Longitudinal Speech and Fistula Outcomes Following Primary Cleft Palate Repair at a Single Institution.

INTRODUCTION: Fistula formation and velopharyngeal insufficiency (VPI) are complications of cleft palate repair that often require surgical correction. The goal of the present study was to examine a single institution's experience with cleft palate repair with respect to fistula formation and need for surgery to correct velopharyngeal dysfunction. METHODS: Institutional review board approval was obtained. Patient demographics and operative details over a 10-year period were collected. Primary outcomes measured were development of fistula and need for surgery to correct VPI. Chi-square tests and independent t tests were utilized to determine significance (0.05). RESULTS: Following exclusion of patients without enough information for analysis, 242 patients were included in the study. Fistulas were reported in 21.5% of patients, and surgery to correct velopharyngeal dysfunction was needed in 10.7% of patients. Two-stage palate repair was associated with need for surgery to correct VPI (P = 0.014). Furlow palatoplasty was associated with decreased rate of fistula formation (P = 0.002) and decreased need for surgery to correct VPI (P = 0.014). CONCLUSION: This study reiterates much of the literature regarding differing cleft palate repair techniques. A 2-stage palate repair is often touted as having less growth restriction, but the present study suggests this may yield an increased need for surgery to correct VPI. Prior studies of Furlow palatoplasty have demonstrated an association with higher rates of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be due to the use of the Children's Hospital of Philadelphia modification. This study suggests clinically superior outcomes of the Furlow palatoplasty over other techniques.

Dehiscence and Fistula Formation Following Anterior Palatal Reconstruction With Vomer Flap.

BACKGROUND AND PURPOSE: Anterior palatal reconstruction using vomer flaps has been described during primary cleft lip repair. In this procedure, the mucoperiosteal tissue of the vomer is elevated to reconstruct the nasal mucosa overlying the cleft of the hard palate. Here the authors, evaluate the efficacy of a technique in which a superiorly based vomer flap is sutured to the lateral nasal mucosa. The authors assess vomer flap dehiscence rates and compare the likelihood of fistula development in this cohort to patients who underwent palatoplasty without vomer flap reconstruction. METHODS: A retrospective chart review was conducted of all palatoplasties performed by the senior author at an academic institution during a 7-year period. Medical records were reviewed for demographic variables, operative characteristics, and postoperative complications up to 1 year following surgery. Logistic regression analysis was conducted to assess the effects of vomer flap reconstruction on fistula formation, adjusting for age and sex. RESULTS: Fifty-eight (N=58) patients met the inclusion criteria. Of these, 38 patients (control group) underwent cleft palate reconstruction without previous vomer flap placement. The remaining 20 patients underwent cleft lip repair with vomer flap reconstruction before palatoplasty (vomer flap group). When bilateral cases were counted independently, 25 total vomer flap reconstructions were performed. Seventeen of these 25 vomer flap reconstructions (68%) were completely dehisced by the time of cleft palate repair. In the vomer flap group, 3 of the 20 patients (15%) developed fistulas in the anterior hard palate following the subsequent palatoplasty procedure. In the control group, only 1 of the 38 patients (2.6%) developed a fistula in the anterior hard palate. There was no significant association between cohorts and the development of anterior hard palate fistulas [odds ratio=10.88, 95% confidence interval (0.99-297.77) P =0.07], although analysis was limited by low statistical power due to the small sample size. CONCLUSIONS: In our patient population, anterior palatal reconstruction using a superiorly based vomer flap technique was associated with complete dehiscence in 68% of cases. Fistula formation in the anterior hard palate was also proportionately higher following initial vomer flap reconstruction (15% versus 2.6%). These results prompted the senior author to adjust his surgical technique to 1 in which the vomer flap overlaps the oral mucosa. While follow-up from these adjusted vomer flap reconstruction cases remains ongoing, early evidence suggests a reduced requirement for surgical revision following implementation of the modified technique.

Outcome of Nasal Layer Reinforcement With Autologous Dermis in Cleft Palate Repair on Postoperative Fistula Formation.

