral to reducing antibiotic resistance. Our aim was to determine whether differing perioperative regimens affect the prevalence of postoperative fistulae. Methods The sample comprised participants from the Cleft Collective who had undergone palatoplasty. Participants were recruited across all 16 UK cleft centers between 2013 and 2021. The exposure was perioperative antibiotic regimen prescribed at the time of palatoplasty. The primary outcome was the presence of palatal fistula. Results Fistula data were available for 167 participants when exploring antibiotic regimen and for 159 when exploring antibiotic agent. There was no evidence to suggest a difference in fistula rate between those receiving antibiotics on induction only versus as an inpatient or up to 7 days postoperatively (χ2 = 4.57; P = 0.10). There was no evidence to suggest a difference in fistula rate between those who received co-amoxiclav and those who had an alternative antibiotic (χ2 = 0.16; P = 0.69). Postoperative fistulae increased with the extent of the cleft (χ2 = 20.39; P < 0.001). When adjusting for cleft type, no evidence of an association between antibiotic regimen and fistulae was found (inpatient antibiotics: OR 1.36; 95% confidence interval, 0.53-3.51; antibiotics up to 7 days postoperatively: OR 0.68; 95% confidence interval, 0.26-1.80). Conclusions The choice of antibiotic and dosing regimen does not influence the formation of postoperative fistulae. These results should be supported by interventional trials.
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Affiliation(s)
- Alex Davies
- From the South West Cleft Service, Bristol Dental Hospital, Bristol, United Kingdom
- The Cleft Collective, Bristol Dental School, University of Bristol, Bristol, United Kingdom
| | - Amy Davies
- The Cleft Collective, Bristol Dental School, University of Bristol, Bristol, United Kingdom
- Bristol Dental School, University of Bristol, Bristol, United Kingdom
| | - Barry Main
- Bristol Dental School, University of Bristol, Bristol, United Kingdom
- Oral and Maxillofacial Surgery, Bristol Dental Hospital, Bristol, United Kingdom
| | - Yvonne Wren
- The Cleft Collective, Bristol Dental School, University of Bristol, Bristol, United Kingdom
- Bristol Dental School, University of Bristol, Bristol, United Kingdom
| | - Scott Deacon
- From the South West Cleft Service, Bristol Dental Hospital, Bristol, United Kingdom
| | - Alistair Cobb
- From the South West Cleft Service, Bristol Dental Hospital, Bristol, United Kingdom
| | - Neil McLean
- Craniofacial Australia, North Adelaide, Australia
| | - David David
- Craniofacial Australia, North Adelaide, Australia
| | - Shaheel Chummun
- From the South West Cleft Service, Bristol Dental Hospital, Bristol, United Kingdom
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11
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Raposo-Amaral CA, Monte TM, Raposo-Amaral CE. Treatment of Velopharyngeal Insufficiency Using Bilateral Myomucosal Buccinator Flaps. Plast Reconstr Surg 2024; 153:411e-414e. [PMID: 37053444 DOI: 10.1097/prs.0000000000010551] [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: 04/15/2023]
Abstract
SUMMARY The buccinator myomucosal flap, also referred to as a buccal myomucosal flap, is an effective technique to address velopharyngeal insufficiency after cleft palate repair. Challenges related to flap harvesting may deter plastic surgeons from incorporating this strategy as a first-line treatment. The primary objective of this study and accompanying video is to provide support regarding indications, planning, and surgical steps of the buccinator myomucosal flap technique, including important technical details for soft-palate dissection and flap harvesting.
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Affiliation(s)
- Cesar Augusto Raposo-Amaral
- From the Institute of Plastic and Craniofacial Surgery, Sobrapar Hospital
- Department of Neurology, University of Campinas
| | - Thais Miguel Monte
- From the Institute of Plastic and Craniofacial Surgery, Sobrapar Hospital
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12
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Lignieres A, Anderson B, Alimi O, Cepeda A, Seitz A, Obinero CG, Teichgraeber JF, Nguyen PD, Greives MR. Do Buccal Flaps Improve Velopharyngeal Insufficiency in Conversion Furlow Palatoplasty for Patients with Cleft Palate? Plast Reconstr Surg 2024; 153:139e-145e. [PMID: 37053453 DOI: 10.1097/prs.0000000000010531] [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: 04/15/2023]
Abstract
SUMMARY Velopharyngeal insufficiency (VPI) is a complication following primary palatoplasty that can lead to hypernasality of the voice and other speech problems. The conversion Furlow palatoplasty for VPI can be performed with the addition of buccal flaps to provide additional tissue for palatal repair. In this study, the authors aimed to determine the effectiveness of buccal flaps with conversion Furlow palatoplasty in secondary management of VPI. A retrospective review of patients undergoing surgical repair of VPI between 2016 and 2020 was performed. Patients underwent either conversion Furlow palatoplasty alone (FA) or conversion Furlow palatoplasty with buccal flaps (FB) for VPI after primary straight-line repair of the palate. The authors reviewed medical records to collect demographics, operative information, and preoperative and postoperative speech scores. Of the 77 patients in the study, 16 (21%) had a revision that incorporated buccal flaps. The median age at cleft palate revision surgery was 8.97 years in the FA group and 7.96 years in the FB group ( P = 0.337). In the FA group, four patients (7%) developed a postoperative fistula, compared with zero patients in the FB group. The average time to follow-up after revision surgery was 3.4 years (range, 7 months to 5.9 years). Both cohorts demonstrated a decrease in hypernasality and total parameter scores postoperatively. The use of buccal flaps in revision Furlow palatoplasty could decrease the risk for postoperative complications. The use of data from a larger patient population from multiple institutions is warranted to determine true significance. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Austin Lignieres
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Brady Anderson
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Oluwatofe Alimi
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Alfredo Cepeda
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Allison Seitz
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Chioma G Obinero
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - John F Teichgraeber
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Phuong D Nguyen
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
| | - Matthew R Greives
- From the Division of Plastic Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston
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13
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Mahajan R, Tambotra A, Ghildiyal H, Singh M, Thussu T, Bhamre A, Srinivasan K. Comparison of Furlow's Double Opposing Z-plasty and Straight-Line Intravelar Veloplasty as Methods of Cleft Palate Repair. Cureus 2024; 16:e52897. [PMID: 38406020 PMCID: PMC10891454 DOI: 10.7759/cureus.52897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 02/27/2024] Open
Abstract
Background One of the common craniofacial abnormalities is cleft lip and palate. Various surgical procedures have been employed to repair the cleft. However, immediate post-operative complications and formation of palatal fistula post surgery are common in surgical procedures. The study aims to compare the fistula rate, soft palate lengthening, and immediate complications of cleft palate repair of Furlow's Z-plasty and straight-line intravelar veloplasty techniques. Method Fifty Patients with isolated or unilateral cleft palate and lip with age between 9-18 months were randomly divided into two groups. One group underwent Furlow's Z-plasty while the other underwent straight-line intravelar veloplasty procedures. Post surgery, after discharge, the patients were followed up at 2 weeks, 1 month, and 3 months intervals. Immediate post-operative complications and fistula formation rate were compared along with other parameters like fistula width, duration of the procedure, intra-operative soft palate length, etc. Results Straight-line procedures took less time as compared to Furlow's Z-plasty. Bleeding (N=2, 8%) and dehiscence (N=1, 4%) of the wound were the immediate post-operative complications found in the straight-line group. Bleeding was also present in the Furlow's group (N=1, 4%). At 1-month follow-up, in the straight-line group (N=3, 12%) patients had fistula while (N=2, 8%) had minimal nasal regurgitation of liquids when compared to the Furlow's group. At 3-month follow-up, patients in the straight-line procedure group (three out of N=25, 12%) exhibited fistula, whereas in the Furlow's group, fistula occurrence was observed in one out of N=25 participants (4%). Intra-operative soft palate lengthening was 6.44 ± 0.768 mm and 1.64 ± 0.952 mm in the Furlow and straight-line groups, respectively. Conclusion Furlow's Z-plasty was observed to be the better surgical procedure for cleft repair as it had low immediate post-operative complications, and fistula development and had higher intra-operative soft palate lengthening.
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Affiliation(s)
- Ravikumar Mahajan
- Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, IND
| | - Ankush Tambotra
- Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, IND
| | - Harish Ghildiyal
- Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, IND
| | - Mahipal Singh
- Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, IND
| | | | - Abhishek Bhamre
- Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, IND
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14
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Geisman MM, Skolnick GB, Grames LM, Naidoo SD, Snyder-Warwick AK, Patel KB. Impact of a Palatal Fistula After Cleft Palate Repair on Velopharyngeal Closure. Cleft Palate Craniofac J 2024; 61:61-67. [PMID: 35912430 DOI: 10.1177/10556656221116534] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE A palatal fistula is an adverse outcome of cleft palate repair. It is unknown if a palatal fistula will influence velopharyngeal closure, even after repair of the fistula. This study determines the effect of a soft palate fistula on the risk of developing velopharyngeal insufficiency. METHODS A retrospective chart review was conducted on patients who underwent primary cleft palate repair between 2000 and 2015, with complete records at 4 years of age. Fistulae involving the secondary palate following primary palatoplasty were classified as the soft or hard palate. A forced-entry multivariate logistic regression model was built to detect predictors of velopharyngeal dysfunction. RESULTS Records of 329 patients were analyzed with a mean follow-up of 8.7 years. A palatal fistula was identified in 89/329 patients (27%) and 29/329 patients (9%) underwent an independent fistula repair. Of the patients with fistula, 44% were located in the hard palate only and 56% had soft palate involvement. Compared to patients without a fistula, rates of velopharyngeal dysfunction were significantly higher in patients with a fistula involving the soft palate (OR 3.875, CI: 1.964-7.648, P < .001) but not in patients with a hard palate fistula (OR 1.140, CI: 0.497-2.613, P = .757). Veau class, age at primary repair, and syndromic status were not significant predictors of VPI (0.128≤P ≤ .975). CONCLUSIONS A palatal fistula involving the soft palate is a significant predictor for development of velopharyngeal dysfunction after primary palatoplasty. Surgical intervention, at the time of fistula repair, to add vascularized tissue may be indicated to prophylactically decrease the risk of velopharyngeal dysfunction.
