Staged repair of secondary cleft palate deformities

Association of Perioperative Antibiotics with the Prevention of Postoperative Fistula after Cleft Palate Repair

Background

There is debate amongst surgeons regarding the use of antibiotics to prevent fistulae after palatoplasty. Prescribing should be evidence based, as antibiotic stewardship is integral to reducing antibiotic resistance. Our aim was to determine whether differing perioperative regimens affect the prevalence of postoperative fistulae.

Methods

The sample comprised participants from the Cleft Collective who had undergone palatoplasty. Participants were recruited across all 16 UK cleft centers between 2013 and 2021. The exposure was perioperative antibiotic regimen prescribed at the time of palatoplasty. The primary outcome was the presence of palatal fistula.

Results

Fistula data were available for 167 participants when exploring antibiotic regimen and for 159 when exploring antibiotic agent. There was no evidence to suggest a difference in fistula rate between those receiving antibiotics on induction only versus as an inpatient or up to 7 days postoperatively (χ2 = 4.57; P = 0.10). There was no evidence to suggest a difference in fistula rate between those who received co-amoxiclav and those who had an alternative antibiotic (χ2 = 0.16; P = 0.69). Postoperative fistulae increased with the extent of the cleft (χ2 = 20.39; P < 0.001). When adjusting for cleft type, no evidence of an association between antibiotic regimen and fistulae was found (inpatient antibiotics: OR 1.36; 95% confidence interval, 0.53-3.51; antibiotics up to 7 days postoperatively: OR 0.68; 95% confidence interval, 0.26-1.80).

Conclusions

The choice of antibiotic and dosing regimen does not influence the formation of postoperative fistulae. These results should be supported by interventional trials.

Revision Surgery of the Cleft Palate

Cleft palate repairs often require secondary surgeries and/or revisions for a variety of reasons. The most common causes are symptomatic oronasal fistulas and velopharyngeal insufficiency. Complications from primary surgery, such as wound dehiscence, infection, and hematomas, contribute to the relatively high rate of revision surgery. Prevention of postoperative complications that may lead to fistula or velopharyngeal insufficiency is key, and many techniques have been described that have reportedly decreased the incidence of secondary surgery. Management varies depending on the nature of the fistulous defect and the type of velopharyngeal insufficiency. Numerous surgical options exist to fix this deficiency.

[Palatal fistula rate after Huaxi Sommerlad-Furlow palatoplasty]

OBJECTIVE

This study aimed to determine the palatal fistula rate, explore the influencing factors of Huaxi Sommerlad-Furlow (SF) palatoplasty.

METHODS

A retrospective review of 385 consecutive cleft-palate cases was performed to determine the incidence of postoperative fistula and assess the possible contributing factors, such as sex, weight, age, cleft type, operator skills, preoperative white blood cell, preventive antibiotic use, and postoperative temperature.

RESULTS

Fistulas occurred in 15/385 patients (3.9%). Among them, 1 fistula was located at the junction of the hard and soft palates, 12 fistulas in hard palate, and 2 fistulas in alveolar near the hard palate. No evidence suggested that sex, weight, age, preoperative white blood cell, preventive antibiotic use, and postoperative temperature are associated with fistula formation. The incidences of cleft palate fistulas as encountered by senior professors (3.03%) and associate senior professors (2.23%) were significantly lower than those by attending doctors (14.29%, P<0.05). The incidences of cleft palate fistulas in bilateral completely cleft palate cases (20.6%) were significantly higher than those in hard and soft (3.6%) and unilateral cleft palate cases (2.6%, P<
0.05).

CONCLUSIONS

Huaxi SF palatoplasty can avoid the inhibited maxillary growth without requiring lateral relaxing incision, which poses an acceptable risk of fistula formation. The palatal fistula rate is not related to the sex, weight, age of operation, prophylactic use of antibiotics before operation, infection before operation, temperature after operation and other factors. The occurrence of the fistula is related mainly to cleft type and experience level of the surgeon.

[Palato velar fistulae in cleft palate]

Palatal fistulas after primary closure of a cleft palate are extremely variable ranging from 15 to 35%. When they are symptomatic, these fistulas affect feeding (nasal regurgitation to liquids, discharge, bad smells) and phonation (hypernasality that can hinder the precise assessment of velar incompetence). First of all, it is important to analyze the cause of the fistula, it helps to avoid early recurrences. The correction must apply to respect the 2 mucosal planes (nasal mucosa and oral mucosa), the only guarantee of surgical success. Different techniques are usually described: lingual flap, lifting of all palatal mucosa, flap hinge, blaster, FAMM. In all cases, postoperative care plays a key role in the success of the surgical correction.

