Palatal fistula risk after primary palatoplasty: a retrospective comparison of humanitarian operations and tertiary hospitals

Plastic Surgical Outreach to Low- and Middle-income Countries and Global Health Priorities: An Analysis of 96 Nongovernmental Organizations

Background

Conditions that are treated by surgery constitute a significant portion of the global burden of disease. In low- and middle-income countries (LMICs), allocation of resources toward the most cost-effective surgical procedures (essential surgery) and care delivery platforms is critical. Nongovernmental organizations (NGOs) and the plastic surgeons who work with them play a significant role in plastic surgical outreach to LMICs. However, it is unknown whether their work aligns with existing global public health recommendations.

Methods

A previously established internet-based methodology was used to identify plastic surgical NGOs. Through direct correspondence with NGOs and publicly available data, plastic surgical NGOs were cataloged with respect to the subspecialty areas of plastic surgery performed, care delivery platforms, and geographic sites. These results were then compared with the existing global public health recommendations.

Results

A total of 96 NGOs met inclusion criteria. The most common subspecialty area was cleft surgery (80.3%), followed by pediatric plastic surgery (46.9%). No NGOs used a continuous care delivery platform. Instead, all NGOs used an intermittent model through short-term surgical missions, of which 62.8% used a nonrotating care model and returned to the same site(s) annually, whereas 37.2% used a rotating care model.

Conclusions

Most NGOs perform cleft surgery, an area considered essential surgery, and thus, collectively, the work of NGOs largely aligns with global public health priorities. However, there is room for improvement for both the types of procedures performed and the care delivery platforms to provide the most cost-effective and sustainable care.

Coordination and Pilot Implementation of a Standardized Data Collection for Touching Hands

PURPOSE

Touching Hands is an American Society for Surgery of the Hand program that provides hand surgeries to the world's underserved communities. The purpose of this study was to develop and implement a systematic data collection method for Touching Hands to assess patient outcomes, volunteer impact, alleviated disease burden, and cost-effectiveness.

METHODS

Research electronic data capture (REDCap) was used as the secure software platform to facilitate data collection. The Quick Disabilities of the Arm, Shoulder and Hand questionnaire was used to assess pre-and postoperative patient-reported outcomes. The Maslach Burnout Inventory-Human Services (Medical Personnel) survey was administered to volunteers before and after the mission to measure impact on volunteers. Case information was collected to calculate disability-adjusted life years and cost-effectiveness.

RESULTS

The data collection system was implemented in some capacity in 4 domestic and 3 international mission sites during 2020 and 2021.

CONCLUSIONS

Substantial limitations exist for the implementation of a systematic data collection framework for Touching Hands and warrant further modification and optimization.

CLINICAL RELEVANCE

A REDCap database can be used for standardized and centralized patient and volunteer data collection for Touching Hands missions.

Modified Buccal Myomucosal Flap Closure of Large Anterior Palatal Oronasal Fistulas

SUMMARY

Large oronasal palatal fistulas can be challenging to reconstruct. The authors present a modified buccal myomucosal flap repair technique and review intermediate-term outcomes. In this technique, large anterior palatal fistulas are closed in two layers. First, apposing nasal turnover flaps of vomer mucosa medially and nasal wall mucosa laterally are approximated. Second, a posteriorly based buccal flap incorporating full-thickness buccinator muscle and overlying mucosa is transposed with interposition of the flap in the retromolar trigone and lateral palate to preserve dental occlusion. Consecutive patient cases performed in low-resource settings were reviewed and outcomes reported. Among eight subjects aged 3 to 22 years, with average defect size of 2.5 cm2 (range, 0.8 to 3.5 cm2), the flap was viable in all cases and required revision or pedicle division in only two patients (25 percent); all patients showed symptom improvement. The modified buccal myomucosal flap shows promising intermediate-term results as a single-stage reconstruction suitable to a wide patient age range, low airway/anesthetic risk, reliable functional outcomes, and low comorbidity.

Analysis of the Intrinsic Predictors of Oronasal Fistula in Primary Cleft Palate Repair Using Intravelar Veloplasty

Introduction:

The purpose of the present study was to investigate various factors of cleft palate and to analyze their effect on fistula occurrence following palatal muscle repair using intravelar veloplasty.

