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

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 Palatal Fistula after One-Stage Palatoplasty and Factors Influencing the Fistula Occurrence

Jurnal Plastik Rekonstruksi ◽

10.14228/jpr.v2i4.176 ◽

1970 ◽

Vol 2 (4) ◽

Author(s):

Nurardhilah Vityadewi ◽

Kristaninta Bangun

Keyword(s):

Body Weight ◽

Cleft Palate ◽

Cleft Lip ◽

Cleft Lip And Palate ◽

Fistula Formation ◽

Bivariate Analysis ◽

One Stage ◽

Cleft Palate Repair ◽

Hypernasal Speech ◽

Palate Repair

Background: Cleft palate repair may be compromised by a number of complications, most commonly the development of a fistula. Fistulas are related to an increased rate of hypernasal speech, articulation problems, and food or liquid regurgitation from the nose. Fistulas also tend to recur after a secondary repair to address the fistulas. This study reviews the rate of fistula in our craniofacial center after a onestage cleft palate repair; and to determine whether, cleft type, age at repair, type of cleft repair, hemoglobin level presurgery, and patients nutritional state influence the risk of fistula occurence. Patient and Method: A retrospective analysis was performed on medical records of 93 patients who underwent palate repair between January 2012 to October 2013. All consecutive cleft (lip and) palate patients are included. Bivariate analysis was performed to identify the predictors of fistula formation. Result: Ninety-three patients (50 male and 43 female) underwent one-stage palatoplasty. Cleft palate fistulas occured in 19 of 93 patients (20,4%). The age of the patients at the time of repair ranged from 9 to 144 months (mode 18 months). All palate repairs were done in one stage, using either the two flap (N=66), Wardill-Kilner (N=24), Furlow (N=2), and Langenback (N=1) techniques. No significant influence was found related between age at the time of repair (p 0.789), body weight (p 0.725), Hemoglobin value (p 0.295), and type of cleft (p 0.249) to the rate of fistula occurrence. Summary: This study found no association between , body weight, preoperative hemoglobin value, and the type of cleft to the rate of fistula following cleft palate surgery.

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

The Cleft Palate-Craniofacial Journal ◽

10.1177/10556656211064769 ◽

2021 ◽

pp. 105566562110647

Author(s):

Rafael Denadai ◽

Pang-Yun Chou ◽

Lun-Jou Lo

Keyword(s):

Cleft Palate ◽

Middle Layer ◽

Fistula Formation ◽

Growth Disturbance ◽

Full Coverage ◽

Oronasal Fistula ◽

Cleft Palate Repair ◽

Single Intervention ◽

Palate Repair ◽

Relaxing Incisions

Pedicled buccal fat flaps have been adopted in primary Furlow double-opposing Z-plasty palatoplasty to reduce oronasal fistula formation or to attenuate maxillary growth disturbance. We combined both goals in a single intervention. This study describes a series of 33 modified Furlow small double-opposing Z-plasty palatoplasties reinforced with a middle layer of pedicled buccal fat flaps between the oral and nasal layers for full coverage of the dissected palatal surfaces, with rapid mucosalization of lateral relaxing incisions and no dehiscence or fistula formation.

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Reliability of Oronasal Fistula Classification

The Cleft Palate-Craniofacial Journal ◽

10.1597/16-186 ◽

2018 ◽

Vol 55 (6) ◽

pp. 871-875 ◽

Cited By ~ 3

Author(s):

Thomas J. Sitzman ◽

Alexander C. Allori ◽

Damir B. Matic ◽

Stephen P. Beals ◽

David M. Fisher ◽

...

