Surgical Outcome of Two-Flap Palatoplasty at King Fahad Medical City: A Tertiary Care Center Experience

Abstract

The purpose of this study was to assess surgical outcomes of two-flap palatoplasty for management of cleft palate. Between January 2009 and January 2017, we recruited 29 nonsyndromic patients who underwent two-flap palatoplasty for cleft palate repair at the oral and maxillofacial department. Their medical records were procured, and surgical outcomes were assessed. Velopharyngeal insufficiency (VPI) was evaluated on the basis of speech assessment by a speech therapist. Speech abnormality (nasality, nasal emission, and articulation error) was assessed by a speech therapist using the GOSS-Pass test. Swallowing and regurgitation were assessed by a swallowing team. Fistula and wound dehiscence were clinically assessed by the primary investigator. Documented data were evaluated using statistical analysis. Among the study patients; 75.8 % had normal speech, 20.7 % developed VPI; 17.3% had hypernasality; 4.3% had hypernasality as well as nasal emission; 4.3% had hypernasality, nasal emission, and articulation errors; and 4.3% had articulation errors. Approximately 20% of the patients had fistulas (83.3% had oronasal fistulas and 16.7% had nasovestibular fistulas). Normal swallowing findings were noted in 93% of the patients. There were statistically significant relationships between age-repair and VPI (r=0.450, t=0.014), age-speech (r=0.525, t=0.003), and age-fistula development (r=0.414, t=0.026). Conversely, there were no significant relationships between age and dehiscence (r=0.127, t=0.512), age and swallowing (r=0.360, t=0.055), and age and regurgitation (r=0.306, t=0.106). Two-flap palatoplasty is a reliable technique with excellent surgical and speech outcomes. Early repair is associated with better speech outcome and less incidence of VPI.

Full text

[Clinics and Practice 2018; 8:1104] [page 104]
Surgical outcome of two-flap
palatoplasty at King Fahad
Medical City: A tertiary care
center experience
Alwaleed Khalid Alammar, Abdulsalam
Aljabab, Gururaj Arakeri
Department of Oral and Maxillofacial
Surgery, King Fahad Medical City,
Riyadh, Saudi Arabia
Abstract
The purpose of this study was to assess
surgical outcomes of two-flap palatoplasty for
management of cleft palate.Between January
2009 and January 2017, we recruited 29 non-
syndromic patients who underwent two-flap
palatoplasty for cleft palate repair at the oral
and maxillofacial department. Their medical
records were procured, and surgical outcomes
were assessed. Velopharyngeal insufficiency
(VPI) was evaluated on the basis of speech
assessment by a speech therapist. Speech
abnormality (nasality, nasal emission, and
articulation error) was assessed by a speech
therapist using the GOSS-Pass test.
Swallowing and regurgitation were assessed
by a swallowing team. Fistula and wound
dehiscence were clinically assessed by the pri-
mary investigator. Documented data were
evaluated using statistical analysis. Among
the study patients; 75.8 % had normal speech,
20.7 % developed VPI; 17.3% had hyper-
nasality; 4.3% had hypernasality as well as
nasal emission; 4.3% had hypernasality, nasal
emission, and articulation errors; and 4.3%
had articulation errors. Approximately 20% of
the patients had fistulas (83.3% had oronasal
fistulas and 16.7% had nasovestibular fistu-
las). Normal swallowing findings were noted
in 93% of the patients. There were statistically
significant relationships between age-repair
and VPI (r=0.450, t=0.014), age-speech
(r=0.525, t=0.003), and age-fistula develop-
ment (r=0.414, t=0.026). Conversely, there
were no significant relationships between age
and dehiscence (r=0.127, t=0.512), age and
swallowing (r=0.360, t=0.055), and age and
regurgitation (r=0.306, t=0.106). Two-flap
palatoplasty is a reliable technique with excel-
lent surgical and speech outcomes. Early
repair is associated with better speech out-
come and less incidence of VPI.
