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( a ) Diagram of the two-flap palatoplasty technique. ( b ) Diagram of the four-flap palatoplasty technique.
Source publication
We studied 73 repairs of cleft palate (48 cleft lip and palate and 25 isolated cleft palate) done during a 7-year period (January 1996-October 2002) by the same plastic reconstructive surgeon. Two-flap or four-flap palatoplasty techniques were used to provide tension-free, three-layer repairs for patients with cleft palate. Their ages ranged from 1...
Context in source publication
Context 1
... of cleft palate is complex. Several techniques have been described for the repair of cleft palate [1 Á / 4], and the controversy about the timing of these procedures is focused on early palatoplasty for improved speech compared with delayed repair of the hard palate for undisturbed facial growth. The timing and technique are the most important influences on speech and facial growth [5]. The complications after repair that are of most concern in the immediate postoperative period are bleeding and respiratory distress. Other complications such as wound dehiscence and oro- nasal fistula develop in the late postoperative period. The incidence of fistula has been reported to be 3% to 45% [1,3,6 Á / 12]. Treatment of a fistula is a difficult problem, and various techniques have been described [7,13], the most common being mobilisa- tion of a local flap [14]. The purpose of this study was to compare the rate of palatal fistulation after repair of the cleft by the two-flap or the four-flap palatoplasty. Table I shows the details of the 73 patients who were operated on between January 1996 and October 2002 by the same plastic surgeon. At the time of the repair, the age of the 73 patients ranged from 10 to 224 months. There were 48 cleft lip and palates (66%) and 25 isolated cleft palates (34%). There were 18 complete and 7 incomplete isolated cleft palates (total 25) and 37 complete and 11 incomplete cleft palates (total 48). The two-flap technique was used in 39 patients (53%) and the four-flap technique in 34 patients (47%). We saw no fistulas in patients with unilateral cleft lip and palate. All patients haemoglobin concentrations were above 100 g/L. Antibiotic prophylaxis was started pre- operatively and continued for five days postoperatively. All operations were done under general endotracheal anaesthesia. The endotracheal tube is inserted through a larger tube to prevent it collapsing from pressure of the blade of the Dingman-Dott self Á / retaining mouth gag and retractor. After the infiltration of 0.5% lignocaine with adrenaline 1:200 000, the cleft palate was repaired either by the two-flap or the four-flap palatoplasty technique. The two-flap technique involves raising of two flaps by incising along the medial margin of the soft palate and hard palate between the nasal and oral mucosa, and along the lateral border of the palate. The lateral alveolopalatal incisions are created and connected anteriorly to incisions of the edge of the cleft. The flaps are raised to create inferior based mucoperiosteal flaps on the palatine vessels. The nasal mucoperiosteum is raised and advanced for closure in continuity in the midline. The oral myomucosal edges of the flaps are closed in the midline. The four-flap technique involves creation of cleft palate incisions in the medial margins and each palatal flap is divided into two anterior and posterior flaps on the hard palate. The lateral alveolopalatal incisions are made and connected to the anterior edge of the posterior palatal flaps. The anterior two flaps and posterior two flaps are raised to create four mucoperiosteal flaps. The nasal mucoperiosteum is raised. The nasal mucoperiosteal and the oral myomucosal layers are sutured in the midline. The anterior and posterior flaps are sutured to each other in the centre (Figure 1). The nasal mucosa is sutured with 5/0 polyglactin 910 (Vicryl), palatal muscle with 3/0 Vicryl, and oral mucosa with 4/0 chromic catgut. At the end of the procedure a 2/0 silk suture is used to transfix the anterior portion of the tongue to control the airway postoperatively. The suture in the tongue is removed the following morning. When the patient is dis- charged, a liquid diet consisting of food prepared in a blender is prescribed for three weeks. During the early postoperative period (one to five weeks after the repair), the patient’s parents were interviewed about whether there had been nasal leaks of fluid. The palatal area and suture lines were inspected to see if there was a fistula. A palatal fistula was defined as a failure of healing or a breakdown in the primary surgical repair of the palate (Figure 2). The dimension was calculated by measuring its longest part with callipers. The median duration of follow-up was 33 months (range 3 Á / 54). Five patients developed palatal fistulas (5/73), and they all had bilateral cleft lip and palate and isolated cleft palate. Of two patients who developed fistulas after two-flap palatoplasty, one had bilateral cleft lip and palate, and one had isolated cleft palate giving a rate of 5% (2/39). Of three patients with palatal fistulas after four-flap palatoplasty two had bilateral cleft lip and palate, and one had isolated cleft palate, and the rate was 9% (3/34). The overall incidence of fistulation was 7%. The mean length of fistulas was 8 mm (range 5 to 13). There is no significant difference between the two ...
