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

Abstract

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. 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. 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. 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.