Introduction
Cleft lip and palate is one of the most
common congenital craniofacial deformities
of multifactorial etiology. They are highly
variable with regard to anatomical and func-
tional abnormalities among patients. Their
management requires a multi-team approach,
including oral and maxillofacial surgery, plas-
tic surgery, otolaryngology, pediatrics, genet-
ics, speech and language pathology, dietetics,
psychiatry, and other allied health special-
ties.1,2 The main goals of cleft palate repair are
achievement of normal speech and adequate
velopharyngeal function with minimal effect
on facial growth.3Surgical techniques and
timing depend on the deformity and surgeon
experience as well as preference.4Multiple
surgical techniques have been described to
achieve optimal results with a low complica-
tion rate.5Two-flap palatoplasty is one of the
most commonly used techniques for cleft
palate repair, which was described by Bardach
in Poland in 1967. This technique is a modifi-
cation and extension of existing techniques
that use nasal and oral mucoperiosteal flaps,
as described by Veau, to achieve closure of the
palatal cleft.6,7 Minimization of the area of
exposed bone of the hard palate to reduce any
adverse effects on maxillary growth8and
complete closure of the entire palatal cleft in a
single operation are perquisites for a good sur-
gical outcome.9There are many controversies
regarding the surgical technique and timing,
but most surgeons recommend repair at 12
months of age. Salyer et al. found that 8.92%
of patients developed speech abnormalities
attributable to velopharyngeal insufficiency
(VPI) in a retrospective study on 382 two-flap
palatoplasties over 20 years. In addition, they
found that 91.14% of the patients demonstrat-
ed normal resonance.10 A fistula is a known
complication of cleft palate repair, and its inci-
dence has been reported to range between
12% and 45%.11 Previous studies analyzing
surgeon experience with two-flap palatoplasty
have noted a low fistula rate of 3.4%.12-14 Few
studies have described incidences of wound
dehiscence, swallowing abnormality, and
regurgitation.15
Materials and Methods
This retrospective study performed in the
oral and maxillofacial department was
approved by the institutional review board of
King Fahad Medical City (IRB00010471).
Between January 2009 and January 2017, we
identified 44 patients who underwent palato-
plasty for cleft palate repair (performed by
one of the author, Abdulsalam Aljabab). Their
medical records were obtained, and postoper-
ative complications were assessed. Fifteen
patients were excluded (six were syndromic
and nine underwent a different technique of
the palatoplasty procedure). Postoperative
complications, including VPI, speech abnor-
mality, fistula formation rate, wound dehis-
cence, swallowing abnormality, and regurgita-
tion, were assessed. VPI was evaluated
according to speech assessment by a speech
therapist. Speech abnormality was assessed
by GOSS-Pass, which is a formal test for
Arabic speaking individuals. The test was
originally a British test for articulation and
resonance and for subjective assessment of
VPI. Fistula and wound dehiscence were clin-
ically assessed by the primary investigator. A
swallowing team assessed swallowing and
regurgitation.
Statistical analysis
Statistical analysis was performed using
Pearson correlation analysis involving r
square and P-value for each parameter. All
analyses were performed using SPSS (Version
22.0) software (IBM Corp., Armonk, NY,
USA).
Results
The study included 29 patients (58.6%
girls and 41.4% boys). The mean patient age
at palatoplasty was 16 (range 9-27) months.
Clinics and Practice 2018; volume 8:1104
Correspondence: Alwaleed Khalid Alammar,
Department of Oral and Maxillofacial Surgery,
King Fahad Medical City, Riyadh, Saudi
Arabia.
E-mail: alwaleed.alammar@gmail.com
Key words: Two-flap palatoplasty; Surgical
outcome; Cleft palate.
Contributions: AKA, drafting of the manu-
script, revision and review of the manuscript,
and approval of the final manuscript as sub-
mitted. AJ and GA, revision and review of the
manuscript, and approval of the final manu-
script as submitted. GA was involved in inter-
pretation of the statistical data. AJ was the pri-
mary operating surgeon; he conceptualized
and designed the study, AKA drafted the initial
manuscript and GA approved the final manu-
script as submitted.