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Retrospective chart review was performed.
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The goals of primary closure of cleft lip and palate include not only re-establishing normal insertions for all of the nasolabial muscles but also restoring the normal position of all the other soft tissues, including the mucocutaneous elements. Conventional surgical wisdom, which recommends waiting until growth is complete before undertaking surgi...
Citations
... Cleft palate repair is a surgery done in order to attain proper closure of the nasal floor, muscle tissue and oral mucosa. 1 Failure in regaining the proper structural integrity results in cleft palate fistula which can be either due to the residual non repaired cleft or the breakdown of the original repaired palate. 2 The approach to palatal fistula depends on the symptoms associated, the site and dimensions of the fistula. The most common symptoms are speech distortions caused by nasal emissions; poor oral hygiene caused by food and fluid seepage into the nasal cavity resulting in nasal lining inflammation. ...
... The incidence of palatal fistula can range from 0-35% with the average overall incidence of 8.6%. [1][2][3][4][5][6][7][8][9] The risk factors of palatal fistula repair ranges from the type of cleft defect, its dimensions, the surgeon's experience and the timing and technique of repair used for the procedure. ...
One of the expected outcomes of palate repair is to achieve complete partition between nasal and oral cavity in addition to good speech. Any failure of achieving complete structural integrity of palate is labelled as an oronasal (palatal) fistula with persistent passage between oral and nasal cavity, it can occur at the anterior, posterior or mid palatal region
The aim of the study is to assess prevalence of palatal fistula, cause of palatal fistula, location of palatal fistula and to derive a more relevant surgical technique.
A retro-prospective study was conducted in operated cleft patients who showed presence of palatal fistula between the age group of 9 months to 7 years. The data collected included age, sex and type of cleft defecttype, width of cleft palatetype of surgery performed, size of fistula, location of fistula, duration of fistula formationpostoperatively
8 palatal fistula were included. The fistula was located mostly at the anterior palatal region (50%) and secondly at the mid palatal region (38%). The occurrence of fistula in operated cleft lip and palate cases was noted mostly after V-Y pushback palatoplasty followed by Von Langenbeck
Among the surgical techniques used for palatoplasty, the Von Langenbeck is proven to be superior than V-Y pushback palatoplasty in accordance with the occurrence of palatal fistula. The anterior palate fistulas were the most common type in the study.
... However, surgical complications are seen even after repairs with these reliable techniques. Oronasal fi stulas are the most common complications [3,4]. ...
... Oronasal fi stulas, which cause nasal air escape, speech impairment, hearing loss, and food & drink regurgitation, are clinically relevant and require re-operation. The review of the literature has shown that the rate of oronasal fi stulas change between 5 and 34% requiring re-operation following palatoplasty [4]. ...
... Optimal timing for cleft palate repair is that it should be done to provide normal velopharyngeal function and optimum speech levels, while preserving the development of the face. Therefore, there is a consensus on the practice of palatal repair before 18 months of age to provide a clear speech [4,9]. Different surgical techniques can be applied to cleft palate repair. ...
p>Background: The most incident and the most persistent complication following cleft palate repair is oronasal fistula. Fistulas involving the soft palate may be corrected via excision and primary closure; however fistulas of the hard palate constitue a majör challange.
Aims: In this study, in order to reduce the rate of oronasal fistula following cleft palate surgery, we present postoperative use of palatal gauze dressing.
Patients and Methods: The patients were enrolled randomly into two groups as Group one and two. For group two patients, at the end of operation, an antibiotic pomade absorbed sterile gauze was fixed at the palate with 2/0 silk sutures, under moderate pressure in order not to interfere with flap circulation.
Results: Of the 7 fistulas in group one, 5 were located on the hard palate and 2 on the soft palate, whereas in, 2 were located on the hard and two on the soft palate. No other complications were encountered.
Conclusion: The use of an antibiotic pomade-absorbed palatal gauze, tight adherence of palatal flaps to the underlying bone is achieved. Besides, serving as a barrier, the gauze prevents infection with food remnants and irritation with foreign bodies.</p
... Surgeon's experience and the selection of surgical procedures have also been associated with fistula presentation (Cohen et al., 1991;Muzaffar et al., 2001;Bekerecioglu et al., 2005;Mak et al., 2006;Bindingnavele et al., 2008). Experienced surgeons had better outcomes than less experienced ones (Shaw et al., 1992;Mulliken, 2004). ...