Palatal fistulae are challenging complications following cleft palate repair. The addition of acellular dermal matrix (ADM) to cleft palate repair has been shown to reduce fistula formation in previous studies. The use of autologous dermal graft has all the structural advantages of ADM, has less rejection and immunogenic potential, and is cost effective.A prospective study.Patients with Group II and III cleft palate (Nagpur Classification) without prior intervention for palatal repair in the Department of Plastic Surgery at PGIMER from January 2020 till June 2021.The addition of autologous dermal graft for palatoplasty.Outcome of the study was fistula development or exposure of dermal graft.Autologous dermal graft was harvested of average dimension of 8.73 cm2 (range 5.25-18 cm2) from groin region. Sixteen patients were included in the study. Among them, 2 patients (12.5%) developed postoperative fistula (Type III &V Pittsburgh Classification).Our study showed that the rates of postoperative fistula formation are comparable with prior literature using artificial dermal matrices.

Use of a haired angularis oris axial pattern flap in a dog to correct a large oronasal fistula secondary to resection of a hard palate multilobular osteochondrosarcoma.

A 6-year-old neutered male mixed-breed dog underwent curative-intent surgical resection of a hard palatal multilobular osteochondrosarcoma and closure of the defect using bilateral buccal mucosal flaps. However, failure of the flaps resulted in a massive hard palatal defect that was subsequently repaired using a haired skin angularis oris axial pattern flap. This report describes the clinical outcome using this surgical approach and novel complications encountered. Key clinical message: The haired skin angularis oris axial pattern flap appears to be a suitable and robust option for reconstruction of large palatal defects.

Utilisation d'un lambeau cutanée poilus avec rotation axiale au niveau de l'artère angularis oris chez un chien pour corriger une fistule oronasale volumineuse secondaire à la résection d'un ostéochondrosarcome multilobulaire du palais dur. Un chien croisé mâle castré de 6 ans a subi une résection chirurgicale à visée curative d'un ostéochondrosarcome multilobulaire du palais dur et une fermeture de l'anomalie par des lambeaux de la muqueuse buccale. Cependant, la défaillance des lambeaux a entraîné un défaut important du palais dur qui a ensuite été réparé à l'aide d'un lambeau de peau avec poils avec rotation axiale au niveau de l'artère angularis oris. Ce rapport décrit les résultats cliniques de cette approche chirurgicale et les nouvelles complications rencontrées.Message clinique clé :L'utilisation d'un lambeau de peau avec poils avec rotation axiale au niveau de l'artère angularis oris semble être une option appropriée et robuste pour la reconstruction des défauts importants du palais.(Traduit par Dr Serge Messier).

Management of chronic exogenous rhinolith with gingivonasal fistula: A case report.

Recurrent rhinorrhoea that occurs chronically, needs to consider the possibility of a fistula in the nasal cavity, which has the potential to form a rhinolith. We report the case of a 39-year-old man with complaints of recurrent rhinorrhoea since four years ago, accompanied by thick secretions, symptoms of post-nasal drips, and olfactory disturbances. The patient had a history of removing the left upper molar (molar I), which causes a fistula in the tooth extraction site, making it more likely for food and drink to enter the left nasal cavity. Anterior rhinoscopy examination revealed a white mass in the left inferior meatus and a purulent odour discharge. In addition, there were gingival defects of the first molar teeth, multi-sinusitis, and nasal septum deviation. Rinolith extraction was performed using functional endoscopic sinus surgery, submucosal resection, and repair of gingivo-nasal defects with rotational flaps. Follow-up for one week showed that the flap was in place and there were no complications.

Free Flap Reconstruction of Recalcitrant Defects in Cleft Palate Patients.