Conflict of interest: the authors declare no
potential conflict of interest.
Funding: none.
Received for publication: 9 September 2018.
Revision received: 19 November 2018.
Accepted for publication: 19 November 2018.
This work is licensed under a Creative
Commons Attribution NonCommercial 4.0
License (CC BY-NC 4.0).
©Copyright A.K. Alammar et al., 2018
Licensee PAGEPress, Italy
Clinics and Practice 2018; 8:1104
doi:10.4081/cp.2018.1104

[page 105] [Clinics and Practice 2018; 8:1104]
The study included the entire spectrum of
cleft types, bilateral cleft lip and palate,
right unilateral cleft lip and palate, left uni-
lateral cleft lip and palate, and cleft palate
only (37.9%, 3.4%, 6.9%, and 51.7%,
respectively) (Table 1). 22 patients had nor-
mal speech, 6 patients developed VPI;4
patients had only hypernasality; one patient
had hypernasality as well as nasal emission;
one patient had hypernasality, nasal emis-
sion, and articulation errors; and one patient
had only articulation errors (Table 2).
Fistulas were noted in 20% of the patients
(83.3% had oronasal fistulas and 16.7% had
nasovestibular fistulas). All fistulas were
conservatively managed, and complete
healing was noted in later follow-ups.
Swallowing assessments showed that 93%
of the patients had a normal pattern. Two
patients had swallowing abnormality, one
patient had nasal regurgitation, and one
patient had nasal regurgitation as well as
silent aspiration. There were statistically
significant relationships between age at
repair and VPI (r=0.450, t=0.014), age and
speech (r=0.525,t=0.003), and age and fistu-
la development (r=0.414, t=0.026).
Conversely, there were no statistically sig-
nificant relationships between age and
dehiscence (r=0.127, t=0.512), age and
swallowing (r=0.360, t=0.055), and age and
regurgitation (r=0.306, t=0.106).
Discussion
Many authors have reported on early
palatal repair and its beneficial effects on
speech.16,17 Haapanen and Rantala found that
speech was significantly better in children
who underwent palatoplasty between 12 and
18 months of age than in those who under-
went the procedure later.17 Dorf and Curtin
used 12 months of age as a dividing point
between early and late palatal repair.16 They
found that speech was better, with fewer
compensatory articulations, in those who
underwent early palatal repair. Conversely, it
was noted that if repair is performed too
early, there is no additional benefit. Salyer et
al. reported that patients achieved consistent-
ly high standards of articulation with a very
low incidence of compensatory articulation
when palatoplasty was performed before 12
months of age.9These authors also found a
significant increase in the rate of secondary
surgery for VPI when patients underwent
palatoplasty at >18 or <12 months of age.9In
our study, we found that patients who under-
went early palatoplasty had better speech
outcomes and a reduced incidence of VPI.
All patients who developed speech abnor-
mality showed improvement with speech
therapy. In addition, 6 (20.6%) of our
patients missed their follow-up for speech
therapy. Therefore, patient education is very
important to achieve better outcomes. The
complication of fistula may present any-
where along the palate. It is usually a result
of inadequate dissection of the flaps, closure
under tension, postoperative bleeding,
hematoma formation between the oral and
nasal layers, or infection. Some studies con-
sider the presence of a palatal fistula as fail-
ure of the surgical technique.4In our study,
we found that approximately 20% of our
patients had fistulas. In addition, all patients
who had fistulas did not have postoperative
complications that could contribute to fistula
formation, such as hematoma or infection.
Indeed, we found a statistically significant
relationship between age and fistula forma-
tion (r=0.414, t=0.026); thus, age at repair
had a large impact on the incidence of com-
plications. In our study, 93% of the patients
had normal swallowing findings, whereas
the remaining patients had swallowing
abnormality, nasal regurgitation, and one
patient had nasal regurgitation as well as
silent aspiration.
