Primary Palate Repair Research Articles

Review of Current Techniques of Cleft Palate Repair Concerning Palatal Innervation: A Preliminary Assumption.

To highlight the possible surgical steps that could affect the neural supply of soft palate and velopharyngeal sphincter during Furlow palatoplasty and posteriorly-based myo-mucosal buccal flaps in patients with persistent velopharyngeal insufficiency after primary cleft palate repair. Institution-based retrospective study. Academic Medical Center. Non-syndromic patients with persistent hypernasality (after primary cleft palate repair) who had Furlow palatoplasty or posteriorly-based buccal myo-mucosal flaps and were followed up for at least 60 months after the secondary surgery. All patients were examined using a fiberoptic endoscopy, the movement of components of the velopharyngeal sphincter: soft palate, and lateral pharyngeal walls were traced on the monitor and given a score from 0-4. The pattern of VPS closure was reported whether coronal, circular, or sagittal for each case. Patients' characteristics, auditory perceptual assessment, the severity of hypernasality, intraoperative lengthening of the palate, and operative complications were recorded. At postoperative (at least 60 months) evaluation of the patients statistically non-significant differences were reported when comparing the pre-versus post-operative auditory perceptual assessment following both procedures (P value ≥0.05). A greater tendency towards improvement was noticed with BF but was non-significant. The nerve supply of the palate could be jeopardized by many techniques of primary or secondary repair of the cleft palate leaving behind a deceiving intact but weak poor-functioning palate. All efforts should be made to provide more neural-preservation techniques in primary/secondary repair of the cleft palate. Further wide-scale research is essential to have final clear conclusions.

Feeding Management and Palate Repair Timing in Infants with Cleft Palate with and without Pierre Robin Sequence: A Multisite Study.

Compare the feeding management practices in infants with cleft palate with and without Pierre Robin sequence (PRS) and determine if specific feeding difficulties or interventions predict delayed palate repair. Retrospective cross-sectional study. Seventeen cleft palate teams contributed data. 414 infants were included in this study: 268 infants with cleft palate only and 146 infants with cleft palate and PRS. Data were collected via parent interview and electronic health records. Outcomes for the primary objective included categorical data for: history of poor growth, feeding therapy, milk fortification, use of enteral feeding, and feeding difficulties. The outcome for the secondary objective was age in months at primary palate repair. Infants with PRS had a significantly higher prevalence of feeding difficulties (81% versus 61%) and poor growth (29% versus 15%) compared to infants with cleft palate only. Infants with PRS received all feeding interventions-including feeding therapy, milk fortification, and enteral feeding-at a significantly higher frequency. Infants with PRS underwent primary palate repair at a mean age of 13.55 months (SD = 3.29) which was significantly (P < .00001) later than infants with cleft palate only who underwent palate repair at a mean age of 12.05 months (SD = 2.36). Predictors of delayed palate repair included diagnosis of PRS as well as Hispanic ethnicity and a history of poor growth. These findings can be used to establish clinical directives focused on providing early, multimodal feeding interventions to promote optimal growth and timely palate repair for infants with PRS.

'Suspension Palatoplasty' - A new Method of Primary Palate Repair for Speaking Un-Repaired Clefts.

To design a technique of palate repair with predictable Velo Pharyngeal (VP) closure and normal speech - 'Suspension Palatoplasty' in speaking unrepaired Cleft Palate (CP) patients. To evaluate the results of patients with CP operated using the technique of 'Suspension palatoplasty' from 2014 -2018 in terms of surgical complications and speech outcomes. An ambi-spective longitudinal clinical study. Comprehensive cleft care clinic in a private trust hospital. Patients above 6 years of age with isolated CP, cleft lip and palate (CLP), operated using 'Suspension Palatoplasty' technique between 2014 and 2018 were included with minimum follow up period of 5 years. Subjective speech evaluation was done by two speech therapists and analysed. Author designed the technique of 'Suspension Palatoplasty' which aims to suspend the soft palate repaired by 'Hybrid Palatoplasty' technique, close to the nasopharynx using narrow pharyngeal flap with the pedicle based superiorly at adenoids, for an acceptable VP closure. Speech outcome and surgical complications were assessed. Out of 94 cases operated with age ranging from 6 to 45 years, 59 (62.8%) had normal speech, 12 (12.8%) had articulation errors but with no Velo-Pharyngeal Insufficiency (VPI) and 23 patients (24.4%) had hypernasality/ nasal emission (Suspected VPI). None of them had difficulty in breathing but one patient had snoring. 'Suspension Palatoplasty' is a simple primary operation with excellent speech outcomes with no obstructive sequelae in patients with speaking unrepaired cleft palate.