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Affiliation(s)
- Mackenzie M Geisman
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Lynn M Grames
- St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Sybill D Naidoo
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Alison K Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Kamlesh B Patel
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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15
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Katsube M, Utsunomiya N, Katayama Y, Yamanaka H, Tsuge I, Sowa Y, Sakamoto M, Morimoto N. Interposition grafting of collagen-gelatin sponge impregnated with basic fibroblast growth factor in primary palatoplasty. Regen Ther 2023; 24:288-293. [PMID: 37559871 PMCID: PMC10406600 DOI: 10.1016/j.reth.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/09/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Abstract
INTRODUCTION An oronasal fistula is a challenging post-operative complication of palatoplasty due to impaired velopharyngeal function or its high recurrence rate. Muscle repositioning, a key procedure in palatoplasty, causes dead space at the junction between the hard and soft palates. Consequently, thin oral and nasal mucosae are prone to break down and form fistulas. In this study, we used basic fibroblast growth factor-impregnated collagen gelatin sponge (bFGF-CGS) in primary palatoplasty to reduce fistula formation. METHODS This retrospective study assessed the complications and efficacy of bFGF-CGS to reduce fistula formation. Patients who underwent primary palatoplasty with bFGF-CGS were included. The same number of patients who underwent primary palatoplasty without bFGF-CGS was included as a control group. The outcomes included post-operative oronasal fistula formation, delayed healing, bleeding, and infection. RESULTS Both groups included 44 patients. Except for age at palatoplasty, there were no statistically significant demographic differences between the two groups; however, the rates of fistula formation in the study and control group were 2.3% and 13.6%, respectively. There were no infections among the patients. CONCLUSIONS The grafting of bFGF-CGS in primary palatoplasty was safe and probably effective in reducing post-operative oronasal fistula formation.
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Affiliation(s)
- Motoki Katsube
- Department of Plastic and Reconstructive Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Natsuko Utsunomiya
- Department of Plastic and Reconstructive Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Yasuhiro Katayama
- Department of Plastic and Reconstructive Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Hiroki Yamanaka
- Department of Plastic and Reconstructive Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Itaru Tsuge
- Department of Plastic and Reconstructive Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Yoshihiro Sowa
- Department of Plastic and Reconstructive Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Michiharu Sakamoto
- Department of Plastic and Reconstructive Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Naoki Morimoto
- Department of Plastic and Reconstructive Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
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16
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Parham MJ, Simpson AE, Moreno TA, Maricevich RS. Updates in Cleft Care. Semin Plast Surg 2023; 37:240-252. [PMID: 38098682 PMCID: PMC10718659 DOI: 10.1055/s-0043-1776733] [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: 12/17/2023]
Abstract
Cleft lip and/or palate is a congenital malformation with a wide range of presentations, and its effective treatment necessitates sustained, comprehensive care across an affected child's life. Early diagnosis, ideally through prenatal imaging or immediately postbirth, is paramount. Access to longitudinal care and long-term follow-up with a multidisciplinary approach, led by the recommendations of the American Cleft Palate Association, is the best way to ensure optimal outcomes. Multiple specialties including plastic surgery, otolaryngology, speech therapy, orthodontists, psychologists, and audiologists all may be indicated in the care of the child. Primary repair of the lip, nose, and palate are generally conducted during infancy. Postoperative care demands meticulous oversight to detect potential complications. If necessary, revisional surgeries should be performed before the child begin primary school. As the child matures, secondary procedures like alveolar bone grafting and orthognathic surgery may be requisite. The landscape of cleft care has undergone significant transformation since early surgical correction, with treatment plans now tailored to the specific type and severity of the cleft. The purpose of this text is to outline the current standards of care in children born with cleft lip and/or palate and to highlight ongoing advancements in the field.
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Affiliation(s)
- Matthew J. Parham
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Arren E. Simpson
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Tanir A. Moreno
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Renata S. Maricevich
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
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17
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Suzuki Y, Toriumi M, Takano J. Idiopathic Palatal Fistula of the Left Soft Palate. J Craniofac Surg 2023; 34:e686-e688. [PMID: 37552136 DOI: 10.1097/scs.0000000000009596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 06/25/2023] [Indexed: 08/09/2023] Open
Abstract
Palatal fistulas, often congenital or trauma-induced, are occasionally encountered in the field of plastic surgery. We report a case of a non-medial 3 mm soft palate fistula in a 43-year-old woman, with no apparent trigger or history of local trauma or infection. The fistula, extending 2 cm toward the lateral pharyngeal wall, was surgically removed under general anesthesia as it was impacting the patient's quality of life. The lumen was stained, and the fistula was removed in one mass. The excised tissue was covered with stratified squamous epithelium and was surrounded by adherent tonsil tissue. No recurrence was observed postoperatively. Despite an initial suspicion of a congenital cause, the fistula's lateral extension and histology suggested a possible origin from the second pharyngeal pouch. To date, there are no reports of fistulas opening on the soft palate. Therefore, this presents an exceptionally rare instance of a soft palate fistula.
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Affiliation(s)
- Yushi Suzuki
- Department of Plastic and Reconstructive Surgery, JCHO Saitama Medical Center, Saitama
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Toriumi
- Department of Plastic and Reconstructive Surgery, JCHO Saitama Medical Center, Saitama
| | - Junji Takano
- Department of Plastic and Reconstructive Surgery, JCHO Saitama Medical Center, Saitama
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18
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Gustafsson C, Heliövaara A, Rautio J, Leikola J. Long-term Follow-up of Bilateral Cleft Lip and Palate: Incidence of Speech-Correcting Surgeries and Fistula Formation. Cleft Palate Craniofac J 2023; 60:1241-1249. [PMID: 35726173 PMCID: PMC10515470 DOI: 10.1177/10556656221102816] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
While bilateral cleft lip and palate (BCLP) constitutes a clinical challenge for the whole cleft team, the ideal surgical protocol remains obscure. This study presents the long-term burden of care in terms of secondary surgeries, defined as fistula repair and speech-correcting surgeries (SCS), in a single center. Outcomes of two surgical protocols utilized over the years were also compared. A retrospective single-center analysis of 81 non-syndromic children with complete BCLP born between 1990 and 2010. Two surgical protocols comprising single-stage and two-stage (delayed hard palate closure) procedures were compared. Outcome was analyzed at the time of alveolar bone grafting (ABG) and post-ABG. Altogether 54 children (66.7%) had underwent secondary surgery by the time of bilateral ABG. At this point, 38.3% (n = 31) of patients had received SCS and 49.4% (n = 40) had undergone fistula repair. The corresponding incidences at the end of follow-up were 46.9% (n = 38) and 53.1% (n = 43). No significant difference emerged in SCS incidence between the 2 protocols; however, prior to ABG the single-stage protocol had a significantly lower need for fistula repair. Regarding the location of fistulas, some differences were observed, with the single-stage procedure more associated with anterior fistulas. BCLP has a high surgical burden of care in terms of secondary surgeries, defined as SCS and fistula repair. In our experience, the single-stage protocol, particularly the two-flap technique, offers better results in the management of BCLP than the two-stage approach with a short delay in hard palate closure.
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Affiliation(s)
| | - Arja Heliövaara
- Cleft and Craniofacial Center, Helsinki University Hospital, Helsinki, Finland
| | - Jorma Rautio
- Cleft and Craniofacial Center, Helsinki University Hospital, Helsinki, Finland
| | - Junnu Leikola
- Cleft and Craniofacial Center, Helsinki University Hospital, Helsinki, Finland
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19
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Sakran KA, Yin J, Yang R, Alkebsi K, Elayah SA, Al-Rokhami RK, Holkom MA, Liu Y, Wang Y, Yang C, Shi B, Huang H. Evaluation of late cleft palate repair by a modified technique without relaxing incisions. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 124:101403. [PMID: 36717021 DOI: 10.1016/j.jormas.2023.101403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/09/2023] [Accepted: 01/26/2023] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate the postoperative outcomes together with analyzing the associated influencing factors following a late cleft palate repair by the Sommerlad-Furlow modified technique (S-F). MATERIALS AND METHODS In a retrospective cohort, 320 consecutive patients with cleft palate, who received S-F technique between 2011 and 2017, were reviewed. The patients were divided into three age groups, less than one year (143), one to two years (113), and greater than 2 years (64). The postoperative outcomes included wound healing (complete/fistula) and velopharyngeal function (VPF). RESULTS The overall cleft width was 10 ± 3.07 mm. The overall rates of complete wound healing and proper velopharyngeal function were 96.6% and 81.56%, respectively. No significant difference was found between the age groups regarding wound healing, with an overall fistula rate of 3.4%. The VPF was significantly varied among the age groups (P<0.001). In context, the rates of velopharyngeal insufficiency (VPI) were 9.8%, 14.2%, and 45.4% among patients repaired at ˂1, 1-2, and >2 years old, respectively. The cleft type was the most potential factor associated with fistula. The age at repair was identified as the most implicating factor for VPI. CONCLUSIONS The S-F technique had achieved low fistula rate and satisfactory speech outcome, especially in early repair group and even in the wide cleft palate. The older age at repair and severe cleft type had a major impact on the postoperative outcomes.