Methods:

A retrospective review of patients who underwent palatoplasty was performed. Primary palatoplasty was performed by a single surgeon in a single center. A total of 165 patients who underwent palatoplasty were enrolled. Primary palatoplasty with levator veli palatini muscle repair using intravelar veloplasty was performed. Three extrinsic factors (age, gender, and body weight) and 6 intrinsic factors (cleft width, ratio of cleft width to intermaxillary tuberosity distance, cleft anterior margin shape, uvula position, cleft lip, and radical intravelar veloplasty) were analyzed.

Results:

Palatal fistula occurred in 11 (6.67%) patients. The occurrence of fistula was significantly correlated with a specific Veau classification, that is, type II ( P = .041). Fistula tended to occur more frequently with a wide cleft palate ( P = .063), and the high-risk cutoff value of the width was 7.75 mm.

Conclusions:

A larger cleft width tended to increase the occurrence of fistula. Close observation and information about the higher risk of fistula formation should be given to patients with a large cleft width who underwent intravelar veloplasty.

Veau III and Veau IV Cleft Palate: Do Peri-Operative Complications Differ?

OBJECTIVE

The Veau classification represents the most commonly used system for characterizing cleft palate severity. Conflicting evidence exists as to how increasing Veau classification affects outcomes. This study compared perioperative outcomes between Veau III and IV cleft palate repairs.

METHODS

The National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was used to identify cleft palate repairs between 2012 and 2016 using CPT codes. Patients with alveolar bone grafts were excluded. Veau III (unilateral) and Veau IV (bilateral) cleft palate repairs were identified using International Classification of Disease code 9 and 10 (ICD-9 and -10 codes. Patient demographics, comorbidities, and adverse events were compared between the cohorts.

RESULTS

A total of 5026 patients underwent cleft palate repair between 2012 and 2016. Of the 2114 patients with identifiable Veau classification, 1302 had Veau III cleft palates and 812 had Veau IV cleft palates.The Veau IV cleft palate patient population was older (377.8 versus 354.1 days, P < 0.001) and had significantly more comorbidities including a higher incidence of chronic lung disease (P = 0.014), airway abnormalities (P = 0.001), developmental delay (P = 0.018), structural central nervous system deformities (P < 0.001), and nutritional support (P < 0.001). Veau IV cleft palate repairs also had longer operative times (153.2 versus 140.2 minutes, P < 0.001). Despite significant differences in comorbidities and perioperative factors, there were no differences in 30-day complications, readmissions, or reoperation rates between Veau III and IV cleft palate repairs.

CONCLUSIONS

Patients undergoing Veau IV cleft palate repair have a significantly greater number of comorbidities than Veau III cleft palate repairs. Despite differences in patient populations, 30-day surgical outcomes are comparable between the cohorts.

Cleft Palate Repair: Description of an Approach, Its Evolution, and Analysis of Postoperative Fistulas

BACKGROUND

Fistulas following cleft palate repair impair speech, health, and hygiene and occur in up to 35 percent of cases. The authors detail the evolution of a surgical approach to palatoplasty; assess the rates, causes, and predictive factors of fistulas; and examine the temporal association of modifications to fistula rates.

METHODS

Consecutive patients (n = 146) undergoing palatoplasty during the first 6 years of practice were included. The technique of repair was based on cleft type, and a common surgical approach was used for all repairs.

RESULTS

The fistula rate was 2.4 percent (n = 125) after primary repair and 0 percent (n = 21) after secondary repair. All complications occurred in patients with type III or IV clefts. Cleft width and cleft-to-total palatal width ratio were associated with fistulas, whereas syndromes, age, and adoption were not. Most complications could also be attributed to technical factors. During the first 2 years, modifications were made around specific anatomical features, including periarticular bony hillocks, maxillopalatine suture, velopalatine pits, and tensor insertion. The fistula rate declined by one-half in subsequent years.

