Reinforcing the Modified Double-Opposing Z-Plasty Approach Using the Pedicled Buccal Fat Flap as an Interpositional Layer for Cleft Palate Repair

Objective: This study assesses the association between risk of secondary surgery for oronasal fistula following primary cleft palate repair and 2 hospital characteristics—cost-to-charge ratio (RCC) and case volume of cleft palate repair. Design: Retrospective cohort study. Setting: This study utilized the Pediatric Health Information System (PHIS) database, which consists of clinical and resource-utilization data from >49 hospitals in the United States. Patients and Participants: Patients undergoing primary cleft palate repair from 2004 to 2009 were abstracted from the PHIS database and followed up for oronasal fistula repair between 2004 and 2015. Main Outcome Measure(s): The primary outcome measure was whether patients underwent oronasal fistula repair after primary cleft palate repair. Results: Among 5745 patients from 45 institutions whom met inclusion criteria, 166 (3%) underwent oronasal fistula repair within 6 to 11 years of primary cleft palate repair. Primary palatoplasty at high-RCC facilities was associated with a higher rate of subsequent oronasal fistula repair (odds ratio [OR] = 1.84 [1.32-2.56], adjusted odds ratio [AOR] = 1.81 [1.28-2.59]; P ≤ .001). Likelihood of surgery for oronasal fistula was independent of hospital case volume (OR = 0.83 [0.61-1.13], P = .233; AOR = 0.86 [0.62-1.20], P = .386). Patients with complete unilateral or bilateral cleft palate were more likely to receive oronasal fistula closure compared to those with unilateral-incomplete cleft palate (AOR = 2.09 [1.27-3.56], P = .005; AOR = 3.14 [1.80-5.58], P < .001). Conclusions: Subsequent need for oronasal fistula repair, while independent of hospital case volume for cleft palate repair, increased with increasing hospital RCC. Our study also corroborates complete cleft palate and cleft lip as risk factors for oronasal fistula.

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Cleft Palate

10.2310/ps.10026 ◽

2018 ◽

Author(s):

Oksana A Jackson ◽

Alison E Kaye ◽

David W Low

Keyword(s):

Cleft Palate ◽

Normal Function ◽

Speech Development ◽

Velopharyngeal Insufficiency ◽

Surgical Interventions ◽

Feeding Difficulties ◽

Oronasal Fistula ◽

Cleft Palate Repair ◽

Palate Repair ◽

Impaired Speech

A cleft of the palate represents one of the most common congenital anomalies of the craniofacial region. Palatal clefting can occur in combination with a cleft of the lip and alveolus or as an isolated finding and can vary significantly in severity. The intact palate is a structure that separates the oral and nasal cavities, and the function of the palate is to close off the nasal cavity during deglutition and to regulate the flow of air between the nose and mouth during speech production. An unrepaired cleft palate can thus result in nasal regurgitation of food and liquid, early feeding difficulties, and impaired speech development. The goals of surgical repair are to restore palatal integrity by closing the cleft defect and repairing the musculature to allow for normal function during speech. The secondary goal of cleft palate repair is to minimize deleterious effects on growth of the palate and face, which can be impacted by standard surgical interventions. This review describes two of the most commonly performed cleft palate repair techniques in use today, as well as highlighting special anatomic considerations, summarizing perioperative care, and reviewing postoperative complications and their management. This review contains 11 figures, 2 videos, 3 tables and 63 references Key words: cleft, cleft team, Furlow, orofacial, oronasal fistula, palatoplasty, speech, submucous cleft, velopharyngeal insufficiency

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Effects of phenytoin spray in prevention of fistula formation following cleft palate repair

Journal of Cranio-Maxillofacial Surgery ◽

10.1016/j.jcms.2019.11.008 ◽

2019 ◽

Vol 47 (12) ◽

pp. 1887-1890

Author(s):

Shahin Abdollahi Fakhim ◽

Masoud Nouri-Vaskeh ◽

Mohamad Amin Fakhriniya

Keyword(s):

Cleft Palate ◽

Fistula Formation ◽

Cleft Palate Repair ◽

Palate Repair

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Modified Von Langenbeck Cleft Palate Repair Using an Anterior Triangular Flap: Decreased Incidence of Anterior Oronasal Fistulas