INTRODUCTION: Defects of the palate can be as a result of oronasal fistula of cleft patients and the ablative surgery of tumors. There are many studies about reconstruction of the defects of plate in the literature and most of them are related to tumor surgery. Despite the use of free flaps in cleft patients being not a new approach, the articles in the literature are very few. The authors describe the experience of oronasal fistula reconstructions with free flaps with a new modification of tensionless inset of the free flap's pedicle. PATIENTS AND METHODS: Between 2019 and 2022, 2 males and 1 female, 3 consecutive cleft patients underwent free flap surgery because of recalcitrant palatal defects. One patient had 5 and each of remain had 3 unsuccessful reconstructive attempts previously. The age of patients was ranged from 20 to 23 years old. Radial forearm flap was the option of oral lining reconstruction for all patients. In 2 patients, the flap was modified as a skin tail was linked to the flap for covering the pedicle as tensionless closure. RESULTS: There was a mucosal swelling in first patient who underwent classical pedicle inset as mucosal tunneling. In 1 patient there was a spontaneous bleeding from the anterior side of the flap and it stopped without medical interventions, spontaneously. There was no additional complication. All flaps survived without anastomosis problems. CONCLUSION: Incision of the mucosa rather than tunneling provides good surgical exposure and bleeding control and modified flap design may be beneficial and reliable for tensionless pedicle inset and covering.

Tongue Flap for Closure of Complex Oronasal Fistula.

Complex oronasal fistula is one of the most frequent secondary complications of cleft palate correction and is considered a reconstructive challenge. Tongue flaps are one of the procedures for the treatment of complex fistulas associated or not with multiple previous procedures, offering a high success rate, few complications, and problems during its development. This study evaluates the efficacy in terms of functionality, esthetic, donor area morbidity and clarifies surgical technique steps. Descriptive cohort study was performed between August 2011 to August 2021 where an anteriorly based dorsal tongue flap was performed in 30 patients with complex palatal fistulas, evaluating outcomes in terms of technique reproducibility and flap viability, correction of oronasal regurgitation, speech, donor site morbidity, complications, and esthetics. The senior author has used this technique with consistent clinical outcomes to improve complex oronasal fistula with minimal complications, with a good success rate in terms of correction of the palatal defect with imperceptible alteration of the lingual donor area. In addition, establishes a specific definition of persistence and recurrence of oronasal fistula. The tongue flap is considered the gold standard in complex oronasal fistula reconstructions with satisfactory outcomes, and it offers an adequate amount of vascularized tissue achieving fistula closure without functional or esthetic impairment of the donor area and is a highly reproducible technique.

Triple Layer Oronasal Fistula Repair Using Local Endonasal Flaps: Case Series of Three Patients.

Oronasal fistula (ONF) is a common complication encountered after palatoplasty. Repair is indicated when symptoms impact speech and swallowing. In spite of the variety of surgical approaches described to repair these defects, recurrence rates remain high. Traditionally, successful closure is said to be achieved in using a double-layered approach due to the three-dimensional aspect of the defect. The extent of the fistula into the nasal cavity has incited an increased curiosity in using local endonasal flaps. In recent years, endonasal reconstructive procedures have seen increased interest and application, from cranial base defect repairs to orbital reconstruction and beyond. The nasoseptal (NSF) and inferior turbinate flaps (ITF) possess a robust arterial supply and an exceptional reach with excellent results demonstrated in large defect repair. However, the use of these flaps in ONF repair is scarcely discussed in the literature, and their effectiveness is relatively undetermined. In this manuscript, we present a series of three patients who underwent a triple layer ONF closure, with the oral portion incorporating a turn-in mucosal flap plus a local palate rotation flap or greater palatine artery pedicled-rotation flap, and a NSF or an ITF for the nasal portion of the defect.

Wound Healing Following Palatoplasty Using Either Honey or Warm Saline Mouth Bath for Postoperative Wound Care: A Randomized-Controlled Study.

OBJECTIVE: To evaluate and compare the effect of honey or saline mouth bath for wound care on the rate of re-epithelisation of the lateral palatal defects and occurrence of early postoperative complications following palatoplasty. METHODOLOGY: This was a prospective randomized study on participants with non-syndromic cleft palate conducted at a tertiary health institution in Lagos, Nigeria. The test group received oral honey drops for post-operative care for an initial period of two weeks post-surgery, while the control group had regular oral toileting using a warm saline solution. The primary outcome was epithelisation of lateral palatal defect at 2- and 4-weeks post repair. Descriptive and comparative statistics were computed, and the p-value was set at <0.05. RESULTS: Fifty participants were recruited into the study, 24 in the Test group and 26 in the Control group. The frequency of occurrence of oronasal fistula in the Test group was 4.0% while in the Control group was 10.0%, however, this was not statistically significant. Complete epithelisation of the lateral palatal defect was clinically observed in 66.7% of the participants in the Test group at 2 weeks post-operation, while only 38.5% of participants in the Control group had clinically observed complete epithelisation at the same time point (ß = 1.70, p = .035, 95% CI 1.122-26.533). At four weeks, all wounds had epithelised irrespective of the study group. CONCLUSION: The application of honey appears to aid earlier epithelization of palatal surgical wounds following cleft palate repair and reduced the incidence of palatal fistula.