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Affiliation(s)
- Karim Ahmed Sakran
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Jiayi Yin
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China
| | - Renjie Yang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China
| | - Khaled Alkebsi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Sadam Ahmed Elayah
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Remsh Khaled Al-Rokhami
- Department of Orthodontics, School of Stomatology, China Medical University, Shenyang, Liaoning, China
| | - Mohammed Ali Holkom
- Department of Oral and Maxillofacial Surgery, School of Stomatology, Wuhan University, Wuhan, Hubei, China
| | - Yingmeng Liu
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yan Wang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China
| | - Chao Yang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China
| | - Hanyao Huang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China; Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan 610041, China.
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20
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Meneses Argalle JD, Espinosa Orozco AM, Prada Madrid JR. Tongue Flap for Closure of Complex Oronasal Fistula. J Craniofac Surg 2023; 34:1872-1875. [PMID: 37344931 DOI: 10.1097/scs.0000000000009468] [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: 04/11/2023] [Accepted: 04/25/2023] [Indexed: 06/23/2023] Open
Abstract
Complex oronasal fistula is one of the most frequent secondary complications of cleft palate correction and is considered a reconstructive challenge. Tongue flaps are one of the procedures for the treatment of complex fistulas associated or not with multiple previous procedures, offering a high success rate, few complications, and problems during its development. This study evaluates the efficacy in terms of functionality, esthetic, donor area morbidity and clarifies surgical technique steps. Descriptive cohort study was performed between August 2011 to August 2021 where an anteriorly based dorsal tongue flap was performed in 30 patients with complex palatal fistulas, evaluating outcomes in terms of technique reproducibility and flap viability, correction of oronasal regurgitation, speech, donor site morbidity, complications, and esthetics. The senior author has used this technique with consistent clinical outcomes to improve complex oronasal fistula with minimal complications, with a good success rate in terms of correction of the palatal defect with imperceptible alteration of the lingual donor area. In addition, establishes a specific definition of persistence and recurrence of oronasal fistula. The tongue flap is considered the gold standard in complex oronasal fistula reconstructions with satisfactory outcomes, and it offers an adequate amount of vascularized tissue achieving fistula closure without functional or esthetic impairment of the donor area and is a highly reproducible technique.
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Affiliation(s)
- Julian D Meneses Argalle
- Department of Plastic, Reconstructive, Aesthetic and Craniofacial Surgery, University Children's Hospital of San Jose
| | - Ana M Espinosa Orozco
- Department of Plastic, Reconstructive, Aesthetic and Craniofacial Surgery, University Children's Hospital of San Jose
| | - José Rolando Prada Madrid
- Department of Plastic, Reconstructive, Aesthetic and Craniofacial Surgery, University Children's Hospital of San Jose
- The Rehabilitation Center for Children with Cleft Lip and Palatal (FISULAB), Bogotá, Colombia
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21
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Martin SV, Van Eeden S, Swan MC. Secondary surgery techniques to optimise functional and aesthetic outcomes in orofacial clefting. Br Dent J 2023; 234:899-905. [PMID: 37349438 DOI: 10.1038/s41415-023-6001-8] [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: 03/21/2023] [Revised: 05/06/2023] [Accepted: 05/09/2023] [Indexed: 06/24/2023]
Abstract
Although the goal of primary surgery is to avoid the need for secondary surgery, in a proportion of patients this is not always possible. Secondary, or revisional, surgery is frequently undertaken in patients with orofacial clefts and may present a complex and challenging problem for the multidisciplinary team. There are a broad range of functional and aesthetic issues that secondary surgery might aim to address. These include palatal fistulae (that may be symptomatic for air, fluid or food), velopharyngeal insufficiency (typically manifesting with decreased intelligibility or nasal regurgitation), suboptimal cleft lip scars (that can significantly impact upon the psychosocial wellbeing of the patient), and nasal asymmetry (that is frequently accompanied by nasal airway concerns). Unilateral and bilateral clefts are each associated with a characteristic nasal deformity that requires a tailored surgical approach. Suboptimal maxillary growth in repaired orofacial clefts may impact negatively on both appearance and function; surgical correction through orthognathic surgery can be transformational for the patient. The general dental practitioner, cleft orthodontist and restorative dentist all play a critical role in this process.
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Affiliation(s)
- Serena V Martin
- Cleft Fellow, Spires Cleft Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, United Kingdom
| | - Simon Van Eeden
- Consultant Cleft and Maxillofacial Surgeon, Alder Hey Children´s Hospital and Aintree University Hospital, Liverpool, L14 5AB, United Kingdom
| | - Marc C Swan
- Consultant Cleft and Plastic Surgeon, Spires Cleft Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, United Kingdom.
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22
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Huang H, Li J, Li C, Yin H, Wu M, Wang Y, Li Y, Yang C, Zeng N, Zheng Q, Shi B. Sommerlad-Furlow modified palatoplasty: A retrospective study. J Craniomaxillofac Surg 2023:S1010-5182(23)00058-6. [PMID: 37164835 DOI: 10.1016/j.jcms.2023.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 03/27/2023] [Accepted: 04/08/2023] [Indexed: 05/12/2023] Open
Abstract
The purpose of this study was to introduce the surgical process of Sommerlad-Furlow modified (S-F) palatoplasty and compare its surgical and functional outcomes with conventional Sommerlad (S) palatoplasty. Patients with non-syndromic cleft palate who had undergone either S-F palatoplasty or S palatoplasty were retrospectively reviewed. Data on the outcomes of velopharyngeal function and postsurgical palatal fistula incidence were collected for all patients. Data for preselected factors, including gender, age at palatoplasty, and cleft type, were also collected. Chi-square tests were conducted. 1254 patients were included. The postsurgical velopharyngeal competence (VPC) rate after S-F palatoplasty was significantly higher than after S palatoplasty (total, 70.5% vs 57.9%, p < 0.0001; age ≤ 1, 87.0% vs 69.2%, p < 0.0001; 1 < age ≤ 2, 78.3% vs 69.3%, p = 0.0479). With regard to different types of cleft palate, the postsurgical VPC rates after S-F palatoplasty were all significantly higher than for S palatoplasty in all patients younger than 2 years of age (complete cleft palate, 78.7% vs 62.4%, p = 0.0016; hard and soft palate cleft, 84.4% vs 74.8%, p = 0.0172; submucosal cleft and soft palate cleft, 96.6% vs 68.4%, p = 0.0114). The postoperative fistula rate after S-F palatoplasty was 4.3%. This modified palatoplasty technique provided adequate cleft palate closure, with satisfactory speech outcomes and low fistula rates, while older age at palatoplasty may affect the postsurgical outcomes. Within the limitations of the study it seems that the Sommerlad-Furlow modified technique is an option for cleft palate repair.
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Affiliation(s)
- Hanyao Huang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases and Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Jingtao Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases and Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Chenghao Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases and Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Heng Yin
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases and Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Min Wu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases and Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Yan Wang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases and Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Yang Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases and Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Chao Yang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases and Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Ni Zeng
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases and Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Qian Zheng
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases and Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases and Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China.
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23
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Sakran KA, Wu M, Alkebsi K, Mashrah MA, Al-Rokhami RK, Wang Y, Mohamed AA, Elayah SA, Al-Sharani HM, Huang H, Shi B. The Sommerlad-Furlow Modified Palatoplasty Technique: Postoperative Complications and Implicating Factors. Laryngoscope 2023; 133:822-829. [PMID: 36120931 DOI: 10.1002/lary.30385] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 07/29/2022] [Accepted: 08/19/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To explore the incidence of postoperative complications and investigate the impact of preselected factors on functional and quality of life outcomes following the Sommerlad-Furlow modified palatoplasty technique. STUDY DESIGN Retrospective cohort. METHODS A total of 429 patients with cleft palate, who received Sommerlad-Furlow modified technique between 2011-2017 were enrolled. The postoperative complications including oronasal fistula (ONF), velopharyngeal insufficiency (VPI), and inadequate quality of life (QOL) were collected. Data of preselected factors including gender, age at palatoplasty, cleft type, cleft width, palatal width, pharyngeal cavity depth, and operation duration were also collected. RESULTS Among 429 patients, 40.1% were males whereas 59.9% were females. The mean age at palatoplasty was 1.23 ± 0.69 (0.42-4) years, and the average cleft width was 10.15 ± 2.95 (4-27) mm. The cleft types had recorded rates of about 6.8%, 69.5%, 17.7%, and 6.1% of Veau I, II, III, and IV, respectively. The overall incidence rates of ONF, VPI, and inadequate QOL were 2.3%, 19.4%, and 31.3%, respectively. In both the univariate and multivariate analyses, the cleft type was significantly implicated in ONF formation (p = 0.023 and 0.032, respectively) whereas the velopharyngeal function was impacted by the palatoplasty age (p ˂ 0.001). The receiver operating characteristic curve indicated that age of palatoplasty ≥1.3 years (area under the curve = 0.611, p = 0.002) was the cutoff value for predicting the incidence of VPI. CONCLUSIONS The Sommerlad-Furlow modified technique appears to have appropriate postoperative outcomes, even in the wide cleft palate. The older age at palatoplasty has a major impact on the overall postoperative outcomes. LEVEL OF EVIDENCE 4 Laryngoscope, 133:822-829, 2023.
