Abstract: Effects of Cleft Width and Veau Type on Rates of Palatal Fistula and Velopharyngeal Insufficiency after Cleft Palate Repair (Plastic Surgery 2012)

Saturday, October 27, 2012: 2:55 PM

Nance Yuan, BA , Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD

Amir H. Dorafshar, MBChB , Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD

Keith E. Follmar, MD , Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD

Courtney Pendleton, BS , Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD

Richard J Redett, MD , Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD

Purpose: Rates of fistula and velopharyngeal insufficiency (VPI) after cleft palatoplasty have been linked to factors including Veau classification and surgical technique[1]. The impact of initial cleft width has only been rarely studied[2]. We explored the effect of cleft width on fistula and VPI outcomes.

Methods: We conducted a retrospective review of all patients undergoing primary cleft palatoplasty by a single surgeon between 2004 and 2011. Primary outcomes were palatal fistula (excluding intentionally unrepaired anterior fistulas) and VPI (recommendation for surgery). Multivariate analysis using logistic regression was performed to identify associations with the primary outcomes.

Results: 177 patients (84 male and 93 female) were identified. Median age at repair was 10 months with median follow-up time of 3.6 years (IQR 2.4-5.3 years). Pre-operative cleft width was ≤10 mm for 72 patients (41%), 11-14 mm for 54 patients (30%), and ≥15 mm for 51 patients (29%). Palatal fistula was observed in 8 patients (4.5%). Only 2 (1.1%) of the fistulae required surgical repair. Fistula was associated with Veau IV classification (odds ratio 8.35, p=0.012) but not with cleft width. VPI needing surgical intervention occurred in 7 patients (4%) and was associated with increasing cleft width (odds ratio 1.39, p=0.01) and age at time of surgery (odds ratio 1.43, p=0.035). Outcomes were similar for patients undergoing surgery in the earlier and later halves of the study. Repair using vomer flaps, osteotomy of the vascular pedicle bony formation for better flap mobilization, and acellular dermal matrix (Alloderm) increased significantly with wider clefts.

Conclusion: Use of advanced repair strategies as appropriate may have contributed to our fistula rates, which were low even in patients with wide clefts. However, techniques for repairing very wide clefts can shorten the palate without recreating physiologic motor function, thus leading to the observed higher VPI rates in patients with wider clefts.

References

1. Phua, Y. S., de Chalain, T. Incidence of oronasal fistulae and velopharyngeal insufficiency after cleft palate repair: an audit of 211 children born between 1990 and 2004. Cleft Palate Craniofac J 45: 172-178, 2008.

2. Landheer, J. A., Breugem, C. C., van der Molen, A. B. Fistula incidence and predictors of fistula occurrence after cleft palate repair: two-stage closure versus one-stage closure. Cleft Palate Craniofac J 47: 623-630, 2010.

20656 Effects of Cleft Width and Veau Type on Rates of Palatal Fistula and Velopharyngeal Insufficiency after Cleft Palate Repair