Sternohyoideus-sternothyroideus muscle flap to reconstruct oronasal fistulas due to maxillary cancer in four dogs.

OBJECTIVE: To describe the repair of oronasal fistulas in dogs treated for maxillary cancer, with a novel sternohyoideus-sternothyroideus muscle flap, and to report the outcome. ANIMALS: Client-owned dogs (n = 4) with oronasal fistulas related to cancer. STUDY DESIGN: Short case series. METHODS: Maxillary defects were caused by tissue destruction by the tumor and tumor response to radiation therapy in two cases and a complication of caudal maxillectomy in two cases, one of which had neoadjuvant radiation therapy. All tumors were >4 cm at the level of the maxilla. Flaps were harvested by transecting the ipsilateral sternothyroideus and sternohyoideus muscles from their origin at the manubrium and costal cartilage. The muscles were rotated around the base of the cranial thyroid artery and tunneled subcutaneously in the neck and through an incision in the caudodorsal aspect of the oral cavity. The muscle flap was sutured to the edges of the oronasal fistula. RESULTS: The flap reached as far rostral as the level of the first premolar without tension. All dogs had clinical signs that improved postoperatively. All dogs had partial dehiscence of the flap. CONCLUSION: This flap was associated with a high rate of complications; however, all flaps were used in challenging cases. Clinical signs related to oronasal fistula were improved in all dogs in this case series.

Tongue Flap for Management of Large Palatal Fistulas.

ABSTRACT: One of the worst complications after a primary palatoplasty is the lesion of the neurovascular bundle, results into a type of flap necrosis, having as a final consequence a residual palatine fistula.In our institution the authors usually use tongue flap to repair large fistulas.The authors retrospectively reviewed all patients with large palatal fistulas that were repaired with tongue flap at Fundacion Gantz between January 2002 and December 2020.Fundacion Gantz has 1.067 patients with palatal surgeries, with an incidence of 5,8% for palatal fistulas and 3,2% (n = 2) were considered large.Surgery was done on 24 patients with large residual palatal fistula, all of them with tongue flaps as outpatient surgery. Fifteen were girls and 9 were boys, between 13 and 40 years.The average size of the fistula was 2,5 cm and 100% are localized in the anterior palate.The incidence of complications with tongue flap was 12, 5%: 2 dehiscences and 1 persistent residual fistula. The authors had no complications in phonation due to the lingual donor area.The authors consider that this outpatient surgery, is a reprodutible and safe technique, with a low rate of complications, which allows us to recommend it for the treatment of large palatal fistulas.

The Palatal Fistula Closure Using Buccal Fat Graft After Palatoplasty for Cleft Palate: Two Case Reports.

Fistula recurrence is high after secondary follow-up operation to close the fistula after primary palatal surgery. Therefore, preventing fistula recurrence is important. Here, we describe the technique of closing palatal fistula after palatal surgery with a buccal fat graft in 2 cases. We elevate the mucosal flap around the palatal fistula, suture the nasal mucosa, transplant the buccal fat between the nasal and oral mucosa for the palatal fistula after palatal surgery, and suture the oral mucosa. Palatal fistula did not recur after surgery. This method is simple and useful for suturable fistula and does not require a local flap.

Surgical Team Trips to Vietnam: Implementation of a Dedicated Cleft Palate Perioperative Program Improves Fistula Rates.

