Two-stage palatal repair in non-syndromic CLP patients using anterior to posterior closure is associated with minimal need for secondary palatal surgery.

OBJECTIVE: The aim of the present study was to assess the need for secondary palatal corrective surgery in a concept of palate repair that uses a protocol of anterior to posterior closure of primary palate, hard palate and soft palate. METHODS: A data base of patients primarily operated between 2001 and 2021 at the Craniofacial and Cleft Care Center of the University Goettingen was evaluated. Cleft lips had been repaired using Tennison Randall and Veau-Cronin procedures in conjunction with alveolar cleft repair. Cleft palate repair in CLP patients was accomplished in two steps with repair of primary palate and hard palate first using vomer flaps at the age of 10-12 months and subsequent soft palate closure using Veau/two-flap procedures 3 months later. Isolated cleft palate repair was performed in a one-stage operation using Veau/two-flap procedures. Data on age, sex, type of cleft, date and type of surgery, occurrence and location of oronasal fistulae, date and type of secondary surgery performed for correction of oronasal fistula (ONF)and / or Velophyaryngeal Insufficiency (VPI) were extracted. The rate of skeletal corrective surgery was registered as a proxy for surgery induced facial growth disturbance. RESULTS: In the 195 patients with non-syndromic complete CLP evaluated, a total number of 446 operations had been performed for repair of alveolar cleft and cleft palate repair (Veau I through IV). In 1 patient (0,5%), an ONF occurred requiring secondary repair. Moreover, secondary surgery for correction of VPI was required in 1 patient (0,5%) resulting in an overall rate of 1% of secondary palatal surgery. Skeletal corrective surgery was indicated in 6 patients (19,3%) with complete CLP in the age group of 15 - 22 years (n = 31). CONCLUSIONS: The presented data have shown that two-step sequential cleft palate closure of primary palate and hard palate first followed by soft palate closure has been associated with minimal rate of secondary corrective surgery for ONF and VPI at a relatively low need for surgical skeletal correction.

Early feeding after free flap reconstruction of the oral cavity: A systematic review and meta-analysis.

BACKGROUND: Traditionally, patients undergoing free flap reconstruction for oral cavity defects have been given nothing by mouth for 6-14 days post-operatively due to concern for orocutaneous fistula development. METHODS: Multiple databases were screened for studies assessing the rate of orocutaneous fistula formation in early (≤5 days) versus late (>5 days) feeding groups following oral cavity free flap reconstruction. Fixed- and random-effects meta-analyses were used. RESULTS: One randomized controlled trial, one prospective cohort, and three retrospective cohort studies were included. The early feeding group displayed no significant increase in orocutaneous fistula formation (RD = -0.02, p = 0.06) or free flap failure (RD = -0.01, p = 0.39), with a significantly shorter hospital length of stay (mean difference [days] = -2.43, p < 0.01). CONCLUSIONS: While further prospective trials are necessary, initiation of oral intake before post-operative day 5 may be appropriate in properly selected patients following oral reconstruction.

Two-flap technique with interpositional dermofat graft for anterior oronasal fistula closure in patients with cleft: A case series.

BACKGROUND: Oronasal fistula at the anterior hard palate is one of the common sequelae after cleft surgery, and the leakage negatively affects the patient's quality of life. Although several surgical techniques have been proposed for reconstruction, it remains challenging because of the scarred regional tissue with a high rate of fistula recurrence. In this study, we present the anterior oronasal fistula repair using a two-flap technique with an interpositional dermofat graft (DFG). METHODS: A retrospective review of anterior oronasal fistula repair performed by the senior author between April 2018 and August 2022 at the Craniofacial Center was conducted. Patients who underwent a fistula repair using the technique were further identified and investigated. RESULTS: Thirty-four operations were performed using the technique, and 31 fistulas were completely closed, with a success rate of 91.2%. The fistula symptom improved but persisted postoperatively in 3 patients, of whom 2 patients underwent a second fistula repair using the same procedure, resulting in successful closure. Fistula recurrence was significantly correlated with fistula size (p = 0.04). The DFG was simultaneously utilized for nasal dorsum and/or vermillion reconstruction in 28 cases. CONCLUSION: The two-flap technique enabled tension-free approximation, and the interpositional DFG facilitated watertight closure of the fistula, resulting in a high success rate of anterior oronasal fistula repair. The fistula closure could be combined with other revisional procedures for cleft-related deformities, where the DFG was simultaneously utilized.

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 barrier membrane to repair congenital hard palate defects and to close oronasal fistulae remaining after cleft palate repair: seven dogs (2019-2022).