Custom-Made Palatal Shield Use in Cleft Palate and Fistula Repair: A Potential Benefit for Fast Postoperative Recovery

OBJECTIVE

To review our experience with a polymethylmethacrylate (PMMA) protective shield used as an adjunct to protect the newly restored palate in wide bilateral cleft and complex fistula closure without diet restrictions.

DESIGN

Clinical cohort study.

SETTING

Division of Plastic Surgery and Maxillary Surgery.

PATIENTS

A selection of 22 cleft palate children undergoing (tertiary) palatal fistula repair (n = 16) or closure of a complex wide primary palatal defect (n = 6).

INTERVENTIONS

One month prior to surgery, a plaster model of the palate was made adding a 5- to 8-mm-thick layer of dental putty to the level of the dental arch. On top of the putty, a 1.5-mm-thick PMMA shield was created to cover the postoperative elevated and restored palate.

MAIN OUTCOME MEASURES

Fistula recurrence rate, postoperative complications, days of hospitalization.

RESULTS

All patients maintained durable and safe palatal closure without fistula recurrence within the follow-up period, varying from 1 until 4 years. Recovery was fast, with a mean duration of hospitalization of 1.5 days. All patients could directly resume their normal diet.

CONCLUSIONS

A PMMA shield has been shown to be a safe and helpful adjunct in complex fistula repair and late anterior palate repair.

Primary Palatoplasty for Unilateral Cleft Lip and Palate Using Mucosal Grafts and Flaps

The mucosal graft and flaps method (MG method) is a palatoplasty technique that was developed for the purpose of improving maxillary growth in patients with cleft palate. In the MG method, full-thickness buccal mucosa is grafted onto the raw surface created by pushback palatoplasty. The method is unlikely to result in severe scarring and has a favorable effect on maxillary growth. In addition, it is unlikely to result in oronasal fistula and provides good speech results. Overall, postive long-term treatment results have been obtained. Although the MG method is technically difficult and requires a lengthy surgery, the technique is considered to be effective for palate closure in terms of speech and maxillary growth.

Acellular dermal matrix in palatoplasty

The primary goal of palatoplasty is to allow normal speech through the correction of velopharyngeal incompetence. Failure to accomplish a tension-free, watertight closure predisposes the palatoplasty patient to postoperative fistula formation. Fistulas may in turn contribute to velopharyngeal incompetence. Reported fistula rates vary widely, ranging from 0% to greater than 70%; recurrence rates after attempted repair approach 65% in some series. These lesions therefore represent a significant clinical burden. Acellular dermal matrix materials have been introduced into various phases of palatoplasty as a strategy to augment repairs and minimize postoperative fistula formation, as well as repair fistulas when they do occur. In this article, the authors review the existing literature regarding acellular dermal matrix in palatoplasty and describe their own algorithm and results for primary and secondary palatoplasty in which acellular dermal matrix plays a central role.

A successful algorithm for limiting postoperative fistulae following palatal procedures in the patient with orofacial clefting

BACKGROUND

Palatal procedures include (1) primary palatoplasty, (2) oronasal fistulas repair, and (3) secondary palatoplasty for velopharyngeal insufficiency. Any time a palatal procedure is performed, postoperative fistulas remain potential consequences. Presented here is a successful algorithm for performing palatal procedures and decreasing the rate of postoperative fistulas in a large, single-surgeon, consecutive series.

METHODS

A retrospective review of all consecutive palatal procedures performed between 2002 and 2006 including (1) primary palatoplasty, (2) oronasal fistulas repair, and (3) secondary palatoplasty for velopharyngeal insufficiency was performed. Cleft Veau type, surgical technique, and outcomes are reviewed. The algorithm included (1) relaxing incisions, (2) complete intravelar veloplasty, (3) total release of the tensor tendon, (4) dissection of the neurovascular bundle with optional osteotomy of the foramen, and (5) incorporation of acellular dermal matrix to achieve complete nasal lining reconstruction.

RESULTS

Two hundred sixty-eight palatal procedures were performed: (1) 132 primary Furlow palatoplasties yielding one symptomatic post-Furlow palatoplasty fistula (0.76 percent) (acellular dermal matrix was used in 39.4 percent of primary palatoplasties); (2) 55 oronasal fistula repairs yielding two symptomatic postoperative fistulas (3.6 percent) (acellular dermal matrix was used in 90.9 percent of fistula repairs); and (3) 81 secondary palatoplasties for velopharyngeal insufficiency resulting in no postoperative fistulas. Acellular dermal matrix was used in 14.8 percent of secondary palatoplasties for velopharyngeal insufficiency. No recommendations for speech surgery followed palatoplasty.