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Affiliation(s)
- Karim Ahmed Sakran
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.,Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Min Wu
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Khaled Alkebsi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.,Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Mubarak Ahmed Mashrah
- Key Laboratory of Oral Medicine, Guangzhou Institute of Oral Disease, Stomatology Hospital of Guangzhou Medical University, Guangzhou, China
| | | | - Yan Wang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Abdo Ahmed Mohamed
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen.,Department of Oral and Maxillofacial Surgery, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Sadam Ahmed Elayah
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.,Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen
| | - Hesham Mohammed Al-Sharani
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Ibb, Yemen.,Department of Maxillofacial Surgery, School of Stomatology, Harbin Medical University, Harbin, China
| | - Hanyao Huang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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24
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Raby-Smith W, Hall P, Southby L, Parfect V, Linford G, Bannister S, Miyagi K. A retrospective analysis of speech and hearing in patients receiving surgery for submucous cleft palate. J Plast Reconstr Aesthet Surg 2023; 77:123-130. [PMID: 36566640 DOI: 10.1016/j.bjps.2022.11.003] [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: 06/28/2021] [Revised: 08/19/2022] [Accepted: 11/15/2022] [Indexed: 11/22/2022]
Abstract
Submucous cleft palate (SMCP) is an uncommon subtype of cleft palate that is associated with symptoms of velopharyngeal insufficiency (VPI), the most common being hypernasal speech. A high proportion of patients also suffer from conductive hearing loss, which is thought to be due to eustachian tube dysfunction. A number of surgical techniques have been proposed to correct the anatomical defect that is responsible for VPI. This exploratory study aims to describe surgical techniques and clinical outcomes in a series of patients who underwent surgical repair of SMCP at a single regional specialist cleft centre between 1999 and 2018. Through a retrospective case note review, records of 57 patients who underwent SMCP repair between the ages of 6 months and 16 years were examined. Patients underwent one of the three surgical techniques: Intravelar Veloplasty, Furlow or a novel technique we have termed as "Hemi-Furlow". Hypernasality, measured on the Great Ormond Street Speech Assessment, showed evidence of improvement post-operatively in all three surgical groups (P<0.005), with no evidence to favour any specific approach. Post-operative complications, including wound dehiscence and fistulae, occurred in nine patients (15.8%). Nine patients (15.8%) required revisional surgery, either due to post-operative complications or persistent speech problems. Otological disease was present in 54.4% of patients, comprising conductive hearing loss due to otitis media with effusion (52.6%) and sensorineural hearing loss (1.8%). There is now a need for large, multi-centre studies with robust outcomes measures to further examine relationships between surgical techniques and clinical outcomes in people born with SMCP.
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Affiliation(s)
- Will Raby-Smith
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP, United Kingdom; Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.
| | - Per Hall
- Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Lucy Southby
- Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Victoria Parfect
- Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Georgina Linford
- Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Sam Bannister
- Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Kana Miyagi
- Cleft.NET.East Regional Cleft Service, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
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25
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Brauner E, Piccoli L, Sallemi K, Romeo U, Laudoni F, Cantore M, Tenore G, Pranno N, De Angelis F, Di Cosola M, Valentini V, Di Carlo S. Evaluation of a Novel Technique for Closure of Small Palatal Fistula. J Pers Med 2022; 13:jpm13010065. [PMID: 36675726 PMCID: PMC9861307 DOI: 10.3390/jpm13010065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/04/2022] [Accepted: 12/16/2022] [Indexed: 12/29/2022] Open
Abstract
A palatal fistula is a pathological condition that connects the nasal cavities with the oral cavity. An oral-nasal fistula is reported as a possible post-surgical complication after the removal of oral carcinomas. The presence of a palatal fistula affects the patient's quality of life, making it necessary to apply a prosthetic device, such as a palatal plate, to keep the nasal cavities separated from the oral one. There are several surgical techniques to close a palatal fistula, but it is not possible to define the optimal technique as the approach is extremely dependent on the characteristics of the fistula. The aim of this article is to propose a minimally invasive technique to reduce the size of palatal fistulae and to reduce the surgical difficulty (NSPF). A total of 20 patients fulfilled the inclusion criteria and were checked every two weeks. The fistula was injured with a needle every 2 weeks. Fifteen patients who healed with complete closure of the fistula reported no need for a palatal protection plate to eat, drink and speak normally. It is possible to conclude that the NSPF protocol is a valid approach for the non-surgical reduction of palatal fistulae, and it is possible, when the appropriate conditions are present, to achieve complete closure.
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Affiliation(s)
- Edoardo Brauner
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6, 00161 Rome, Italy
- Implanto-Prosthetic, Policlinico Umberto I, Viale Regina Elena 287b, 00161 Rome, Italy
| | - Luca Piccoli
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6, 00161 Rome, Italy
- Implanto-Prosthetic, Policlinico Umberto I, Viale Regina Elena 287b, 00161 Rome, Italy
| | - Karim Sallemi
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6, 00161 Rome, Italy
- Correspondence:
| | - Umberto Romeo
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6, 00161 Rome, Italy
| | - Federico Laudoni
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6, 00161 Rome, Italy
| | - Marco Cantore
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6, 00161 Rome, Italy
| | - Gianluca Tenore
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6, 00161 Rome, Italy
| | - Nicola Pranno
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6, 00161 Rome, Italy
| | - Francesca De Angelis
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6, 00161 Rome, Italy
| | - Michele Di Cosola
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy
| | - Valentino Valentini
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6, 00161 Rome, Italy
- Oncological and Reconstructive Maxillo-Facial Surgery Unit, Policlinico Umberto I, Viale del Policlinico 155, 00167 Rome, Italy
| | - Stefano Di Carlo
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6, 00161 Rome, Italy
- Implanto-Prosthetic, Policlinico Umberto I, Viale Regina Elena 287b, 00161 Rome, Italy
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26
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Janzekovic J, Betar NM, Heald A, Calvisi R, Matsika A, Phua Y. Heterotopic ossification in a soft tissue free flap vascular pedicle: a case report. AUSTRALASIAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.34239/ajops.v5n1.295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
To our knowledge this is the first described case of HO of the pedicle of a RAFF, and the first description of HO after cleft palate reconstruction. We speculate that inflammatory stimulus related to an emergent operation to arrest postoperative haemorrhage may have contributed to this unusual complication. This case sheds further light on both the pathophysiological mechanisms of HO development, as well as broadens the clinical setting where HO can be encountered.
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Incidence of fistula after primary cleft palate repair: a 25-year assessment of one surgeon’s experience. Arch Plast Surg 2022; 49:43-49. [PMID: 35086308 PMCID: PMC8795648 DOI: 10.5999/aps.2021.01396] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/18/2021] [Indexed: 11/26/2022] Open
Abstract
Background Cleft lip and cleft palate are the most frequent congenital craniofacial deformities, with an incidence of approximately 1 per 700 people. Postoperative palatal fistula is one of the most significant long-term complications. This study investigated the incidence of postoperative palatal fistula and its predictive factors based on 25 years of experience at our hospital. Methods We retrospectively reviewed 636 consecutive palatal repairs performed between January 1996 and October 2020 by a single surgeon. Data from patients’ medical records regarding cleft palate repair were analyzed. The preoperative extent of the cleft was evaluated using the Veau classification system, and the cleft palate repair technique was chosen according to the extent of the cleft. SPSS version 25.0 was used for all statistical analyses, and exploratory univariate associations were investigated using the t-test. Results Fistulas occurred in 20 of the 636 patients; thus, the incidence of palatal fistula was 3.1%. The most common fistula location was the hard palate (9/20, 45%), followed by the junction of the hard and soft palate (6/20, 30%) and the soft palate (5/20, 25%). The cleft palate repair technique significantly predicted the incidence of palatal fistula following cleft palate repair (P=0.042). Fistula incidence was significantly higher in patients who underwent surgery using the Furlow double-opposing Z-plasty technique (12.1%) than in cases where the Busan modification (3.0%) or two-flap technique (2.0%) was used. Conclusions The overall incidence of palatal fistulas was 3.1% in this study. Moreover, the technique of cleft palate repair predicted fistula incidence.
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28
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Steroid Use in Palatoplasty: A Single Surgeon Comparative Retrospective Cohort Study. J Craniofac Surg 2022; 33:526-529. [PMID: 35013068 DOI: 10.1097/scs.0000000000008305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Fistula rates in cleft palate repair vary by technique, surgeon, and institution. Although steroids are commonly used in airway surgery, many plastic surgeons are reluctant to use steroids because of concerns with wound healing. This study aims to assess outcomes and safety of steroid use in Furlow palatoplasty and determine its impact on fistula formation. METHODS A retrospective cohort study was done of all cleft palate surgeries performed by a single surgeon between 2010 and 2014. Data reviewed included demographics, type of cleft, steroid use, length of surgery, length of stay, and fistula formation rate. RESULTS One hundred thirty-five patients underwent palatoplasty, of which 101 received steroids and 34 did not. The mean age was 4.6 years. A total of 42.2% of patients underwent primary palatoplasty, 48.1% underwent submucous cleft palatoplasty, and 9.7% underwent conversion palatoplasty. The overall fistula rate was 1.5% and was comparable between the 2 groups (steroids = 2.0%, no steroids = 0.0%, P = 0.558), and all occurred in primary palatoplasty patients. The average length of stay in the hospital was shorter among patients receiving steroids (steroids = 2.0 days, no steroids = 2.5 days, P < 0.05). CONCLUSIONS Steroid use in cleft palate surgery appears to be safe and likely not associated with impaired wound healing or increased fistula formation. It may also shorten length of hospitalization.