The Cleft Palate-Craniofacial Journal ◽

10.1597/07-185.1 ◽

2009 ◽

Vol 46 (3) ◽

pp. 299-304 ◽

Cited By ~ 16

Author(s):

Tara Lynn Stewart ◽

David M. Fisher ◽

Jaret L. Olson

Keyword(s):

Cleft Palate ◽

Anterior Margin ◽

Fistula Formation ◽

Anterior Portion ◽

Oronasal Fistula ◽

Triangular Flap ◽

Secondary Palate ◽

Nasal Side ◽

Cleft Palate Repair ◽

Hypernasal Speech

Objective: A complication following cleft palate surgery is the development of oronasal fistulas. Despite recent advances aimed at addressing this concern, rates of postoperative fistulas have remained unchanged and are reported at between 3% and 60%. Oronasal fistulas commonly occur between the hard and soft palate and at the anterior portion of the cleft. These fistulas lead to functional problems with nasal emission, hypernasal speech, and food regurgitation through the nose. For clefts of the secondary palate, we developed a modification of the Von Langenbeck technique in which an anterior triangular flap is used to decrease the incidence of postoperative fistulas. Method: A triangular flap composed of oromucosa was designed for isolated clefts of the secondary palate only. It is based at the anterior margin of the cleft and is used as a turnover flap to allow closure of the often very tight anterior nasal side. A retrospective chart analysis was performed from 2000 to 2007. All patients who had isolated clefts of the secondary palate and had undergone a modified Von Langenbeck procedure were included in the study. Patients were evaluated 4 to 8 weeks postoperatively for the presence of oronasal fistulas. Results: With the introduction of the anterior triangular flap, we show that 0 of 182 patients developed a postoperative oronasal fistula. Conclusions: This modification of the standard Von Langenbeck uses an anterior triangular flap and confers the advantage of assisting in nasal side closure of the anterior margin of the cleft; in doing so, it reduces the rate of fistula formation.

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Incidence of Fistula Formation and Velopharyngeal Insufficiency in Early Versus Standard Cleft Palate Repair

Journal of Craniofacial Surgery ◽

10.1097/scs.0000000000006307 ◽

2020 ◽

Vol 31 (4) ◽

pp. 980-982 ◽

Cited By ~ 2

Author(s):

Michael J. Eliason ◽

Stephen Hadford ◽

Lauren Green ◽

Travis Reeves

Keyword(s):

Cleft Palate ◽

Velopharyngeal Insufficiency ◽

Fistula Formation ◽

Cleft Palate Repair ◽

Palate Repair

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Cleft Palate

10.2310/ot.10026 ◽

2018 ◽

Author(s):

Oksana A Jackson ◽

Alison E Kaye ◽

David W Low

Keyword(s):

Cleft Palate ◽

Normal Function ◽

Speech Development ◽

Velopharyngeal Insufficiency ◽

Surgical Interventions ◽

Feeding Difficulties ◽

Oronasal Fistula ◽

Cleft Palate Repair ◽

Palate Repair ◽

Impaired Speech

A cleft of the palate represents one of the most common congenital anomalies of the craniofacial region. Palatal clefting can occur in combination with a cleft of the lip and alveolus or as an isolated finding and can vary significantly in severity. The intact palate is a structure that separates the oral and nasal cavities, and the function of the palate is to close off the nasal cavity during deglutition and to regulate the flow of air between the nose and mouth during speech production. An unrepaired cleft palate can thus result in nasal regurgitation of food and liquid, early feeding difficulties, and impaired speech development. The goals of surgical repair are to restore palatal integrity by closing the cleft defect and repairing the musculature to allow for normal function during speech. The secondary goal of cleft palate repair is to minimize deleterious effects on growth of the palate and face, which can be impacted by standard surgical interventions. This review describes two of the most commonly performed cleft palate repair techniques in use today, as well as highlighting special anatomic considerations, summarizing perioperative care, and reviewing postoperative complications and their management. This review contains 11 figures, 2 videos, 3 tables and 63 references Key words: cleft, cleft team, Furlow, orofacial, oronasal fistula, palatoplasty, speech, submucous cleft, velopharyngeal insufficiency