Objective:
To develop a standardized all-encompassing protocol for the assessment of cleft lip and palate patients with clinical and research implications.
Method:
Electronic database searches were conducted and 13 major cleft centers worldwide were contacted in order to prepare for the development of the protocol. In preparation, the available evidence was reviewed and potential fistula-related risk determinants from 4 different domains were identified.
Results:
No standardized protocol for the assessment of cleft patients could be found in any of the electronic database searches that were conducted. Interviews with representatives from several major centers revealed that the majority of centers do not have a standardized comprehensive strategy for the reporting and follow-up of cleft lip and palate patients. The protocol was developed and consisted of the following domains of determinants: (1) the sociodemographic domain, (2) the cleft defect domain, (3) the surgery domain, and (4) the fistula domain.
Conclusion:
The proposed protocol has the potential to enhance the quality of patient care by ensuring that multiple patient-related aspects are consistently reported. It may also facilitate future multicenter research, which could contribute to the reduction of fistula occurrence in cleft lip and palate patients.
... Other authors found a 41.67% incidence of small fistulae, 25% of medium-sized fistulae, and 33.33% of larger fistulae 17 . In another study 27 , fistulae considered large by the criterion adopted in this study were reported in 7% of patients at a mean 8 mm (range, 5-13 mm). ...
Introduction
The primary surgical correction of the palate is of fundamental importance in the rehabilitation of individuals with labiopalatine cleft and aims for local anatomical restoration and closure of the existing communication between the nasal and oral cavities, such as functional restoration of the velopharyngeal ring through repositioning of the palatine muscles. Palate closure techniques have evolved progressively over the years and increasingly involve repositioning of the muscles responsible for closing the velopharyngeal sphincter, called intravelar veloplasty. This procedure encourages the synergistic operation of the velar and pharyngeal musculature, thereby avoiding the symptoms resulting from velopharyngeal insufficiency. However, despite efforts to achieve adequate velopharyngeal function, intraoperative events and immediate postoperative and/or late complications may contribute to primary palatoplasty failure and consequently lead to hypernasality.
Methods
Sixty patients underwent primary palatoplasty with intravelar veloplasty. Intraoperative events and immediate and late postoperative complications were investigated. The presence and location of palatal fistula or dehiscence was assessed by clinical evaluation. The patients also made an audio recording of their speech that was analyzed by three speech therapists. The intraoperative events and postoperative complications were descriptively analyzed. The association between intraoperative events and immediate and late postoperative complications with the formation of fistulae as well as that between the occurrence of fistulae and dehiscences and the presence and absence of hypernasality was analyzed using Fisher’s exact test.
Results
Overall, there was a 5% incidence of intraoperative events, 20% incidence of immediate complications, and 13.3% incidence of late complications. Fistulae and hypernasality were found in 16.67% and 18.6% of cases, respectively.
Conclusion
Palatoplasty with intravelar veloplasty is a safe and easily implemented technique that is efficient for speech and has low complication rates.
Keywords:
Palate/surgery; Palatine muscles; Cleft lip; Cleft palate; Velopharyngeal insufficiency; Velopharyngeal sphincter; Postoperative complications.
... La Medicina plantea como principio básico el no hacer daño, de ahí que el uso innecesario y excesivo de cirugías sobre los tejidos viola de alguna forma esta norma. El protocolo individualizado que proponemos permite obtener un cierre anatómico adecuado sin que se produzca un mayor número de fístulas palatinas en comparación con los estudios publicados (0 a 25%) (20)(21)(22)(23)(24). ...
El propósito del presente estudio es comparar los resultados obtenidos en el tratamiento quirúrgico de las fisuras palatinas empleando 2 protocolos diferentes. Realizamos un estudio retrospectivo comparado un protocolo A, que emplea una sola técnica para tratar las diferentes formas de fisura palatina, y otro protocolo B, que emplea diferentes técnicas de acuerdo a la clasificación que proponemos. Hacemos la comparación de resultados en base al número de fístulas e insuficiencia velofaringea obtenidos con cada protocolo. Observamos diferencias significativas en el número de fístulas entre ambos protocolos a favor del protocolo B (p: 0.0001). No encontramos diferencias significativas en el número de casos con insuficiencia velofaringea entre ambos protocolos (p: 0.64). Concluimos que, dada la aparición de un menor número de fístulas palatinas con la aplicación del protocolo B (protocolo individualizado) en el tratamiento de las fisuras palatinas, se demuestra la eficacia de la clasificación propuesta y de las técnicas empleadas. Estas conclusiones avalan las aportaciones que proponemos en este artículo con la nueva clasificación y con el protocolo quirúrgico propuesto.