A Retrospective and Prospective Cohort Study Comparing Pediatric Patients With Cleft Lip and Palate From the United States and Guatemala.

Orofacial clefts (OFC) remain among the most prevalent congenital abnormalities worldwide. In the United States in 2010 to 2014, 16.2 of 10,000 live births are born with OFC compared with 23.6 of 10,000 in Alta Verapaz, Guatemala in 2012. Demographics and cleft severity scores were retrospectively gathered from 514 patients with isolated OFC at the Children's Hospital of Philadelphia scheduled for surgery from 2012 to 2019 and from 115 patients seen during surgical mission trips to Guatemala City from 2017 to 2020. Risk factors were also gathered prospectively from Guatemalan families. The Guatemalan cohort had a significantly lower prevalence of cleft palate only compared with the US cohort, which may be a result of greater cleft severity in the population or poor screening and subsequent increased mortality of untreated cleft palate. Of those with lip involvement, Guatemalan patients were significantly more likely to have complete cleft lip, associated cleft palate, and right-sided and bilateral clefts, demonstrating an increased severity of Guatemalan cleft phenotype. Primary palate and lip repair for the Guatemalan cohort occurred at a significantly older age than that of the US cohort, placing Guatemalan patients at increased risk for long-term complications such as communication difficulties. Potential OFC risk factors identified in the Guatemalan cohort included maternal cooking-fire and agricultural chemical exposure, poor prenatal vitamin intake, poverty, and risk factors related to primarily corn-based diets. OFC patients who primarily rely on surgical missions for cleft care would likely benefit from more comprehensive screening and investigation into risk factors for more severe OFC phenotypes.

Number and timing of primary cleft lip and palate repair surgeries in England: whole nation study of electronic health records before and during the COVID-19 pandemic

ObjectiveTo quantify differences in number and timing of first primary cleft lip and palate (CLP) repair procedures during the first year of the COVID-19 pandemic (1 April 2020 to 31...

Hybrid Palatoplasty: A Simplified DOZ (Double Opposing Z Plasty) with Palatal Myoplasty for Primary Palate Repair.

Introduction Surgical techniques for soft palate repair aiming for zero velopharyngeal insufficiency (VPI) are still not achieved. Straight line closure of the soft palate by various techniques of intravelar veloplasty (IVVP) leads to higher incidence of VPI due to scar contracture. Furlow's Z plasty has long, narrow, thin mucosal flaps and mucomuscular flaps with malaligned muscle closure. We present a technique of "hybrid palatoplasty" which borrows from and adds to the existing methods, is robust, is easy to replicate, and results in normal speech consistently. Aim (1) To design a technique of "hybrid palatoplasty"-combining double opposing Z (DOZ) plasty and IVVP, which is applicable to all types of cleft palate. (2) To evaluate the results of cleft palate children operated using the technique of "hybrid palatoplasty" from 2014 to 2015 in terms of surgical complications (fistulae and dehiscence) and incidence of VPI. Methods Our procedure combines aspects of both DOZ and IVVP. It is simplified with design of smaller Z plasties. On one side, from the oral Z plasty muscle is dissected off and sutured to the nasal mucomuscular flap of the opposite side to complete the palatal sling. Oral Z plasty is purely mucosal and reverse of the nasal side. A total of 123 cases, operated below 5 years of age were followed up. Speech was assessed by direct evaluation and tele-evaluation. Results A total of 123 cases, below 5 years of age, were operated between 2014 and 2016 with at least 5 years of follow-up. Note that 120 had normal speech, and 3 had VPI of which 2 were subsequently corrected and went on to develop normal speech. Conclusion This novel "hybrid palatoplasty" is a simple technique with good speech outcome as it combines the principles of Z plasty and direct muscle repair with palatal sling formation.