OBJECTIVE: To describe the use of a barrier membrane in dogs for repair of congenital hard palate defects and closure of oronasal fistulae (ONF) remaining after previous cleft palate (CFP) repair. ANIMALS: 7 client-owned dogs. METHODS: The hard palate defect was closed with medially positioned flaps (Von Langenbeck technique) or pedicle flaps (2-flap palatoplasty) and a membrane composed of autologous auricular cartilage from the pinna or allogenous fascia lata underlying the mucoperiosteal flaps. RESULTS: All palate defects were considered to have a high risk of dehiscence based on their type and size and the characteristics of the surrounding tissue. The barrier membrane was used in 5 dogs for repair of congenital hard palate defects and in 2 dogs for closure of ONF remaining after previous CFP repair. Resolution of clinical signs occurred in all cases. Complete success (ie, complete closure of the palate defect and absence of clinical signs) was achieved in 5 dogs (4 with congenital hard palate defects and 1 with an ONF remaining after previous CFP repair). The persistent ONF in 1 dog with functional success (incomplete closure, but no clinical signs) was smaller than prior to surgery. CLINICAL RELEVANCE: Barrier membranes underlying mucoperiosteal flaps may constitute an alternative technique in dogs for repair of congenital hard palate defects and closure of ONF remaining after previous CFP repair.

Anchored sutures for fixation of the anterolateral thigh flap and prevention of orocutaneous fistula in oral and oropharyngeal cancer reconstruction.

OBJECTIVE: This study aims to assess the efficacy of anchored sutures (AS) in securing the anterolateral thigh (ALT) flap during oral and oropharyngeal reconstructions, and its impact on the occurrence of orocutaneous fistula (OCF). MATERIALS AND METHODS: A retrospective study was performed on patients who underwent ALT flap reconstruction in our department in the year 2022. The patients were divided into two groups based on whether the AS technique was used. The incidence of OCF was compared between the two groups, and AS-related complications were reported. Fisher's exact test was employed to assess the differences in baseline characteristics and the incidence of OCF between the two groups. RESULTS: The study included 214 patients, with 156 in the conventional suture (CS) group and 58 in the AS group. The incidence of OCF in the AS group was significantly lower compared to that in the CS group (P = 0.039). However, there was a weak correlation between OCF and the AS technique (φ = -0.149). Among the 58 cases in the AS group, three (5.17%) experienced AS-related granuloma (ASRG) as complications. CONCLUSION: The use of ALT flap reconstruction with the AS technique reduces the incidence of OCF; however, ASRG may be a potential complication. CLINICAL RELEVANCE: This study demonstrates the effectiveness of AS technique in securing ALT flaps, leading to a decreased risk of OCF in oral and oropharyngeal defect reconstruction.

Surgical treatment for cleft palate in dogs yields excellent outcomes despite high rates of oronasal fistula formation: a narrative review.

Cleft palate is the most common congenital orofacial defect in dogs. Although this topic has been extensively studied in experimental dogs, current literature on clinical patients is limited to case reports and small case series studies with many individual opinions based on experience. This narrative review summarizes the literature of the last 10 years with application to clinical practice, focusing on the preparation of the patient until surgery, options for surgical management, and perioperative complications. Surgical treatment must be performed to obtain separation between the nasal/nasopharyngeal and oral/oropharyngeal passages. This will allow the dog to have independent function and reduce clinical signs associated with food, water, and other foreign material entering the respiratory tract. Surgical treatment has good to excellent outcomes when the procedure is carefully planned and appropriately executed despite the high rates of postoperative oronasal fistula reported.

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.

Intravelar veloplasty in submucous cleft palate without lateral relaxing incision or nasal mucosal incision.

BACKGROUND: Surgical treatment is recommended for patients with symptomatic submucous cleft palate once velopharyngeal insufficiency has been proven. This study describes the procedure and clinical outcomes of minimally invasive intravelar veloplasty. METHODS: From August 2013 to March 2017, seven patients (median age, 36 months; range, 16-60 months, 5 females and 2 males) with submucous cleft palate underwent intravelar veloplasty. Neither a nasal mucosal incision nor a lateral relaxing incision was applied. Follow-up was performed at least twice: once at three weeks postoperatively and again between two and three years postoperatively (average, 31 months; range, 26-35 months). Speech was assessed by speech-language pathologists when the patients were at least 3 years old. RESULTS: There were no cases of oronasal fistula or noticeable disturbance of facial development. All seven patients showed no or mild hypernasality and air emission and competent or at least borderline competent velopharyngeal function. CONCLUSION: Intravelar veloplasty could serve as another option for managing submucous cleft palate with velopharyngeal insufficiency, resulting in satisfactory improvement in velopharyngeal function. Because neither a lateral nor a nasal incision was used, the burden of facial growth and risk of oronasal fistula can be minimized.

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.

Rapid Additive Manufacturing of a Superlight Obturator for Large Oronasal Fistula in Pediatric Patient.

This study developed a novel digital workflow to fabricate a 3D printed hollow obturator for the prosthetic reconstruction of palatal fistula. It will provide cleft surgeons and therapists a choice for treating children with large palatal fistula before the appropriate age for surgical reconstruction. Laryngoscope, 133:1507-1512, 2023.

The Sommerlad-Furlow Modified Palatoplasty Technique: Postoperative Complications and Implicating Factors.

