The Effect of Acellular Dermal Matrix on the Success of Primary Palatoplasty With Intravelar Veloplasty

BackgroundAcellular Dermal Matrix graft is usually used to repair fistulas following a cleft palate and has had positive results. But its use for primary palatoplasty has been less studied. Our aim was to compare the usefulness of using Acellular Dermal Matrix transplantation for primary palatoplasty with intravelar veloplasty in contrast to its lack of useMaterials and methodsA total of 72 children (6 months to 6 years old) with cleft palate were included in the study. The case-control prospective observations were conducted. A group underwent primary palatoplasty with intravelar veloplasty using Acellular Dermal Matrix and the control group had the same surgery without using Acellular Dermal Matrix. Patients were monitored for fistula formation, post-operative infection, and ulcers.ResultsNo post-surgical infection and wound opening was seen in any group. In the recipients of Acellular Dermal Matrix and control group three and six fistula was reported in which patients had soft and hard palate involvement and the cleft with length greater than 15 mm.ConclusionsConsidering the double incidence of fistulas in the control group compared to the ADM recipient, it seems that the use of ADM can be effective in reducing the incidence of fistulas. Since fistula is one of the complications of primary palatoplasty surgery and leads to secondary surgeries, the use of ADM can be helpful.

Comparative Evaluation of Palatal Length, Speech Outcome, and Surgical Complications With Use of Von Langenbeck and Bardach 2 Flap Technique for the Repair of Cleft Palate: A Prospective Randomized Study

Purpose: Successful closure of cleft palate is no more the sole criteria for determining the success of palatoplasty. Approximating soft palate musculature plays an equally important role. A continuous palate with muscular sling, speech and unhampered maxillary growth are 3 important goals of palatoplasty. The current study compared 2 popular palatoplasty techniques and also focused on other vital secondary parameters which would alter the final outcome of palatoplasty. Methods: Thirty-two primary cleft palate patients with repaired cleft lip ranging from 4 to 30 years were randomly and equally divided into 2 groups. Group A underwent Langenbeck and Group B underwent Bardach palatoplasty. Sommerlad’s Intra-Velar Veloplasty was performed in all patients. The patients were evaluated for certain palatal and cleft measurements, speech, and surgical complications. The study also compared impact of cleft severity on speech and complications. Results: All the patients showed improvement in palatal length and speech. Significant palatal lengthening was achieved by Bardach as compared to Langenbeck palatoplasty ( P = .002). Amongst the various speech parameters so compared Bardach group showed better speech articulation post-operatively ( P = .020). No significant difference was found between the 2 groups in relation to other speech parameters. Total 4 complications were encountered 2 belonging to each group. Conclusion: Hard palate cleft repair technique plays little role as far as speech outcomes are concerned. It was Intravelar Veloplasty which reestablished the velopharyngeal sphincter and improved the quality of speech. Hence restoring the muscular sling of soft palate using radical dissection should be stressed upon by the surgeons besides the closure of cleft. The current study found few confounding factors such as age, cleft width, and Veau’s class which altered the speech outcomes and/or complications of palatoplasty.

Furlow Versus Straight Line Repair With Intravelar Veloplasty: A 7-Year Single Institution Experience with Fistula Formation

Introduction: We aimed to characterize and identify potential risk factors for fistula formation including demographic variables, palatoplasty technique, Veau cleft classification, and adoption status at a large tertiary pediatric facility. Methods: Retrospective chart review was performed for patients undergoing primary palatoplasty via either Furlow or straight line with intravelar veloplasty (IVVP) technique from November 2011 to September 2018. Variables collected included age at time of surgery, gender, language, payer status, adoption status, syndromic status, presence of moderate and/or bilateral hearing loss, Veau cleft type, and presence of a postoperative fistula. Results: Of the 108 patients included, 34 underwent the Furlow procedure and 74 underwent the straight line repair procedure with IVVP. A significant correlation was found between fistula formation and both adoption status and Veau cleft type. Only patients with Veau cleft types 3 and 4 developed a postoperative fistula. Postoperative fistulae developed in 9 patients: 1/34 (2.9%) in the Furlow group and 8/74 (10.8%) in the straight line with IVVP group. Conclusions: At our institution, rate of fistula formation is not greatly different between Furlow and straight line with IVVP palatoplasty techniques despite their being a trend toward increased risk of postoperative fistulas within the latter group, supporting previous literature that did not find an association between technique and fistula rate. Veau cleft classification and adoption status were more closely associated with the formation of postoperative fistulae.