Conclusions
Two-flap palatoplasty is a reliable tech-
nique with excellent surgical and speech
outcomes. Early and regular speech assess-
ments, patient education, and appropriate
treatment when indicated are integral
aspects of a multidisciplinary approach to
achieve good speech outcomes.
References
1. Myers EN, Carrau RL. Cleft lip and
palate: comprehensive treatment and tech-
nique. In: Myers EN, Carrau RL.
Operative otolaryngology head and neck
surgery. Philadelphia: Saunders Elsevier;
2008. pp 765-790.
2. Dong Y, Dong F, Zhang X, Hao, et al. An
effect comparison between Furlow double
opposing Z-plasty and two-flap palato-
plsty on velopharyngeal closure. Int J Oral
Maxillofac Surg 2012; 41:604-11.
3. Sadler TW. Head and neck embryology. In
Sadler TW, ed. Langman’s medical
embryology. 6th ed. Baltimore: Williams
& Wilkins: 1990. pp 313-320.
4. Agrawal K. Cleft palate repair and varia-
tions. Indian J Plast Surg 2009;42: S102-9.
5. Latham RA. Anatomy of the facial skele-
ton in cleft lip and palate. In: McCarthy
JG, ed. Plastic surgery. Vol. 4.
Philadelphia: WB Saunders; 1990. pp
2581.
6. Bardach J. Two-Flap palatoplasty:
Bardach’s technique. Oper Tech Plast
Reconstr Surg 1995;2:211-4.
7. Bardach J, Salyer KE. Surgical techniques
in cleft lip and palate. 2nd ed. St Louis:
Mosby Year Book; 1991. pp. 224-273.
8. Bardach J, Kelly KM. Does interference
with mucoperiosteum and palatal bone
affect craniofacial growth? An experimen-
tal study in beagles. Plast Reconstr Surg
1990;86:1093-100.
9. Salyer KE, Sng KW, Sperry EE. Two-flap
palatoplasty: 20-year experience and evo-
lution of surgical technique. Plast Reconstr
Surg 2006;118:193-204.
10. Sullivan SR, Jung YS, Mulliken JB.
Outcomes of cleft palatal repair for inter-
nationally adopted children. Plast
Reconstr Surg 2004;133:1445-52.
11. Smith DM, Vecchione L, Jiang S, et al.
The Pittsburgh fistula classification sys-
tem: a standardized scheme for the
description of Palatal fistulas. Cleft Palate-
Craniofac J 2007;44:590-4.
12. Andrades P, Espinosa-de-los-Monteros A,
Shell DH, et al. The importance of radical
intravelar veloplasty during two-flap
palatoplasty. Plast Reconstr Surg
2008;122:1121-30.
13. Vlastos IM, Koudoumnakis E, Houlakis
M, et al. Cleft lip and palate treatment of
530 children over a decade in a single cen-
ter. Int J Pediatr Otorhinolaryngol
2009;73:993-7.
14. Sullivan SR, Marrinan EM, LaBrie RA, et
al. Palatoplasty outcomes in nonsyn-
dromic patients with cleft palate: a 29-year
assessment of one surgeon’s experience. J
Craniofac Surg 2009;20:612-6.
15. Fujikawa H, Wakami S, Motomura H. The
influence of palatoplasty on eating func-
tion. Plast Reconstr Surg Global Open
2016;4:e840.
16. Dorf DS, Curtin JW. Early cleft palate
repair and speech outcome. Plast Reconstr
Surg 1982;70:74.
17. Haapanen ML, Rantala SL. Correlation
between the age at repair and speech out-
come in patients with isolated cleft palate.
Scandin J Plast Reconstr Surg Hand Surg
1992;26:71.
Brief Report
Table 1. Cleft type.
Bilateral cleft lip and palate 11 37.9%
Cleft palate 15 51.7%
Unilateral cleft lip and palate - Left 1 3.4%
Unilateral cleft lip and palate - Right 2 6.9%
Table 2. Speech assessment.
Normal speech 22 75.8%
Articulation errors 2 8.6%
Hypernasality 6 20.6%
Nasal emission 2 8.6%