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29
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Kobayashi S, Yabuki Y, Kokubo K, Yasumura K, Hirakawa T, Fukawa T, Yamamoto K. A predictor of postoperative fistula following double opposing Z-plasty in bilateral cleft lip and palate patients. J Plast Reconstr Aesthet Surg 2022; 75:1931-1936. [DOI: 10.1016/j.bjps.2022.01.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 12/15/2021] [Accepted: 01/18/2022] [Indexed: 11/30/2022]
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30
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Gustafsson C, Heliövaara A, Leikola J. Long-Term Follow-up of Unilateral Cleft lip and Palate: Incidence of Speech-Correcting Surgeries and Fistula Formation. Cleft Palate Craniofac J 2021; 59:1537-1545. [PMID: 34866444 PMCID: PMC9585542 DOI: 10.1177/10556656211055641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The ideal surgical protocol and technique for primary closure of unilateral cleft lip and palate (UCLP) are unclear, and the development of velopharyngeal insufficiency and fistulae following primary repair is common. This study aimed to determine the long-term surgical burden of care in terms of secondary surgeries, defined as speech-correcting surgeries (SCSs) and fistula repair, in a UCLP population, and to compare outcomes of various surgical protocols. DESIGN Retrospective, single-center review. PARTICIPANTS The study comprised 290 nonsyndromic children with complete UCLP. Different surgical protocols entailing both single-stage and 2-stage approaches were compared, and the surgical outcome was analyzed at the time of alveolar bone grafting (ABG) and post ABG. RESULTS Altogether 110 children (37.9%) underwent secondary surgery by the time of ABG. Of the total population 25.9% (n = 75) had undergone SCS and 17.2% (n = 50) had undergone fistula repair. The respective incidences at follow-up (post ABG) were 30.3% (n = 88) and 18.9% (n = 55). Median age at ABG was 9.8 years and at follow-up was 16.3 years. No significant difference emerged in terms of secondary surgeries between the techniques and protocols applied at primary repair. However, some differences occurred regarding the location of fistulae; the single-stage procedure had more anterior fistula repairs, particularly connected to a perialveolar fistula. CONCLUSIONS Although the outcome differences between the surgical protocols were small, indicating that none of the treatment protocols was clearly superior to another, attention was drawn to the favorable outcomes of the single-stage protocol.
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Affiliation(s)
- Charlotta Gustafsson
- Cleft Palate and Craniofacial Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Arja Heliövaara
- Cleft Palate and Craniofacial Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Junnu Leikola
- Cleft Palate and Craniofacial Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
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31
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Square-root Palatoplasty: Comparing a Novel Modified-Furlow Double-opposing Z-palatoplasty Technique to Traditional Straight-line Repair. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3777. [PMID: 34667705 PMCID: PMC8517311 DOI: 10.1097/gox.0000000000003777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to introduce a modification of the Furlow double-opposing Z-plasty (DOZ)-the square-root palatoplasty (SRP)-and critically evaluate outcomes compared to children who underwent straight-line repair (SLR). Methods A retrospective review was performed of all nonsyndromic children undergoing primary cleft palate closure either by SRP or SLR at our institution between 2009 and 2017. Outcomes of interest included rates/location of oronasal fistula, secondary surgery, speech delay/deficits, resonance, nasal air emission (NAE), articulation errors, and velopharyngeal function. Logistic regression was used to assess for the effect of surgery type on outcomes while controlling for Veau cleft type, age, and gender. Results Seventy-eight patients were included; 46 (59%) underwent SRP, and 32 (41%) underwent SLR. The mean follow-up was 4.07 years. When compared to SLR, children who underwent SRP were less likely to have oronasal fistula [odds ratio (OR) 4.8, P = 0.0159], speech delay/deficits (OR 7.7, P < 0.001), NAE (OR 9.7, P < 0.001), articulation errors (OR 10.2, P < 0.001), or need for secondary speech surgery (OR 13.2, P < 0.0002). Patients who underwent SRP were also more likely to have normal resonance (78.26% versus 43.75%, respectively; P = 0.0043) and good VP function (84.78% versus 56.25%, respectively; P = 0.0094). Conclusions This study describes and evaluates outcomes following a modified-Furlow DOZ technique-the SRP. After adjusting for Veau classification, age, and gender in nonsyndromic children, SRP is associated with significantly less speech delay/deficits, NAE, articulation errors, and need for secondary speech surgery when compared to children who underwent SLR.
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Swanson MA, Auslander A, Morales T, Jedrzejewski B, Magee WP, Siu A, Ayala R, Swanson JW. Predictors of Complication Following Cleft Lip and Palate Surgery in a Low-Resource Setting: A Prospective Outcomes Study in Nicaragua. Cleft Palate Craniofac J 2021; 59:1452-1460. [PMID: 34658290 DOI: 10.1177/10556656211046810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Higher rates of postoperative complication following cleft lip or palate repair have been documented in low resource settings, but their causes remain unclear. This study sought to delineate patient, surgeon, and care environment factors in cleft complications in a low-income country. DESIGN Prospective outcomes study. SETTING Comprehensive Cleft Care Center. PATIENTS Candidate patients presenting for cleft lip or palate repair or revision. INTERVENTIONS Patient anthropometric, nutritional, environmental and peri- and post-operative care factors were collected. Post-operative evaluation occurred at standard 1-week and 2-month postoperative intervals. MAIN OUTCOME MEASURES Complication was defined as fistula, dehiscence and/or infection. RESULTS Among 408 patients enrolled, 380 (93%) underwent surgery, of which 208 (55%) underwent lip repair (124) or revision (84), and 178 (47%) underwent palate repair (96) or revision (82). 322 (85%) were evaluated 1 week and 166 (44%) 2 months postoperatively. 50(16%) complications were identified, including: 25(8%) fistulas, 24(7%) dehiscences, 17(5%) infections. Mid-upper arm circumference (MUAC) ≤12.5 cm was associated with dehiscence after primary lip repair (OR = 28, p = 0.02). Leukocytosis ≥11,500 on pre-operative evaluation was associated with dehiscence (OR = 2.51, p = 0.04) or palate revision fistula (OR = 64, p < 0.001). Surgeons who performed fewer previous-year palate repairs had higher likelihood of palate complications, (OR = 3.03, p = 0.01) although there was no difference in complication rate with years of surgeon experience or duration of surgery. CONCLUSIONS Multiple patient, surgeon, and perioperative factors are associated with higher rates of complication in a low-resource setting, and are potentially modifiable to reduce complications following cleft surgery.
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Affiliation(s)
- Marco A Swanson
- School of Medicine, 24575Case Western Reserve University, Cleveland, OH.,20313Operation Smile International, Virginia Beach, VA
| | - Allyn Auslander
- Institute for Global Health, 5116University of Southern California, Los Angeles, CA
| | | | | | - William P Magee
- Institute for Global Health, 5116University of Southern California, Los Angeles, CA.,5150Children's Hospital Los Angeles, Los Angeles, CA
| | - Armando Siu
- 2569Operación Sonrisa Nicaragua, Managua, Nicaragua
| | - Ruben Ayala
- 20313Operation Smile International, Virginia Beach, VA
| | - Jordan W Swanson
- 5150Children's Hospital Los Angeles, Los Angeles, CA.,20313Operation Smile International, Virginia Beach, VA.,Perelman School of Medicine, 6567Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
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Tezuka M, Kamikuri Y, Ishihata K, Kibe T, Fuchigami T, Amir MS, Matsunaga K, Nakamura N. Comparison of recurrence rate and speech outcome between two different techniques for cleft palatal fistula closure: A retrospective cohort study. J Craniomaxillofac Surg 2021; 50:86-92. [PMID: 34657791 DOI: 10.1016/j.jcms.2021.09.018] [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] [Received: 08/13/2020] [Revised: 06/28/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022] Open
Abstract
The aim of this retrospective cohort study was to compare the recurrence rate and speech outcomes between two techniques for palatal fistula closure of cleft palate (CP). Patients with CP who underwent secondary palatal fistula closure using the single hinge-flap method with double-breasted mattress suture (hinge-flap group) and those who were treated with the conventional sliding palatal flap method (sliding-flap group) were retrospectively evaluated for demographic and perioperative variables. Recurrence rate of palatal fistula, perceptual speech outcomes, and nasalance scores were further reviewed in patients who met the inclusion criteria. A total of 31 patients, 21 in the hinge-flap group and 10 in the sliding-flap group, were included in this study. The fistula recurrence rate in the hinge-flap group (0%) was significantly lower than that in the sliding-flap group (30.0%) (P = 0.027). In the speech assessment, hypernasality and nasalance scores decreased post-operatively in both groups and significance was observed in the hinge-flap group (P = 0.013, P < 0.001, respectively). Articulation disorders were significantly improved in the hinge-flap group (P = 0.001). Within the limitations of the study it seems that the single hinge-flap method with double-breasted mattress suture should be preferred whenever appropriate.
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Affiliation(s)
- Masahiro Tezuka
- Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Graduate School of Medical and Dental Sciences, Kagoshima University, Japan
| | - Yuhei Kamikuri
- Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Graduate School of Medical and Dental Sciences, Kagoshima University, Japan
| | - Kiyohide Ishihata
- Department of Oral and Maxillofacial Surgery, Kagoshima University Hospital, Japan
| | - Toshiro Kibe
- Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Graduate School of Medical and Dental Sciences, Kagoshima University, Japan
| | - Takao Fuchigami
- Department of Oral and Maxillofacial Surgery, Kagoshima University Hospital, Japan
| | - Muhammad Subhan Amir
- The Department of Oral Surgery, Faculty of Dental Medicine, Airlangga University, Indonesia
| | - Kazuhide Matsunaga
- The 2nd Department of Oral and Maxillofacial Surgery, School & Graduate School of Dentistry, Osaka University, Japan
| | - Norifumi Nakamura
- Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Graduate School of Medical and Dental Sciences, Kagoshima University, Japan; The Department of Oral Surgery, Faculty of Dental Medicine, Airlangga University, Indonesia.