Current surgical practice for children born with a cleft lip and/or palate in the United Kingdom

Background: This study describes primary surgical reconstructions performed for children born with a cleft lip and/or palate in the United Kingdom. Methods: Data were obtained from the Cleft Collective, a national longitudinal cohort study. Data forms completed at the time of surgery included details on timing, technique and adjuncts used during the operative period. Demographic data on participants were validated via parental questionnaires. Results: Between 2015 and 2021, 1782 Cleft Collective surgical forms were included, relating to the primary reconstructions of 1514 individual children. The median age at primary cheiloplasty was 4.3 months. Unilateral cleft lips were reconstructed with an anatomical subunit approximation technique in 53%, whereas bilateral cleft lips were reconstructed with a broader range of eponymous techniques. Clefts of the soft palate were reconstructed at a median age of 10.3 months with an intravelar veloplasty in 94% cases. Clefts of the hard palate were reconstructed with a vomer flap in 84% cases in a bi-modal age distribution, relating to reconstruction carried out simultaneously with either lip or soft palate reconstruction. Antibiotics were used in 96% of cases, with an at-induction-only regimen used more commonly for cheiloplasties (p<0.001) and a 5 to 7day post-operative regime used more commonly for soft palatoplasties (p<0.001). Peri-operative steroids were used more commonly in palatoplasties than cheiloplasties (p<0.001) but tranexamic acid use was equivalent (p=0.73). Conclusion: This study contributes to our understanding of current cleft surgical pathways in the United Kingdom and will provide a baseline for analysis of the effectiveness of utilised protocols.

Exploring the Relationship Between Palatal Cleft Type and Width With the Use of Relieving Incisions in Primary Repair

Objective: The mainstay of palatal repair in the United Kingdom is the intravelar veloplasty (IVVP). It is not always possible to align the oral mucosa in the midline to achieve tension-free repair. The addition of lateral relieving incisions may aid transposition of the oral mucosa to allow closure. The aim of this study was to explore cleft features that may predispose to a requirement for relieving incisions in order to allow palate closure. Design: We performed a national multiinstitutional retrospective study using data from the UK Cleft Collective cohort study. Patients: The study sample consisted of 474 patients who had undergone IVVP at the time of palatal closure across all 16 of the UK cleft units. Results: We found strong evidence for the requirement for relieving incisions in patients with an increased degree of clefting per the Veau classification ( P < .001), increasing palatal soft-edge width ( P < .001) and moderate evidence of an associated use in patients with Pierre Robin sequence ( P = .015). Insufficient data were available to explore the relationship between intertuberosity distance and the presence of fistula formation with the use of relieving incisions. Conclusions: The results of this study identify cleft features that increase the likelihood for requiring lateral relieving incisions to allow palatal closure. The degree to which the addition of relieving incisions to IVVP affects maxillary growth and speech outcomes is unknown. Further study is required to answer this important question.

Surgical Variation Between Consultant Surgeons Performing a Sommerlad Radical Intravelar Veloplasty

Background: Although cleft surgeons in the United Kingdom follow a similar training pathway, and cleft centers adhere to similar protocols regarding timing of palate surgery and surgical technique, speech outcomes still vary significantly between centers. Objective: To explore if differences in technique exist between individual surgeons, performing a Sommerlad radical intravelar veloplasty (IVVP). Design: An exploratory, qualitative approach was adopted to understand the views of UK cleft surgeons performing a Sommerlad radical IVVP for primary cleft palate repair and to discuss what was important in the adoption, adaptation, and evolution of this technique within their own practice. Method: A semistructured interview schedule was designed. Interviews were conducted in person or via videoconferencing, with interested surgeons. The interviews were recorded, transcribed, and checked for accuracy. Analysis involved inductive thematic analysis. Results: Fourteen cleft consultants from the United Kingdom participated (3 females and 11 males). Seven of the consultants were trained in plastic surgery and 4 in oral and maxillofacial surgery. Eight themes were identified from the thematic analysis. One theme—Surgical Variation—is discussed. Conclusions: The findings provide insight into areas of variation seen within one surgical technique of cleft palate repair. These variations may have arisen to accommodate heterogeneity in the patient population or may have evolved in relation to different experiences of training or influences of colleagues. Further work is needed to explore the reasons for these differences in technique and to identify if any of these subtle differences contributed to variability in outcomes.