OBJECTIVE: To explore the incidence of postoperative complications and investigate the impact of preselected factors on functional and quality of life outcomes following the Sommerlad-Furlow modified palatoplasty technique. STUDY DESIGN: Retrospective cohort. METHODS: A total of 429 patients with cleft palate, who received Sommerlad-Furlow modified technique between 2011-2017 were enrolled. The postoperative complications including oronasal fistula (ONF), velopharyngeal insufficiency (VPI), and inadequate quality of life (QOL) were collected. Data of preselected factors including gender, age at palatoplasty, cleft type, cleft width, palatal width, pharyngeal cavity depth, and operation duration were also collected. RESULTS: Among 429 patients, 40.1% were males whereas 59.9% were females. The mean age at palatoplasty was 1.23 ± 0.69 (0.42-4) years, and the average cleft width was 10.15 ± 2.95 (4-27) mm. The cleft types had recorded rates of about 6.8%, 69.5%, 17.7%, and 6.1% of Veau I, II, III, and IV, respectively. The overall incidence rates of ONF, VPI, and inadequate QOL were 2.3%, 19.4%, and 31.3%, respectively. In both the univariate and multivariate analyses, the cleft type was significantly implicated in ONF formation (p = 0.023 and 0.032, respectively) whereas the velopharyngeal function was impacted by the palatoplasty age (p Ë‚ 0.001). The receiver operating characteristic curve indicated that age of palatoplasty ≥1.3 years (area under the curve = 0.611, p = 0.002) was the cutoff value for predicting the incidence of VPI. CONCLUSIONS: The Sommerlad-Furlow modified technique appears to have appropriate postoperative outcomes, even in the wide cleft palate. The older age at palatoplasty has a major impact on the overall postoperative outcomes. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:822-829, 2023.

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.

Endoscope-Assisted Multilayered Repair in Oronasal Fistula.

Oronasal fistula following cleft palate repair is a considerable complication with a recurrence rate of 33% to 37% and remains a challenging problem for surgeons. Furthermore, many patients have undergone several operations and experienced scar problems and other forms of morbidity. Therefore, we report a multilayered technique for oronasal fistula closure using an endoscopic nasal inferior turbinate composite graft with a palatal advance flap. This will increase the success rate after closure of small-sized oronasal fistula surgery without complications or recurrence (IRB: 2020-1671-0001).

Nasal Septal Flaps for Repair of Large or Recurrent Palatal Fistula: Report of Technique and 4-Year Experience.

SUMMARY: Large or multiply recurrent oronasal fistulas following cleft palate repair present a challenging problem. Nasal septal mucoperichondrial flaps have been widely used for repair of skull base defects; however, their use in the repair of oronasal cleft palate fistulas has not previously been described. In this pilot study, the authors describe anterior palatal fistula repair using a nasal septal flap and review their experience with this technique over 4 years. Fourteen patients with anterior palatal fistulas not amenable to repair using local palatal flaps were included for analysis. The mean size of the fistula was 12 mm in maximum dimension. Flap healing with complete or near-complete closure of fistula was achieved in 13 patients (93%). Five of these patients had a small, slit-like residual fistula that was asymptomatic. Nasal septal flaps are a new technique for repair of large or recurrent palatal fistulas. The procedure is well-tolerated with minimal side effects, high success rate, and low incidence of recurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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.

Otomicroscopic and functional outcomes after cleft palate repair via Sommerlad intravelar veloplasty vs. modified Veau-Wardill-Kilner push-back.

OBJECTIVE: We aim to compare the modified Veau-Wardill-Kilner push-back technique (VWK) and the Sommerlad intravelar veloplasty (Sommerlad IVVP) in terms of middle ear outcomes and oronasal fistulae frequency in three years old children. METHODS: For this retrospective cohort study, data were collected and anonymized from consecutive patients with cleft palate (with or without cleft lip) who underwent surgery in our hospital between January 2008 and December 2018. Patients with syndromic diagnoses and patients who underwent surgical treatment elsewhere were excluded. We collected data from 101 children (202 ears) regarding middle ear complications at the age of three, including acute otitis media, middle ear effusion, tympanic membrane retraction, tympanic membrane perforation, tympanic membrane atelectasis and chronic otitis media with cholesteatoma. In addition, the presence of oronasal fistulae and the number of ventilation tubes received by the age of three were recorded. RESULTS: The odds of children having a normal middle ear evaluation were 3.07 (95% Confidence interval (95%CI): [1.52, 6.12]; p < 0.05) times higher when children received Sommerlad IVVP compared to modified VWK. With 40.7% compared to 26.7%, a significantly higher incidence of middle ear effusion was present in the modified VWK group compared to Sommerlad IVVP (X2(1) = 4.38, p < 0.05). Furthermore, this group needed significantly more ventilation tube reinsertions (X2(2) = 12.22, p < 0.05) and was found to have a significantly higher incidence of oronasal fistula (53.5% vs. 17.2%, X2(1) = 14.75, p < 0.05). The latter was significantly associated with a higher need for ventilation tube reinsertion (X2(1) = 7.34, p < 0.05). CONCLUSION: This study shows superior middle ear outcomes and fewer oronasal fistulae after Sommerlad IVVP compared to modified Veau-Wardill-Kilner push-back at the age of three.