... A cleft palate fistula is defined as a failure of healing or a breakdown in the primary surgical repair of the palate (Muzaffar et al., 2001). Studies over the last 15 years show an incidence of fistulas after palatoplasty with a range of 0e58% (Table 1) (Lin et al., 1999;Mackay et al., 1999;Schendel et al., 1999;Muzaffar et al., 2001;Wilhelmi et al., 2001;Yu et al., 2001;Rosenstein et al., 2003;Sommerlad, 2003;Henkel et al., 2004;Jackson et al., 2004;LaRossa et al., 2004;Bekerecioglu et al., 2005;Inman et al., 2005;Savaci et al., 2005;Agrawal and Panda, 2006;Helling et al., 2006;Mak et al., 2006;Richard et al., 2006;Hassan and Askar, 2007;Holland et al., 2007;Andersson et al., 2008;Andrades et al., 2008;Bindingnavele et al., 2008;Khosla et al., 2008;Losee et al., 2008;Phua and de Chalain, 2008;Koh et al., 2009;Murthy et al., 2009;Parwaz et al., 2009;Shi et al., 2009;Stewart et al., 2009;Ferdous et al., 2010;Hodges, 2010;Landheer et al., 2010;Lu et al., 2010;Saleh, 2010;Agrawal and Panda, 2011;et al., 2014). Several factors may influence the occurrence of fistulas, including type of cleft palate (Muzaffar et al., 2001;Andersson et al., 2008;Lu et al., 2010), type of cleft repair (Landheer et al., 2010), cleft width (Parwaz et al., 2009;Landheer et al., 2010;de Agostino Biella Passos et al., 2014), age at the time of palatal closure (Andersson et al., 2008;Landheer et al., 2010) and surgical experience. ...
Objectives:
The aim of the study was to assess the influence of the experience of the surgeon on the occurrence of fistulas following palatoplasty.
Materials and methods:
A retrospective review was performed of consecutive children treated between 2006 and 2013 for cleft palate by a single surgeon. Cleft palate repair was performed using the von Langenbeck technique, Furlow palatoplasty, buccal flap or Vomer flap. Data was collected for age, sex, date of birth, syndrome, adoption, cleft palate type, type of repair, cleft width, fistula occurrence and location of fistula.
Results:
A total of 276 operations were performed in 200 children (Veau I, II, III, IV). Mean age at surgery was 21.9 months (range: 6.2 months to 26 years 8.3 months). Postoperatively, palatal fistulas occurred in eight patients (4.0%), however, the incidence was 3.0% in the non-adoption group and 9.7% in the adoption population. In this study there was no statistically significant evidence of a surgical learning curve, and no significant associations between fistula rate and sex, adoption, syndrome, cleft type, cleft width, or type of repair.
Conclusion and clinical relevance:
This study demonstrates a fistula formation rate of 3.0% for the non-adoption population and 9.7% for the adoption population. There was no statistically significant evidence of a learning curve during the first few years of performing cleft palate repair. No other independent risk factors for postoperative fistula formation were identified; however, the benefit of a vomer flap and subsequent reduction in fistula incidence was demonstrated.
... Rates of fistula development recorded in our patients were similar to or even lower than those of other publications (0-58%). [23][24][25] Most postoperative fistulas developed in patients with severe clefting (group A, 66.6%; group B, 62.5%) ( Table 2), which validates use of the palatal index to establish severity of cleft palate. 17,[26][27][28] This method allowed us to examine the relationship between severity of clefting (gauged by palatal index) and surgical outcomes. ...
... Rates of fistula development recorded in our patients were similar to or even lower than those of other publications (0-58%). [23][24][25] Most postoperative fistulas developed in patients with severe clefting (group A, 66.6%; group B, 62.5%) ( Table 2), which validates use of the palatal index to establish severity of cleft palate. 17,[26][27][28] This method allowed us to examine the relationship between severity of clefting (gauged by palatal index) and surgical outcomes. ...
The 2-flap palatoplasty technique is actually the approach most commonly used in the United States for cleft palate repair. This is a one-time surgery that enables closure under minimal tension, lowering rates of subsequent fistula development. However, its primary disadvantage is potential detriment to maxillary growth (due to extent of dissection on both sides of the cleft and raw lateral surfaces). Since 2007, a surgical technique using only one mucoperiosteal flap from the noncleft side has been performed by us, reducing the extent of the surgery and its potential nondesirable effects over the palate. The purpose of this study is to evaluate the utility of this technique for unilateral cleft palate repair.