Keyword(s):

Cleft Palate ◽

Classification System ◽

Surgical Quality ◽

General Classification ◽

Oronasal Fistula ◽

Secondary Palate ◽

Cleft Palate Repair ◽

Individual Surgeon ◽

Palate Repair

Objective: Oronasal fistula is an important complication of cleft palate repair that is frequently used to evaluate surgical quality, yet reliability of fistula classification has never been examined. The objective of this study was to determine the reliability of oronasal fistula classification both within individual surgeons and between multiple surgeons. Design: Using intraoral photographs of children with repaired cleft palate, surgeons rated the location of palatal fistulae using the Pittsburgh Fistula Classification System. Intrarater and interrater reliability scores were calculated for each region of the palate. Participants: Eight cleft surgeons rated photographs obtained from 29 children. Results: Within individual surgeons reliability for each region of the Pittsburgh classification ranged from moderate to almost perfect (κ = .60-.96). By contrast, reliability between surgeons was lower, ranging from fair to substantial (κ = .23-.70). Between-surgeon reliability was lowest for the junction of the soft and hard palates (κ = .23). Within-surgeon and between-surgeon reliability were almost perfect for the more general classification of fistula in the secondary palate (κ = .95 and κ = .83, respectively). Conclusions: This is the first reliability study of fistula classification. We show that the Pittsburgh Fistula Classification System is reliable when used by an individual surgeon, but less reliable when used among multiple surgeons. Comparisons of fistula occurrence among surgeons may be subject to less bias if they use the more general classification of “presence or absence of fistula of the secondary palate” rather than the Pittsburgh Fistula Classification System.

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Is Risk of Secondary Surgery for Oronasal Fistula Following Primary Cleft Palate Repair Associated With Hospital Case Volume and Cost-to-Charge Ratio?

The Cleft Palate-Craniofacial Journal ◽

10.1177/1055665620959528 ◽

2021 ◽

Vol 58 (5) ◽

pp. 603-611

Author(s):

Giap H. Vu ◽

Christopher L. Kalmar ◽

Carrie E. Zimmerman ◽

Laura S. Humphries ◽

Jordan W. Swanson ◽

...

Keyword(s):

Cleft Palate ◽

Outcome Measure ◽

Charge Ratio ◽

Fistula Repair ◽

Case Volume ◽

Secondary Surgery ◽

Hospital Case ◽

Oronasal Fistula ◽

Cleft Palate Repair ◽

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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Closure of Palatal Fistula with a Local Mucoperiosteal Flap Lined with Buccal Mucosal Graft

The Cleft Palate-Craniofacial Journal ◽

10.1597/1545-1569_2000_037_0127_copfwa_2.3.co_2 ◽

2000 ◽

Vol 37 (2) ◽

pp. 127-129 ◽

Cited By ~ 6

Author(s):

M.B.O.M. Honnebier ◽

D.S. Johnson ◽

A.A. Parsa ◽

A. Dorian ◽

F.D. Parsa

Keyword(s):

Standard Form ◽

Senior Author ◽

Fistula Formation ◽

Fistula Repair ◽

Suitable Alternative ◽

Buccal Mucosal Graft ◽

Nasal Side ◽

Long Term Follow Up ◽

Mucoperiosteal Flap ◽

Cleft Palate Repair

Objective Oro-nasal fistula is a common complication of palatoplasty. Current methods for fistula repair utilize mucoperiosteal flaps or pedicled flaps. These procedures are often cumbersome and leave a raw nasal surface, which may increase the incidence of postoperative risks and problems. In addition, the recurrence rate of the fistula is as high as 34%. We propose a simple two-layer method of fistula repair to avoid recurrences. Design A standard mucoperiosteal flap is raised on the oral side. A buccal mucosal graft is harvested from the cheeks and sutured to the nasal side of the flap that is then inset into the fistula. Setting Patients were either referred to the senior author's private practice (four patients) or were patients who had previously been operated on by the senior author himself (three patients). Subjects Study subjects consisted of seven patients, four males and three females, ages 14 months to 8 years. All patients had previously undergone cleft palate repair, complicated by subsequent oro-nasal fistula formation. Interventions All patients underwent oro-nasal fistula repair under general anesthesia with a local mucoperiosteal flap lined with buccal mucosal grafts placed on the nasal side of the flap. Results In all cases, the fistula was completely closed at first attempt without complications. Patients were followed for a minimum of 2 years, without evidence of recurrence. Conclusions Our proposed surgical procedure for fistula closure using a standard mucoperiosteal flap lined with a buccal mucosal graft is a suitable alternative for the repair of postpalatoplasty oro-nasal fistulas. Further study and long-term follow-up is needed to establish this method as a new standard form of repair.