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Impact of Cleft Palate on Tongue-Based Upper Airway Obstruction in Pierre Robin Sequence: Implications for Mandibular Distraction Osteogenesis and Timing of Cleft Palate Repair. J Craniofac Surg 2021; 33:459-462. [PMID: 34538802 DOI: 10.1097/scs.0000000000008178] [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
INTRODUCTION The objectives of this study are to analyze the impact of cleft palate (CP) on upper airway obstruction using polysomnography in patients with Pierre Robin Sequence (PRS) undergoing mandibular distraction osteogenesis (MDO) and subsequent CP repair. METHODS A single-surgeon, retrospective chart review was performed of all patients with nonsyndromic PRS treated with MDO. Severity of upper airway obstruction was evaluated pre- and post-distraction via polysomnography. Details of MDO and CP repair were collected and any complications recorded. RESULTS Twenty-one nonsyndromic PRS patients with CP and 6 patients without CP met inclusion criteria. There was no significant difference in predistraction apnea-hypopnea index between the 2 groups (53.4 ± 42.1 versus 34.4 ± 18.9; P = 0.3). Patients with CP had significantly higher predistraction SpO2 saturation (94.5 ± 1.6% versus 91.0% ± 4.8%; P = 0.01), SpO2 nadir (74.5% ± 9.1% versus 63.6% ± 11.6%; P = 0.03) and lower percentage time spent below 90% SpO2 (6.0% ± 7.2% versus 23.6% ± 29.9%; P = 0.04). The rate of oronasal fistulas formation was 38%. The time between MDO and CP repair was shorter for patients with complications (250.8 ± 3.3 versus 370.8 ± 191.9 days; P = 0.08). Five patients experienced relapse of respiratory difficulties after CP repair. CONCLUSIONS The presence of CP in nonsyndromic PRS patients decreases the severity of obstructive sleep apnea by oxygen parameters on PSG. Palatal fistulas and relapse of respiratory distress are common complications of CP repair following MDO. Delaying CP repair may help to decrease complication rates.
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Anderson BJ, Fallah KN, Lignieres AA, Moffitt JK, Luu KL, Cepeda A, Doringo IL, Nguyen PD, Teichgraeber JF, Greives MR. Predictive Factors for Velopharyngeal Insufficiency Following Primary Cleft Palate Repair. Cleft Palate Craniofac J 2021; 59:825-832. [PMID: 34396792 DOI: 10.1177/10556656211026861] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Velopharyngeal insufficiency (VPI) remains a known complication of primary palatoplasty. We sought to identify factors associated with the incidence of VPI and create a predictive model for VPI development in our population. DESIGN A single-institution, retrospective review. SETTING Multidisciplinary clinic in a tertiary academic institution. PATIENTS A total of 453 consecutive patients undergoing primary palatoplasty from 1999 to 2016 were reviewed. Inclusion required follow-up past age 5. Patients who were non-verbal, and thus unable to undergo speech evaluation, were excluded. MAIN OUTCOME MEASURES Primary outcome was VPI, defined as revision palatoplasty or recommendation by speech-language pathology. RESULTS Of 318 patients included, 179 (56%) were male. Median age at primary repair was 1.0 years (0.9-1.1) with a median age of 8.8 years at last follow-up. One hundred nineteen (37%) patients developed VPI at a median age of 5.0 years (3.8-6.5). Higher rates were seen with posterior fistula (65% vs 14%, P <.01) and straight-line repair (41% vs 9%, P <.01), with lower rates in patients with Veau I clefts (22% vs 39%, P <.05). Patients with VPI were older at last follow-up. Following multivariate regression, factors remaining significant were posterior fistula (odds ratio [OR]: 11.3, 95% CI: 6.1-22.0), primary Furlow repair (OR: 0.18, 95% CI: 0.03-0.68), genetic diagnoses (OR: 2.92, 95% CI: 1.1-7.9), and age at last follow-up (OR: 1.11, 95% CI: 1.01-1.2). CONCLUSIONS Length of follow-up, posterior fistulae, and genetic diagnoses are associated with VPI formation. Furlow repair may protect against formation of VPI. Use of allograft, Veau class, birth type, birth weight, and race are not independently associated with VPI formation.
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Affiliation(s)
- Brady J Anderson
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Kasra N Fallah
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Austin A Lignieres
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Joseph K Moffitt
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Kim-Loan Luu
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Alfredo Cepeda
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Irene L Doringo
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Phuong D Nguyen
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - John F Teichgraeber
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Matthew R Greives
- Division of Plastic Surgery, Department of Surgery, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
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Abstract
PURPOSE OF REVIEW The aim of this article is to present the current opinion on the prevention and management of oronasal fistulas in cleft palate patients. RECENT FINDINGS Though cleft palate repair has seen numerous modifications and improvements, oronasal fistulas remain one of the most common complications of palatoplasty. There are various techniques available for preventing and managing this complication. SUMMARY Oronasal fistulas can be minimized by employing proper principles for palatoplasty. Once a fistula occurs, the repair technique should be appropriate for the fistula type. Oronasal fistula classifications, various repair techniques, tissue adjuncts, and biomaterials used in both the primary palate repair and oronasal fistula repair are discussed in this review.
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Affiliation(s)
- Florence Othieno
- Department of Otolaryngology - Head and Neck Surgery, SUNY Upstate Medical University, Syracuse, New York, USA
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Evaluation of Prognostic Factors for Palatal Fistulae after Cleft Lip and Palate Surgery in a North-Western Romanian Population over a 10-Year Period. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147305. [PMID: 34299755 PMCID: PMC8304784 DOI: 10.3390/ijerph18147305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/26/2021] [Accepted: 07/06/2021] [Indexed: 11/23/2022]
Abstract
Cleft lip and palate is the most frequent birth anomaly, with increasing reported rates of complications, such as palate fistulae. Current studies concerning the occurrence rate of cleft lip and palate (CLP) report 2 to 10 cases in 10,000 births. The purpose of this study was to investigate the existence of factors that could predict the occurrence of fistulae after cleft lip and palate surgery. A retrospective study was performed by collecting and analyzing data from all patients who were operated for cleft lip and/or palate in the Maxillo-Facial Department of the Emergency Clinical County Hospital of Cluj-Napoca, Romania, between 2010 and 2020. We investigated the existing evidence for possible links between the number of fistulae observed after the primary palatoplasty and the age at which the primary palatoplasty was performed, the sex of the patient, the type of cleft, the timing of the surgical corrections, and the presence of comorbidities. A total of 137 cases were included for analysis. A significant link between the number of fistulae and the type of cleft was found (with fistulae occurring more frequently after the surgical correction of CLP—p < 0.001). No evidence was found for the existence of significant links between the number of fistulae and the patient’s sex, the timing of surgery, or the presence of comorbidities. This study concluded that the incidence of palatal fistulae appears to be influenced by the type of cleft (CLP), but not by the sex of the patient, the timing of surgery, or the presence of comorbidities.
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Abstract
BACKGROUND Oronasal fistula (ONF) is a common complication following cleft palate surgery. This study aims to determine the prevalence of ONF and the factors that influence development of ONF following primary palatoplasty. MATERIALS AND METHODS There were 234 patients undergoing primary palatoplasty during 2012 to 2016 included in this cross-sectional study. Patient demographics, surgeon's experience, age at the time of primary palatoplasty, cleft type by Veau classification, cleft width, and operative technique were recorded. The prevalence of fistulae was the primary outcome. Association of age at the time of repair, cleft type, cleft associated with syndromes, cleft width, and surgeon's experience with fistula rate were secondary outcomes. RESULTS There were 234 consecutive patients (128 boys [54.7%] and 106 girls [45.3%]). The mean age at primary palatoplasty was 13 months. Oronasal fistulae occurred in 61 (26.07%) patients. There was a statistically significant association between postoperative oronasal fistulae and the following independent variables: Veau classification (adjusted odds ratio 2.1; 95% confidence interval [CI] = 1.45-3.1, P < 0.01), cleft associated with syndromes (adjusted odds ratio 4.76; 95% CI = 1.48-15.2, P < 0.01) and cleft width more than 11.5 mm (adjusted odds ratio 1.96; 95% CI = 1.00-3.85, P = 0.04). CONCLUSION The overall number of fistulae was moderate in patients who had undergone primary palatoplasty in our center. Cleft severity as defined by the Veau classification, cleft width, and cleft associated with syndromes were predictive factors for development of postoperative fistulae.