BACKGROUND: ReSurge International is a nongovernmental organization that organizes surgical team trips to low- and middle-income countries. Cleft palate repair is commonly performed on these trips. A comprehensive cleft care program was implemented to help reduce postoperative palatal fistula rates. METHODS: A retrospective review of all patients undergoing cleft palate repair surgery with ReSurge International in Vietnam from 2013 through 2019 was performed. The cleft care program was implemented in 2018. This intervention involved preoperative education of patients and close postoperative monitoring. Critically, this program also provided closer access to providers. Subsequent follow-up was performed by a ReSurge physician. Parent-reported outcomes were assessed preoperatively and postoperatively using 5-point Likert-like survey questions. RESULTS: Two hundred three patients underwent cleft palate repair. The patients were older and of higher Veau classification than is usually seen in the United States. The palatal fistula rate in the preintervention group was 37.5% and 14.3% in the intervention group (P = 0.014). Patients without fistulas demonstrated improvements on parent-reported outcomes compared with those with fistulas, with food less likely to go up their nose (P < 0.001), less difficulty eating (P < 0.001), and more understandable speech (P = 0.015). CONCLUSIONS: Implementation of a comprehensive cleft palate program reduced postoperative fistula rates by more than 50%. Improvements in parent-reported outcomes were observed after surgery among patients without fistulas. The blueprint for improved outcomes in these more complex patients includes enhanced perioperative patient counseling, close follow-up, and maintenance of communication with patients.

Primary Palatoplasty With Intravelar Veloplasty Using Acellular Dermal Matrix Interpositional Graft.

ABSTRACT: The aim of this study was to analyze the effect of acellular dermal matrix (ADM) on fistula formation after primary palatoplasty using intravelar veloplasty for levator veli palatini muscle repair.This single-center retrospective study included patients who underwent primary palatoplasty with intravelar veloplasty for reorientation of the levator veli palatini muscles between April 2014 and March 2018. In the control group (group A) conventional intravelar veloplasty was performed, while in the ADM group (group B) intravelar veloplasty using ADM was performed. The study sample was composed of 162 patients, 81 in each of the 2 groups (A and B). In group B, securely dissected muscles were overlapped, and a pentagon-shaped ADM (AlloDerm, LifeCell Corp., Branchburg, NJ) of 1.6 mm mean thickness, 11.3 mm mean width, and 14.4 mm mean length was designed, and placed under the repaired levator muscle sling. The outcome variable was the occurrence of oronasal fistula within the first 6 months after surgery.Postoperative fistula formation was reported in 6 patients in group A (7.4%) and in 5 patients in group B (6.2%). There was no statistically significant difference between the 2 groups (P = 0.755). There were 7 cases of ADM exposure and 2 cases of wound dehiscence in group B.The results of this study demonstrated that ADM use did not have any disadvantage with respect to oronasal fistula complications after intravelar veloplasty for levator veli palatini muscle repair.

Soft Palate Fistula in a Patient With Normal Palate as a Rare Complication After Septoplasty.

ABSTRACT: While the formation of a palatal fistula after septoplasty has been reported previously, it is a rare occurrence, especially in a patient with a normal palate. In most of the previous reports, the palatal fistulas were located on the hard palate and associated with various underlying conditions. Here, we present a case of soft palate fistula which developed in a patient with a normal palate after septoplasty. The 20-year old woman complained of liquid regurgitation after her septoplasty procedure. A pin-point size fistula opening was observed on the soft palate. A shallow depression was identified at the junction between the hard and soft palate by a computed tomography scan done before surgery. The fistula was subsequently repaired through a palatal flap. After surgery, the defect was completely closed, and the patient had no more symptoms. In addition, we review the previously reported cases of palatal fistula after septoplasty.

A Toolbox of Surgical Techniques for Palatal Fistula Repair.