CONCLUSIONS

Using the proposed algorithm in this single-surgeon consecutive series of 268 cases, the authors achieved the lowest reported incidence of postoperative fistulas in all forms of palatal procedures, including the lowest incidence (0.76 percent) of symptomatic palatal fistulas following primary Furlow palatoplasty.

Fistula after 2-flap palatoplasty: a 20-year review

Oronasal fistula formation is a recalcitrant complication following palatoplasty, resulting in nasal emission during speech and deglutition. We review our series to identify factors associated with fistula incidence. A retrospective review of all children with nonsyndromic cleft palate who underwent 2-flap palatoplasty by the senior author from July 1983 to August 2004, was performed. Patient demographics, cleft characteristics, and operative techniques were recorded for each patient. The incidence rates of fistula, pharyngeal flap, and reoperation were used as primary outcomes. Statistical comparisons of frequencies were performed using Fisher exact test. Comparisons of means were performed using chi2 analysis. A total of 332 consecutive children met inclusion criteria. Mean age at palatoplasty was 10.8 months, and mean follow-up was 74.1 months. Eight children (2.4%) were found to have fistulae postoperatively, ranging in size from 2 to 15 mm. Four palatal fistulas occurred in the soft palate, 2 at the junction of the hard and soft palate, 1 in the hard palate, and 1 at the incisive foramen. Symptomatic nasal emission requiring reoperation occurred in 5 children. Two of these 5 children required a second operation to achieve fistula closure. Forty pharyngeal flaps were required for correction of velopharyngeal incompetence (12.0%). Two-flap palatoplasty remains a highly successful technique for closure of a variety of palatal clefts, with low fistula incidence. Surgical technique and experience are factors associated with low fistula incidence.

The Pittsburgh Fistula Classification System: a standardized scheme for the description of palatal fistulas

OBJECTIVE

Vague terminology is a problem in cleft palate research. No classification scheme for palatal fistulas has been proposed to date. Although a well-healed velum is a significant outcome of palatoplasty, it is nearly impossible to compare fistula-related palatoplasty results in the literature or in medical records without a standardized vocabulary. We endeavor to devise a palatal fistula classification system that may have clinical and research applicability.

DESIGN

PubMed was searched for definitions and classifications of palatal fistula as well as incidence and recurrence rates of this outcome. Next, a 25-year retrospective review of our Cleft Center's records was performed, and fistulas were identified (n=641 charts reviewed). The fistula descriptions yielded by this chart review were evaluated in the context of anatomical descriptions in the literature, and a clinician-friendly classification scheme was designed.

RESULTS

A literature review failed to reveal a standardized fistula classification system. An anatomically based numerical fistula classification system was devised: type I, bifid uvula; type II, soft palate; type III, junction of the soft and hard palate; type IV, hard palate; type V, junction of the primary and secondary palates (for Veau IV clefts); type VI, lingual alveolar; and type VII, labial alveolar.

CONCLUSIONS

We propose a standardized numerical classification system for palatal fistulas. Its clinical adoption may prospectively clarify ambiguities in the literature and facilitate future cleft palate research and clinical practice.

Surgical Technique for the Correction of Postpalatoplasty Fistulae of the Hard Palate

Postpalatoplasty fistulas of the hard palate remain challenging. The reported recurrence rate after surgical correction ranges between 33 and 37 percent. The authors describe a surgical technique for the correction of postpalatoplasty fistulas by total elevation of the palatal gingivoperiosteum starting at the dental sulcus, excision of the fistula, and watertight separate closure of the nasal and palatal mucosa by means of the transoral approach. This technique has the advantages of providing adequate exposure for closure of the nasal mucosal gap and allowing closure of the palatal defect under minimal tension. Placement of interdental sutures leaves no raw bone surfaces exposed. The authors have used this technique on 60 consecutive patients with fistulas of the primary and secondary hard palate between 1998 and 2003. Their overall success rate of fistula closure was 90 percent. The success rate for previously unoperated postpalatoplasty fistulas was 96.9 percent. All of the failures occurred in patients who had bilateral cleft lip and palate. No complications of tooth loss or gingival recession were observed. A detailed description of the technique with illustrations is provided.