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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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Oral Flora and Perioperative Antimicrobial Interventions in Cleft Palate Surgery: A Review of the Literature

The Cleft Palate-Craniofacial Journal ◽

10.1177/1055665620977363 ◽

2020 ◽

pp. 105566562097736

Author(s):

Miles J. Pfaff ◽

Leila Musavi ◽

Maxwell M. Wang ◽

Christos S. Haveles ◽

Claire Liu ◽

...

Keyword(s):

Cleft Palate ◽

Antibiotic Use ◽

Fistula Formation ◽

Cochrane Library ◽

Oral Flora ◽

Oronasal Fistula ◽

Perioperative Antibiotics ◽

Antimicrobial Interventions ◽

The Cochrane Library

Background: The role of perioperative antibiotics in cleft palate remains a topic of debate. Advocates stress their importance in preventing local and systemic infections and decreasing the incidence of oronasal fistula formation. However, few studies to date have directly evaluated the role of antibiotics and other antimicrobial measures in cleft palate surgery. Objective: The aim of this review is to evaluate the evidence surrounding the use of perioperative antibiotics and other antimicrobial interventions in cleft palate surgery. Additionally, we review the literature on the oral flora unique to the cleft palate patient population. Methods: This was accomplished utilizing PubMed, Medline, and the Cochrane Library with MeSH and generic terms. Articles were selected based on predefined inclusion and exclusion criteria. Results: This review highlights the lack of higher level evidence on perioperative antibiotic use and other antimicrobial interventions in cleft palatoplasty and calls for further research on the matter. Conclusions: The literature appears to support the use of preoperative antibiotics for cleft palatoplasty, but the benefits of prolonged postoperative antibiotic use remain questionable.

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Induced Velopharyngeal Fatigue Effects in Speakers with Repaired Palatal Clefts

The Cleft Palate-Craniofacial Journal ◽

10.1597/06-098 ◽

2007 ◽

Vol 44 (3) ◽

pp. 251-260 ◽

Cited By ~ 11

Author(s):

Jerald B. Moon ◽

David P. Kuehn ◽

Grace Chan ◽

Lili Zhao

Keyword(s):

Cleft Palate ◽

Muscle Activity ◽

Regression Line ◽

Pressure Load ◽

Nasal Side ◽

Velopharyngeal Closure ◽

Cleft Palate Repair ◽

Palate Repair ◽

Nasal Pressure ◽

Force Data

Objective: To address whether speakers with cleft palate exhibit velopharyngeal mechanism fatigue and are more susceptible to muscle fatigue than are speakers without cleft palate. Methods: Six adults with repaired palatal clefts and mild-moderate hypernasality served as subjects. Velopharyngeal closure force and levator veli palatini muscle activity were recorded. Subjects were asked to repeat /si/ 100 times while an external load consisting of air pressure (0, 5, 15, 25, 35 cm H2O) was applied via a mask to the nasal side of the velopharyngeal mechanism. Fatigue was defined as a reduction in velopharyngeal closure force across the series of /si/ productions, as evidenced by a negatively sloped regression line fit to the closure force data. Results: Absolute levels of velopharyngeal closure force were much lower than those observed previously in speakers without palatal clefts. All subjects showed evidence of fatigue. Furthermore, all subjects demonstrated exhaustion, where they were unable to close the velopharyngeal port against the nasal pressure load. This occurred at pressure load levels lower than those successfully completed by speakers without cleft palate. Conclusions: In speakers with a repaired palatal cleft, the velopharyngeal closure muscles may not possess the same strength and/or endurance as in normal speakers. Alternatively, muscles may possess adequate strength, but not be positioned optimally within the velopharynx following cleft palate repair or may be forced to move velopharyngeal structures that are stiffer as a result of surgical scarring.

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