OBJECTIVE: To provide an inventory of oronasal fistula repair techniques alongside expert commentary on which techniques are appropriate for each fistula type. DESIGN: A 4-stage approach was used to develop a consensus on surgical techniques available for fistula repair: (1) in-person discussion of oronasal fistula cases among cleft surgeons, (2) development of a schema for fistula management using transcripts of the in-person case discussion, (3) evaluation of the preliminary schema via a web-based survey of additional cleft surgeons, and (4) revision of the management schema using survey responses. PARTICIPANTS: Six cleft surgeons participated in the in-person case discussion. Eleven additional surgeons participated in the web-based survey. Participants had diverse training experiences, having completed residency and fellowship at 20 different hospitals. RESULTS: A schema for fistula management was developed, organized by fistula location. The schema catalogues all viable approaches for each location. For fistulae involving the soft palate, the schema stresses the importance of evaluating for velopharyngeal insufficiency (VPI) and incorporating VPI management into fistula repair. For fistulae involving the hard palate, the schema separately enumerates the techniques available for nasal lining repair and for oral lining repair in each region. The schema also catalogues the diversity of approaches to lingual- and labioalveolar fistula, including variation in timing, orthodontic preparation, and simultaneous alveolar bone grafting. CONCLUSIONS: This study employed consensus methods to create a comprehensive inventory of available fistula repair techniques and to identify preferential techniques among a diverse group of surgeons.

Is Risk of Secondary Surgery for Oronasal Fistula Following Primary Cleft Palate Repair Associated With Hospital Case Volume and Cost-to-Charge Ratio?

OBJECTIVE: This study assesses the association between risk of secondary surgery for oronasal fistula following primary cleft palate repair and 2 hospital characteristics-cost-to-charge ratio (RCC) and case volume of cleft palate repair. DESIGN: Retrospective cohort study. SETTING: This study utilized the Pediatric Health Information System (PHIS) database, which consists of clinical and resource-utilization data from >49 hospitals in the United States. PATIENTS AND PARTICIPANTS: Patients undergoing primary cleft palate repair from 2004 to 2009 were abstracted from the PHIS database and followed up for oronasal fistula repair between 2004 and 2015. MAIN OUTCOME MEASURE(S): The primary outcome measure was whether patients underwent oronasal fistula repair after primary cleft palate repair. RESULTS: Among 5745 patients from 45 institutions whom met inclusion criteria, 166 (3%) underwent oronasal fistula repair within 6 to 11 years of primary cleft palate repair. Primary palatoplasty at high-RCC facilities was associated with a higher rate of subsequent oronasal fistula repair (odds ratio [OR] = 1.84 [1.32-2.56], adjusted odds ratio [AOR] = 1.81 [1.28-2.59]; P ≤ .001). Likelihood of surgery for oronasal fistula was independent of hospital case volume (OR = 0.83 [0.61-1.13], P = .233; AOR = 0.86 [0.62-1.20], P = .386). Patients with complete unilateral or bilateral cleft palate were more likely to receive oronasal fistula closure compared to those with unilateral-incomplete cleft palate (AOR = 2.09 [1.27-3.56], P = .005; AOR = 3.14 [1.80-5.58], P < .001). CONCLUSIONS: Subsequent need for oronasal fistula repair, while independent of hospital case volume for cleft palate repair, increased with increasing hospital RCC. Our study also corroborates complete cleft palate and cleft lip as risk factors for oronasal fistula.

Efficacy of Staged Oronasal Fistula Reconstruction and Improved Bone Graft Survival in Cleft Patients Undergoing Secondary Reconstruction.

OBJECTIVE: To evaluate the efficacy of the senior author's technique of staged reconstruction in patients with recalcitrant oronasal fistulas. DESIGN: A retrospective review of the Pediatric Plastic Surgery Cleft & Craniofacial Surgery Database of cases from September 2013 to December 2018 was conducted. PATIENTS: A total of 31 patients who had previously undergone >1 surgical attempt to repair a fistula or patients who have failed >1 attempt at bone graft were included in this study. All patients were referrals from outside facilities. MAIN OUTCOME MEASURES: Primary outcomes examined included fistula recurrence, infection rates, ability to proceed with second stage bone grafting after first stage fistula takedown and reconstruction, and bone graft loss. RESULTS: Charts of 1053 patients were reviewed and 31 (2.94%) cases met inclusion criteria for this study. Nineteen (61.3%) of these patients proceeded with the second stage of reconstruction and 100% did not experience any graft loss. Seven patients who completed the first stage are undergoing orthodontic optimization prior to bone grafting. The remaining 5 are adult patients not interested in pursuing bone grafting. All 31 patients with recurrent and recalcitrant fistulas had successful fistula reconstruction with our approach, despite multiple previous failed reconstructions. CONCLUSIONS: The 2-staged reconstructive approach described herein effectively resulted in resolution of prior recurrent recalcitrant fistulas and resulted in eventual bone grafting. By employing this technique, we report successful fistula repair and bone grafting in patients who had previously undergone multiple surgical reconstructions.