CONCLUSIONS

The authors describe a surgical approach to cleft palate repair, its evolution, and surgically relevant anatomy. Fistulas were associated with increasing cleft severity but could also be attributed to technical factors. A reduction in frequency and severity of fistulas was consistent with a learning curve and may in part be associated with modifications to the surgical approach.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Palatal Fistula Risk after Primary Palatoplasty

Background:

Humanitarian surgical organizations provide palatoplasties for patients without access to surgical care. Few organizations have evaluated the outcomes of these trips. This study evaluates the palatal fistula rate in patients from two cohorts in rural China and one in the United States.

Methods:

This study compared the odds of fistula formation among three cohorts whose palates were repaired between 2005 and 2009. One cohort included 97 Chinese patients operated on by teams from the United States and Canada under the auspices of Resurge International. They were compared to cohorts at Huaxi Stomatology Hospital and the University of California San Francisco (UCSF). Age, fistula presence, and Veau class were compared among cohorts using Chi-square tests. Logistic regression was used to analyze predictors of fistula formation.

Results:

The fistula risk was 35.4% in patients treated by humanitarian teams, 12.8% at Huaxi University Hospital and 2.5% at UCSF ( P < 0.001). Age and Veau class were associated with fistula formation (Age P = 0.0015; Veau P < 0.001). ReSurge and Huaxi patients had 20.2 and 5.6 times the odds of developing a fistula, respectively, compared to UCSF patients ( P < 0.01, both). A multivariable model controlling for surgical group, age, and gender showed an association between Veau class and the odds of fistula formation.

Conclusions:

Chinese children undergoing palatoplasty by international teams had higher odds of palatal fistula than children treated by Chinese surgeons in established institutions and children treated in the United States. More research is required to identify factors affecting complication rates in low-resource environments.

New biomaterials versus traditional techniques: advances in cleft palate reconstruction

PURPOSE OF REVIEW

Cleft lip and palate still remains one of the most common congenital anomalies, and consequently surgical correction of these anomalies is still commonplace. Despite numerous existing surgical techniques having good outcomes, it is still recognized that the morbidity of certain surgical procedures and success rates regarding outcomes can be improved. The purpose of this review is to evaluate new literature and techniques compared with the time tested procedures that are commonly used.

RECENT FINDINGS

As technology continues to advance, the understanding of details regarding biochemical pathways responsible for the development of cleft defects and also the efficacy of biomaterials that can be used in their correction are being discovered and better understood. Many studies have been conducted in both animal and human study participants that further the understanding of these questions. The efficacy and benefit of newly devised biomaterials seems to indicate that these biomaterials are a viable adjunct and often an alternative in the treatment of cleft palate patients.

SUMMARY

In this review of recent literature, the discussion begins with a review of the more traditional and widely accepted iliac crest bone grafting and then evolves into a discussion of several animal and human studies to delineate the progress being made in this field. The literature exploring the details regarding biochemical pathways and cellular mediators that are involved in cleft formation, as well as biomaterials used in surgical repair are evaluated. The findings in the literature suggest that there is a bright future in better understanding the cause of cleft formation on a molecular level and associated attempts that can be made in altering some of these factors along with discovering new biomaterials that can be a useful adjunct to existing techniques.

Cleft Lip and Palate Repair Using a Surgical Microscope

Background

Cleft lip and palate repair requires a deep and small surgical field and is usually performed by surgeons wearing surgical loupes. Surgeons with loupes can obtain a wider surgical view, although headlights are required for the deepest procedures. Surgical microscopes offer comfort and a clear and magnification-adjustable surgical site that can be shared with the whole team, including observers, and easily recorded to further the education of junior surgeons. Magnification adjustments are convenient for precise procedures such as muscle dissection of the soft palate.

Methods

We performed a comparative investigation of 18 cleft operations that utilized either surgical loupes or microscopy. Paper-based questionnaires were completed by staff nurses to evaluate what went well and what could be improved in each procedure. The operating time, complication rate, and scores of the questionnaire responses were statistically analyzed.

Results

The operating time when microscopy was used was not significantly longer than when surgical loupes were utilized. The surgical field was clearly shared with surgical assistants, nurses, anesthesiologists, and students via microscope-linked monitors. Passing surgical equipment was easier when sharing the surgical view, and preoperative microscope preparation did not interfere with the duties of the staff nurses.

Conclusions

Surgical microscopy was demonstrated to be useful during cleft operations.