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A Successful Algorithm for Limiting Postoperative Fistulae following Palatal Procedures in the Patient with Orofacial Clefting

Losee, Joseph E. M.D.; Smith, Darren M. M.D.; Afifi, Ahmed M. M.D.; Jiang, Shao M.D.; Ford, Matthew M.S., C.C.C., S.L.P.; Vecchione, Lisa D.M.D., M.D.S.; Cooper, Gregory M. Ph.D.; Naran, Sanjay B.S.; Mooney, Mark P. Ph.D.; Serletti, Joseph M. M.D.

Plastic and Reconstructive Surgery: August 2008 - Volume 122 - Issue 2 - p 544-554
doi: 10.1097/PRS.0b013e31817d6223
Pediatric/Craniofacial: Original Articles

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.

Pittsburgh, Pa.

From the Division of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh.

Received for publication September 24, 2007; accepted January 2, 2008.

Presented at the 64th Annual Meeting of the American Cleft Palate-Craniofacial Association, in Broomfield, Colorado, April 24 through 28, 2007.

Disclosure: The senior author (J.E.L.) has received educational and research funding in the past from LifeCell Corp.

Joseph E. Losee, M.D., Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, G437 De Soto Wing, Pittsburgh, Pa. 15213,

©2008American Society of Plastic Surgeons