Oronasal Fistula Incidence Associated With Vomer Flap Repair of Cleft Palate: A Systematic Review and Meta-Analysis.

OBJECTIVES: To determine the incidence of oronasal fistulas (ONF) associated with primary repair of the anterior palate using a single-layered, superiorly based, vomer mucoperiosteal flap. DESIGN: A systematic review of MEDLINE, PubMed, Cochrane, and Web of Science databases using the keywords: "vomer flap" and "cleft palate repair" were carried out. A meta-analysis was performed using random effect modeling with stratified analysis by syndromic diagnosis, number of surgeons, and mean age. MAIN OUTCOME MEASURE(S): Incidence of ONFs. RESULTS: The meta-analysis included 9 studies with a total of 464 children who met inclusion criteria. The overall ONF rate was 3.0% (95% CI: 1.0-9.0). Fistula rates were not significantly different in studies that included syndromic patients compared to studies that did not, 5.0% (95% CI: 1.0-24.0) versus 3.0% (95% CI: 1.0-6.0), respectively. There was no significant difference between studies in which there was a single surgeon versus multiple surgeons, 3.0% (95% CI: 1.0-13.0) versus 4.0% (95% CI: 1.0-8.0), respectively. Age at the time of cleft repair showed no statistically significant difference in fistula rate when comparing children with a mean age less than 12 months to those greater than 12 months, 3.0% (95% CI: 1.0-5.0) versus 5.0% (95% CI: 1.0-28.0), respectively. CONCLUSIONS: The vomer flap technique in cleft palate repair appears to be associated with a low ONF rate unaffected by syndromic diagnosis, number of surgeons, or patient age at time of repair.

Does the Children's Hospital of Philadelphia Modification Improve the Fistula Rate in Furlow Double-Opposing Z-Plasty?

PURPOSE: Oronasal fistulas (ONFs) have been the most common complication of primary cleft palatoplasty. The present study evaluated the incidence of ONFs after primary standard Furlow and modified Furlow palatoplasty and a buccal fat pad flap (BFPF) as a viable tissue layer to facilitate wound healing. PATIENTS AND METHODS: A retrospective cohort study was conducted. The data from all the patients who had met the criteria for primary palatoplasty from 2003 to 2016 and had undergone surgery by a single surgeon were retrospectively reviewed from an established cleft databank. An initial group of patients (2003 to 2007; standard Furlow palatoplasty) and a subsequent group (2008 to 2016; modified Furlow palatoplasty), all of whom had received the BFPF, were evaluated. The primary outcome variable was the development of palatal fistula. An additional outcome predictor included single versus staged palatoplasty. A χ2 analysis using a 1-tailed Fisher exact test was used, with statistical significance established at P ≤ .05 to determine the difference in ONF development using different operative techniques. RESULTS: A total of 49 patients had undergone standard Furlow palatoplasty, with an ONF rate of 22.4%. Of the 49 patients, 28 had had isolated cleft palate (ICP; 6 ONFs), 12 had had unilateral cleft lip/palate (UCLP; 2 ONFs), 9 had had bilateral cleft lip/palate (BCLP; 3 ONFs). A total of 65 patients had undergone modified Furlow palatoplasty with a BFPF, with a total ONF rate of 3%. Of the 65 patients, 40 had had ICP (1 ONF), 18 had had UCLP, and 7 had had BCLP (1 ONF). This difference in the ONF rate was statistically significant (P = .0015). The staged repairs resulted in an ONF rate (22.6%) that was significantly greater (P = .029) than the rate with nonstaged repairs (7.1%). The occurrence of ONFs tended to be greater in the patients with BCLP, syndromic patients, after staged repairs, and patients with wide cleft defects. CONCLUSIONS: A reduced ONF rate appeared to be associated with the modified Furlow palatoplasty and single-stage palatoplasty. Among the cleft types, BCLP showed a tendency to an increased postoperative ONF rate.