This is a retrospective, simple-blinded cohort study between 2 groups of 120 patients each with unilateral cleft palate who were operated on using the 2-flap and 1-flap techniques by the Outreach Surgical Center Program Lima from 2007 to 2012. Data collection was accomplished by physical examination to evaluate the presence or absence of a fistula and to evaluate the presence of hypernasality. Postoperative bleeding was also studied.
We have observed no increase in the rate of fistulas and velopharyngeal insufficiency between these 2 studied groups (P = 0.801 and P = 1.000).
Use of a 1-flap technique for unilateral cleft palate repair allowed us to achieve results comparable to those of a 2-flap technique in terms of postoperative fistula development and hypernasal speech. Additional studies are required to evaluate the effect of this technique on palatal growth.
... Comparative analysis has been made more difficult given the inconsistency of reporting surgical outcome details, inclusion or exclusion of submucous cleft palate repair, a wide range of patient populations, and myriad surgical techniques. Many factors have been suggested to increase risk for development of an ONF, including surgeon's experience (Jackson et al., 2004), Treacher Collins syndrome (Bresnick et al., 2003), extent of cleft, procedure selection (Bekerecioglu et al., 2005;Bindingnavele et al., 2008;Steinbacher et al., 2011), and age at palatal closure (Bresnick et al., 2003). In the face of these challenges, the goal of this study was to perform a meta-analysis to answer the questions: What is the rate of ONF formation following primary cleft palate repair, and what risk factors are associated with their development? ...
Background:
Despite decades of craniofacial surgeons repairing cleft palates, there is no consensus for the rate of fistula formation following surgery. The authors present a meta-analysis of studies that reported on primary cleft palate to determine the rate of oronasal fistula and to identify risk factors for their development.
Methods:
A literature search for the period between 2000 and 2012 was performed. Articles were queried and strict inclusion and exclusion criteria were applied to focus on primary cleft palate repair. A meta-analysis of these data was conducted.
Results:
The meta-analysis included 11 studies, comprising 2505 children. The rate of oronasal fistula development was 4.9% (95% confidence interval, 3.8% to 6.1%). When analyzing a larger cohort, there was a significant relationship between Veau classification and the occurrence of a fistula (P < .001), with fistulae most prevalent in patients with a Veau IV cleft. The most common location for a fistula was at the soft palate-hard palate junction. One study used decellularized dermis in cleft repair with a fistula rate of 3.2%.
Conclusions:
Using 11 studies comprising 2505 children, we find the rate of reported fistula occurrence to be 4.9%. Furthermore, patients with a Veau IV cleft are significantly more likely to develop an oronasal fistula. When fistulae do occur, they do so most often at the soft palate-hard palate junction. A deeper understanding of fistula formation will help cleft palate surgeons improve their outcomes in the operating room and will allow them to effectively communicate expectations with patients' families in the clinic.
... After full review of each selected article, 44 were included in the final analysis ( Fig. 1). There were five randomized controlled trials 35,37,42,48,55 and 39 nonrandomized studies, [1][2][3]5,9,13,17,[21][22][23][24][25][26][27][28][29][30][31][32][33][34]36,[38][39][40][41][43][44][45][46][47][49][50][51][52][53][54]56,57 of which 10 were comparative studies and 29 were noncomparative. The mean Detsky score for the randomized controlled trials was 14, with two studies considered to be of high quality. ...
Background:
The development of an oronasal fistula after primary cleft palate repair has a wide variation reported in the literature. The aim of this review is to identify the reported oronasal fistula incidence to provide a benchmark for surgical practice.
Methods:
A systematic review was undertaken to investigate the incidence of fistula. Multiple meta-analyses were performed to pool proportions of reported fistulae, in each data set corresponding to the continent of origin of the study, type of cleft, and techniques of cleft palate repair used.
Results:
A total of 9294 patients were included from 44 studies. The overall incidence of reported fistula was 8.6 percent (95 percent CI, 6.4 to 11.1 percent). There was no significant difference in the fistula incidence corresponding to the continent of origin of each study or the repair technique used. The incidence of fistula in cleft lip-cleft palate was 17.9 percent, which was significantly higher (p = 0.03) than in cases of cleft palate alone (5.4 percent).
Conclusions:
Palatal fistulae were more likely to occur in cases of combined cleft lip-cleft palate, compared with cleft palate alone. The authors would recommend the prospective examination and recording of all fistulae to a standardized classification scheme.
Clinical question/level of evidence:
Therapeutic, III.