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The Nasoalveolar Molding Cleft Protocol: Long-Term Treatment Outcomes from Birth to Facial Maturity. Plast Reconstr Surg 2021; 147:787e-794e. [PMID: 33890899 DOI: 10.1097/prs.0000000000007828] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The authors present outcomes analysis of the nasoalveolar molding treatment protocol in patients with a cleft followed from birth to facial maturity. METHODS A single-institution retrospective review was conducted of cleft patients who underwent nasoalveolar molding between 1990 and 2000. Collected data included surgical and orthodontic outcomes and incidence of gingivoperiosteoplasty, alveolar bone grafting, surgery for velopharyngeal insufficiency, palatal fistula repair, orthognathic surgery, nose and/or lip revision, and facial growth. RESULTS One hundred seven patients met inclusion criteria (69 with unilateral and 38 with bilateral cleft lip and palate). Eighty-five percent (91 of 107) underwent gingivoperiosteoplasty (unilateral: 78 percent, 54 of 69; bilateral: 97 percent, 37 of 38). Of those patients, 57 percent (52 of 91) did not require alveolar bone grafting (unilateral: 59 percent, 32 of 54; bilateral: 54 percent, 20 of 37). Twelve percent (13 of 107) of all study patients underwent revision surgery to the lip and/or nose before facial maturity (unilateral: 9 percent, six of 69; bilateral: 18 percent, seven of 38). Nineteen percent (20 of 107) did not require a revision surgery, alveolar bone grafting, or orthognathic surgery (unilateral: 20 percent, 14 of 69; bilateral: 16 percent, six of 38). Cephalometric analysis was performed on all patients with unilateral cleft lip and palate. No significant statistical difference was found in maxillary position or facial proportion. Average age at last follow-up was 20 years (range, 15 years 4 months to 26 years 10 months). CONCLUSIONS Nasoalveolar molding demonstrates a low rate of soft-tissue revision and alveolar bone grafting, and a low number of total operations per patient from birth to facial maturity. Facial growth analysis at facial maturity in patients who underwent gingivoperiosteoplasty and nasoalveolar molding suggests that this proposal may not hinder midface growth. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Abreu A, Lima MH, Hatten E, Klein L, Levy-Bercowski D. Intraoral Digital Impression for Speech Aid/Obturator in Children: Report of 2 Cases. Cleft Palate Craniofac J 2021; 59:262-267. [PMID: 33761802 DOI: 10.1177/10556656211002686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cleft patients may develop an abnormal opening (fistula) between the oral and the nasal cavities. Surgical repair minimizes the adverse effect on speech and feeding. However, an obturator prosthesis is a nonsurgical approach to help close the communication. The purpose of the case report presented is to show the clinical use of an intraoral digital impression in the fabrication of obturator/speech aid appliances in children with cleft lip and palate deformity. Minimal adjustments were needed, and patients and caregivers responded positively. Prostheses demonstrated good stability and retention at delivery. The use of digital technology seems to have several benefits as an alternative method for capturing impressions, especially in young children with cleft lip and palate deformity.
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Affiliation(s)
- Amara Abreu
- Department of Restorative Sciences, Dental College of Georgia, 1421Augusta University, GA, USA
| | - Maria Helena Lima
- Section of Plastic and Reconstructive Surgery, 1421Augusta University, GA, USA.,Craniofacial Center, Children's Hospital of Georgia, Augusta, GA, USA
| | - Eric Hatten
- Department of Orthodontics, Dental College of Georgia, 1421Augusta University, GA, USA
| | - Laura Klein
- Dental College of Georgia, 1421Augusta University, GA, USA
| | - Daniel Levy-Bercowski
- Craniofacial Center, Children's Hospital of Georgia, Augusta, GA, USA.,Department of Orthodontics, Dental College of Georgia, 1421Augusta University, GA, USA
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Abstract
BACKGROUND The oronasal fistula in cleft patients is one of the complications that can be found after primary surgeries due to a failure of healing of the surgical repair that causes the communication between the oral and nasal cavities. A number of procedures can be implemented to correct the fistula and it is not clear if a particular technique is the best to be recommended. OBJECTIVE This study aims to systematically analyze the scientific evidence regarding the treatment of oronasal fistulas located in the lingual-alveolar and labial-alveolar regions in patients with cleft lip and palate who have undergone primary surgeries. MATERIAL AND METHODS A bibliographic search of articles published until September 2018 without restricted year and language of publication, in PubMed (Medline), Scopus, Cochrane, Web of science, and BVS databases. The MeSHterms "Fistula," "Oral Fistula," and "Cleft Lip" were used, which were related to each other and with other keywords related to the subject of the review through the "OR" and "AND" operators. The quality of the publications was evaluated according to the guidelines of the Methodological Index for Nonrandomized Studies. RESULTS After applying the eligibility criteria, a total of 18 articles were selected for the extraction of data and qualitative analysis. CONCLUSION All publications analyzed in this review reported the fistula treatment at the same surgical time as the bone graft, independently of the donor area, the type of cleft treated and the patient's age at operation. There was no consensus among the studies on the best treatment type for oronasal fistulas located in the alveolar region, and further comparative studies between the existing techniques will be necessary to address this question.
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Awad AN, Watman OF, Nguyen BN, Kanth AM, Adetayo OA. Efficacy of Staged Oronasal Fistula Reconstruction and Improved Bone Graft Survival in Cleft Patients Undergoing Secondary Reconstruction. Cleft Palate Craniofac J 2020; 58:1077-1085. [PMID: 33291986 DOI: 10.1177/1055665620976046] [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: 11/16/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of the senior author's technique of staged reconstruction in patients with recalcitrant oronasal fistulas. DESIGN A retrospective review of the Pediatric Plastic Surgery Cleft & Craniofacial Surgery Database of cases from September 2013 to December 2018 was conducted. PATIENTS A total of 31 patients who had previously undergone >1 surgical attempt to repair a fistula or patients who have failed >1 attempt at bone graft were included in this study. All patients were referrals from outside facilities. MAIN OUTCOME MEASURES Primary outcomes examined included fistula recurrence, infection rates, ability to proceed with second stage bone grafting after first stage fistula takedown and reconstruction, and bone graft loss. RESULTS Charts of 1053 patients were reviewed and 31 (2.94%) cases met inclusion criteria for this study. Nineteen (61.3%) of these patients proceeded with the second stage of reconstruction and 100% did not experience any graft loss. Seven patients who completed the first stage are undergoing orthodontic optimization prior to bone grafting. The remaining 5 are adult patients not interested in pursuing bone grafting. All 31 patients with recurrent and recalcitrant fistulas had successful fistula reconstruction with our approach, despite multiple previous failed reconstructions. CONCLUSIONS The 2-staged reconstructive approach described herein effectively resulted in resolution of prior recurrent recalcitrant fistulas and resulted in eventual bone grafting. By employing this technique, we report successful fistula repair and bone grafting in patients who had previously undergone multiple surgical reconstructions.
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Affiliation(s)
| | | | | | - Aditi M Kanth
- Medical City Children's Hospital Craniofacial Center, Dallas, TX, USA
| | - Oluwaseun A Adetayo
- Pediatric Plastic Surgery, Children's Hospital & Medical Center, University of Nebraska Medical Center, Omaha, NE, USA
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Echlin K, Whitehouse H, Schwaiger M, Nicholas R, Fallico N, Atherton DD. A Cadaveric Study of the Buccal Fat Pad: Implications for Closure of Palatal Fistulae and Donor-Site Morbidity. Plast Reconstr Surg 2020; 146:1331-1339. [PMID: 33234964 DOI: 10.1097/prs.0000000000007351] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND For the cleft surgeon, palatal fistulae after cleft palate repair remain a difficult problem, with a paucity of local tissue options to aid closure. Small clinical series have described the use of the buccal fat pad flap to repair palatal fistulae; however, there is no literature detailing the anatomical coverage of the flap. This study delineates the anatomy of the buccal fat pad flap to guide surgeons in patient selection and examines the residual buccal fat after flap harvest to provide new information with regard to possible effects on the donor site. METHODS Buccal fat pad flaps were raised in 30 hemicadavers. The reach of the flap across the midline, anteriorly and posteriorly, was recorded. In 18 hemicadavers, the entire buccal fat pad was then exposed to determine the effects of flap harvest on movement and volume of the residual fat. RESULTS All buccal fat pad flaps provided coverage from the soft palate to the posterior third of the hard palate and all across the midline. Approximately three-fourths of flaps would cover the mid hard palate. The flap constitutes 36 percent of the total buccal fat pad on average, and a series of retaining ligaments were identified that may prevent overresection. CONCLUSIONS The buccal fat pad flap is a useful tool for coverage of fistulae in the soft palate to the posterior third of the hard palate. In most cases, it will also reach the middle third; however, it is not suitable for more anterior defects. On average, two-thirds of the buccal fat pad remains within the cheek after flap harvest, which may protect against unwanted alteration in aesthetics.
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Affiliation(s)
- Kezia Echlin
- From Birmingham Children's Hospital; and South Thames Cleft Service, Guy's and St Thomas' Hospital
| | - Harry Whitehouse
- From Birmingham Children's Hospital; and South Thames Cleft Service, Guy's and St Thomas' Hospital
| | - Michael Schwaiger
- From Birmingham Children's Hospital; and South Thames Cleft Service, Guy's and St Thomas' Hospital
| | - Rebecca Nicholas
- From Birmingham Children's Hospital; and South Thames Cleft Service, Guy's and St Thomas' Hospital
| | - Nefer Fallico
- From Birmingham Children's Hospital; and South Thames Cleft Service, Guy's and St Thomas' Hospital
| | - Duncan D Atherton
- From Birmingham Children's Hospital; and South Thames Cleft Service, Guy's and St Thomas' Hospital
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Kara M, Calis M, Kara I, Incebay O, Kulak Kayikci ME, Gunaydin RO, Ozgur F. Does early cleft palate repair make difference? Comparative evaluation of the speech outcomes using objective parameters. J Craniomaxillofac Surg 2020; 48:1057-1065. [DOI: 10.1016/j.jcms.2020.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/02/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022] Open
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Saralaya S, Desai AK, Ghosh R. Buccal fat pad in cleft palate repair- An institutional experience of 27 cases. Int J Pediatr Otorhinolaryngol 2020; 137:110218. [PMID: 32658803 DOI: 10.1016/j.ijporl.2020.110218] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/07/2020] [Accepted: 06/18/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The purpose of this paper is to consider the anatomical basis and surgical technique along with the utility of buccal fat pad (BFP) for the reconstruction in cleft lip and palate patients. METHODS We reviewed 27 cases of CLAP treated with BFP over three year period in our institution which included 2 cases of primary palatoplasty & 25 cases of secondary palatoplasty. Inclusion criteria consisted of patients operated by a single surgeon with a minimum follow up of 2yrs. Exclusion criteria included all syndromic cleft lip and palate patients. Predictor variables recorded were demographic characters, follow up period, type of cleft, type of surgical procedure, site & dimension of the fistula. Outcome variables of the study were post-operative fistula formation, post-operative hemorrhage & speech assessment. RESULTS The study included 8 female & 19 male patients with mean age group 3.75 ± 1.75yrs. Cleft of soft palate & Lt. CLAP were the most common type of cleft. The surgical technique used was: BFP with V-Y pushback palatoplasty for primary palate repair, BFP with Furlow's technique for VPI correction, and BFP in conjugation with rotation flap, straight-line closure or redohardpalatoplasty for fistula closure. All cases showed satisfactory healing with favorable speech assessment outcomes for 18 patients (67%). CONCLUSION BFP along with other types of flap is the choice of treatment in cases of moderate defect owing to its favorable anatomic location & high vascularity. The size limitation of the BFP must be known to permit a successful outcome.