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Throat Swabs Taken on the Operating Table Prior to Cleft Palate Repair and Their Relevance to Outcome: A Prospective Study

The Cleft Palate-Craniofacial Journal ◽

10.1597/08-082.1 ◽

2009 ◽

Vol 46 (3) ◽

pp. 275-279 ◽

Cited By ~ 13

Author(s):

Andrew Rennie ◽

Linda J. Treharne ◽

Bruce Richard

Keyword(s):

Tract Infection ◽

Respiratory Tract ◽

Cleft Palate ◽

Fistula Formation ◽

Operating Table ◽

Upper Respiratory Tract ◽

Operating Microscope ◽

Cleft Palate Repair ◽

Palate Repair ◽

Upper Respiratory

Objective: The main objective of this study was to determine whether bacteria cultured from oral swabs taken at the time of surgery predicted postoperative fistula formation. Design: The study was a prospective longitudinal audit. Setting: The setting was a designated U.K. N.H.S. cleft center. Patients: Subjects consisted of the patients of a single cleft surgeon who were undergoing surgery for cleft palate repair or cleft fistula repair. Interventions: Oral microbiological swabs were taken from patients while they were on the operating table just before surgery. Main outcome measures: The results from microbiological culture of the swabs were recorded, as was the presence or absence of a fistula at 6 months postoperatively. Additional collected information was related to the severity of the cleft, whether the operating microscope was used during surgery, and whether the patient had developed a postoperative upper respiratory tract infection. Results: Positive swab cultures were not significantly associated with fistula formation. Use of the operating microscope was not associated with an increase or decrease in the number of fistulas. A fistula developed in all patients who experienced a postoperative upper respiratory tract infection. Conclusions: The practice of performing routine preoperative mouth swabs should be abandoned because the presence of bacteria in the mouth does not increase the risk of fistula formation.

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The Buccal Flap—A Useful Technique in Cleft Palate Repair?

The Cleft Palate-Craniofacial Journal ◽

10.1597/02-124 ◽

2004 ◽

Vol 41 (2) ◽

pp. 144-151 ◽

Cited By ~ 45

Author(s):

Ian T. Jackson ◽

Andrea A. Moreira-Gonzalez ◽

Amy Rogers ◽

Barbara J. Beal

Keyword(s):

Cleft Palate ◽

Cleft Lip And Palate ◽

Care Center ◽

Speech Quality ◽

Fistula Formation ◽

Study Cohort ◽

Primary Care Center ◽

Oronasal Fistula ◽

Velopharyngeal Incompetence ◽

Palate Repair

Objective To evaluate speech quality and oronasal fistula after primary palate repair using a buccal mucosal flap. Design Retrospective study cohort of patients with cleft palate. Setting Primary care center for treatment of craniofacial congenital anomalies. Patients and Method One hundred fifty-six nonsyndromic patients underwent palatoplasty with the buccal myomucosal flap by the senior surgeon between 1989 and 2002. The preoperative workup, surgical technique, and other factors that might affect the outcome were identical in every case. Oronasal fistula and variables affecting speech quality were analyzed. Results The most common type of cleft was unilateral cleft lip and palate (43.5%). The median follow-up was 5.8 years (0.4 to 21 years), and the median age at repair was 6.2 months. The overall fistula formation was 3.6%, decreasing progressively: 1989 to 1994: 2.9%, 1995 to 2002: 0.7% (p < .05). Velopharyngeal incompetence (VPI) occurred in 8.8% of the patients, decreasing from 5.3% to 3.5% in the last years. VPI and oronasal fistulae were observed mainly in unilateral and bilateral clefts of the lip and palate. Velopharyngeal adequacy occurred in 91.1% of the children, and resonance was normal in 91.1 %. None of the patients had severe hypernasality or hyponasality. Articulation was normal in 97.9% of the children. Speech quality was good in 89% of the patients. Conclusions The technique presented has been effective, with the advantages of palatal closure without tension, good muscular reconstruction, lengthening of the nasal layer, and palatal closure without raw areas. The technique, early repair, and surgeon's skills were the most important variables for good outcomes regarding speech and fistula formation.

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