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Affiliation(s)
- Shruthi Saralaya
- Department of Oral &Maxillofacial Surgery &Department of Craniofacial Surgery and Research Centre, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, 580009, India; Cleft & Craniofacial Fellow, GSR Institute of Facial & Plastic Surgery, 17-1-383/55, Vinay Nagar Colony, IS Sadan, Hyderabad, Telangana, 500059, India.
| | - Anil Kumar Desai
- Department of Oral &Maxillofacial Surgery &Department of Craniofacial Surgery and Research Centre, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, 580009, India
| | - Rajarshi Ghosh
- Department of Oral &Maxillofacial Surgery &Department of Craniofacial Surgery and Research Centre, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, 580009, India
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Effect of collagen matrix on postoperative palatal fistula in cleft palate repair. Sci Rep 2020; 10:15236. [PMID: 32943682 PMCID: PMC7498452 DOI: 10.1038/s41598-020-72046-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 08/20/2020] [Indexed: 11/20/2022] Open
Abstract
Palatal fistula is a challenging complication following cleft palate repair. We investigated the usefulness of collagen matrix in the prevention of postoperative fistula. We performed a retrospective cohort study of patients with cleft palate who underwent primary palatoplasty (Furlow’s double opposing z-plasty) in Seoul National University Children’s Hospital. Collagen Graft and Collagen Membrane (Genoss, Suwon, Republic of Korea) were selectively used in patients who failed complete two-layer closure. The effect of collagen matrix on fistula formation was evaluated according to palatal ratio (cleft width to total palatal width) and cleft width. A total of 244 patients (male, 92 and female, 152; median age, 18 months) were analyzed. The average cleft width was 7.0 mm, and the average palatal ratio was 0.21. The overall fistula rate was 3.6% (9/244). Palatal ratio (p = 0.014) and cleft width (p = 0.004) were independent factors impacting the incidence of postoperative fistula. Receiver operating characteristic curve analysis showed that the cutoff values in terms of screening for developing postoperative fistula were a palatal ratio of 0.285 and a cleft width of 9.25 mm. Among nonsyndromic patients with values above those cutoffs, the rates of fistula development were 0/5, 1/6 (16.7%), and 4/22 (18.2%) for those who received Collagen Graft, Collagen Membrane, and no collagen, respectively. Collagen matrix may serve as an effective tool for the prevention of palatal fistula when complete two-layer closure fails, especially in wide palatal clefts. The benefit was most evident in Collagen Graft with thick and porous structure.
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Abstract
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.
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Rothermel AT, Lundberg JN, Samson TD, Tse RW, Allori AC, Bezuhly M, Beals SP, Sitzman TJ. A Toolbox of Surgical Techniques for Palatal Fistula Repair. Cleft Palate Craniofac J 2020; 58:170-180. [PMID: 32806926 DOI: 10.1177/1055665620949321] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To provide an inventory of oronasal fistula repair techniques alongside expert commentary on which techniques are appropriate for each fistula type. DESIGN A 4-stage approach was used to develop a consensus on surgical techniques available for fistula repair: (1) in-person discussion of oronasal fistula cases among cleft surgeons, (2) development of a schema for fistula management using transcripts of the in-person case discussion, (3) evaluation of the preliminary schema via a web-based survey of additional cleft surgeons, and (4) revision of the management schema using survey responses. PARTICIPANTS Six cleft surgeons participated in the in-person case discussion. Eleven additional surgeons participated in the web-based survey. Participants had diverse training experiences, having completed residency and fellowship at 20 different hospitals. RESULTS A schema for fistula management was developed, organized by fistula location. The schema catalogues all viable approaches for each location. For fistulae involving the soft palate, the schema stresses the importance of evaluating for velopharyngeal insufficiency (VPI) and incorporating VPI management into fistula repair. For fistulae involving the hard palate, the schema separately enumerates the techniques available for nasal lining repair and for oral lining repair in each region. The schema also catalogues the diversity of approaches to lingual- and labioalveolar fistula, including variation in timing, orthodontic preparation, and simultaneous alveolar bone grafting. CONCLUSIONS This study employed consensus methods to create a comprehensive inventory of available fistula repair techniques and to identify preferential techniques among a diverse group of surgeons.
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Affiliation(s)
- Alexis T Rothermel
- Division of Plastic Surgery, 12310Penn State Hershey Medical Center, Hershey, PA, USA
| | | | - Thomas D Samson
- Departments of Pediatrics and Neurosurgery, 12311Penn State Hershey Medical Center, Hershey, PA, USA
| | - Raymond W Tse
- Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Alexander C Allori
- Division of Plastic, Maxillofacial & Oral Surgery, 22957Duke University Hospital & Children's Health Center, Durham, NC, USA
| | - Michael Bezuhly
- Division of Plastic & Reconstructive Surgery, 3688Dalhousie University, Halifax, Nova Scotia, Canada
| | - Stephen P Beals
- Division of Plastic Surgery, Mayo Clinic Arizona and Barrow Cleft and Craniofacial Center, Phoenix, AZ, USA
| | - Thomas J Sitzman
- Division of Plastic Surgery, 14524Phoenix Children's Hospital, University of Arizona College of Medicine, Mayo Clinic Arizona; and Barrow Cleft and Craniofacial Center, Phoenix, AZ, USA
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Feasibility of Surgeon-Delivered Audit and Feedback Incorporating Peer Surgical Coaching to Reduce Fistula Incidence following Cleft Palate Repair: A Pilot Trial. Plast Reconstr Surg 2020; 146:144-153. [PMID: 32590658 DOI: 10.1097/prs.0000000000006907] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Improving surgeons' technical performance may reduce their frequency of postoperative complications. The authors conducted a pilot trial to evaluate the feasibility of a surgeon-delivered audit and feedback intervention incorporating peer surgical coaching on technical performance among surgeons performing cleft palate repair, in advance of a future effectiveness trial. METHODS A nonrandomized, two-arm, unblinded pilot trial enrolled surgeons performing cleft palate repair. Participants completed a baseline audit of fistula incidence. Participants with a fistula incidence above the median were allocated to an intensive feedback intervention that included selecting a peer surgical coach, observing the coach perform palate repair, reviewing operative video of their own surgical technique with the coach, and proposing and implementing changes in their technique. All others were allocated to simple feedback (receiving audit results). Outcomes assessed were proportion of surgeons completing the baseline audit, disclosing their fistula incidence to peers, and completing the feedback intervention. RESULTS Seven surgeons enrolled in the trial. All seven completed the baseline audit and disclosed their fistula incidence to other participants. The median baseline fistula incidence was 0.4 percent (range, 0 to 10.5 percent). Two surgeons were unable to receive the feedback intervention. Of the five remaining surgeons, two were allocated to intensive feedback and three to simple feedback. All surgeons completed their assigned feedback intervention. Among surgeons receiving intensive feedback, fistula incidence was 5.9 percent at baseline and 0.0 percent following feedback (adjusted OR, 0.98; 95 percent CI, 0.44 to 2.17). CONCLUSION Surgeon-delivered audit and feedback incorporating peer coaching on technical performance was feasible for surgeons.
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A comparative study of three palatoplasty techniques in wide cleft palates. Int J Oral Maxillofac Surg 2020; 50:191-197. [PMID: 32758385 DOI: 10.1016/j.ijom.2020.07.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 05/14/2020] [Accepted: 07/14/2020] [Indexed: 11/20/2022]
Abstract
The aim of this study was to clinically evaluate the effectiveness of various palatoplasty techniques for the repair of cleft palates greater than 8mm in width. This prospective cohort study included 142 patients with complete cleft palate between September 2017 and January 2019. Among the patients, 60 underwent a modified palatoplasty with Furlow Z-plasty (MPFZP), 51 underwent a von Langenbeck (VL) repair, and 31 underwent a two-flap palatoplasty (2FP). The MPFZP technique was modified with bilateral relaxing incisions and a radical intravelar veloplasty. Descriptive statistics and the χ2 test were used to explore and compare the rates of complications among the three surgical techniques. No statistically significant difference in sex, age at repair, cleft width, or cleft Veau type was found among the three groups. Rates of wound dehiscence at 1 week and fistula formation at 3 months after the surgery also did not differ significantly among the three techniques. However, velopharyngeal function for speech was better in patients who underwent MPFZP compared to the other two techniques (P<0.05). The repair of a wide cleft palate can be difficult due to the tension at closure. Although the study findings did not demonstrate a difference in complication rates among the three techniques, MPFZP appears to have the best functional outcomes in patients with a cleft palate wider than 8mm.
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