Unraveling a Major Burden of Orofacial Clefts Analyses: Classification of Cleft Palate Fistulas by Cleft Surgeons.

The objective of this study was to investigate how cleft surgeons classify palatal fistulas. We focused on three different anatomical locations (ie, hard palate, soft palate, junction hard/soft palate) to analyze agreement/disagreement at various anatomical locations. Cross-sectional survey study. Participants in an international webinar that focused on palatal fistula treatment were included. Participants were presented with a survey pre- and post-webinar. Frequency of used classification systems for classifying oronasal fistulas and the inter-rater reliability of the Pittsburgh classification system. A total of 141 participants completed the questionnaires prior to the webinar and 109 participants completed the survey after the webinar. In total, four classification systems were used (ie, Pittsburgh, Pakistan Comprehensive Fistula Classification [PCFC], anatomical and 'other'). The Pittsburgh classification was the most commonly used system in all cases. However, Pittsburgh inter-rater reliability was low (κ = 0.136 pre-webinar, and κ = 0.174 post-webinar). Surprisingly, a substantial shift was observed from the anatomical to Pittsburgh classification after the webinar, indicating increased awareness of the usability of the Pittsburgh classification system. This study demonstrates a large heterogeneity with regards to the classification of cleft palate fistulas. Interestingly, a shift was observed from the anatomical to Pittsburgh classification after the webinar. However, the inter-rater reliability for using the Pittsburgh classification was low. Classifying palatal fistulas in a homogenous fashion could enhance comparison of primary palate repair and could improve treatment of palatal fistulas.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: Speech proficiency at 10years of age.

To assess consonant proficiency and velopharyngeal function in 10-year-old children born with unilateral cleft lip and palate (UCLP) within the Scandcleft project. Three parallel group, randomized, clinical trials were undertaken as an international multicentre study by nine cleft teams in five countries. Three different surgical protocols for primary palate repair (Arm B-Lip and soft palate closure at 3-4months, hard palate closure at 36months, Arm C-Lip closure at 3-4months, hard and soft palate closure at 12months, and Arm D-Lip closure at 3-4months combined with a single-layer closure of the hard palate using a vomer flap, soft palate closure at 12months) were tested against a common procedure (Arm A-Lip and soft palate closure at 3-4months followed by hard palate closure at 12months) in the total cohort of 431 children born with a non-syndromic UCLP. Speech audio and video recordings of 399 children were available and perceptually analysed. Percentage of consonants correct (PCC) from a naming test, an overall rating of velopharyngeal competence (VPC) (VPC-Rate), and a composite measure (VPC-Sum) were reported. The mean levels of consonant proficiency (PCC score) in the trial arms were 86-92% and between 58% and 83% of the children had VPC (VPC-Sum). Only 50-73% of the participants had a consonant proficiency level with their peers. Girls performed better throughout. Long delay of the hard palate repair (Arm B) indicated lower PCC and simultaneous hard and soft palate closure higher (Arm C). However, the proportion of participants with primary VPC (not including velopharyngeal surgeries) was highest in Arm B (68%) and lowest in Arm C (47%). The speech outcome in terms of PCC and VPC was low across the trials. The different protocols had their pros and cons and there is no obvious evidence to recommend any of the protocols as superior. Aspects other than primary surgical method, such as time after velopharyngeal surgery, surgical experience, hearing level, language difficulties and speech therapy, need to be thoroughly reviewed for a better understanding of what has affected speech outcome at 10years. What is already known on the subject Speech outcomes at 10years of age in children treated for UCLP are sparse and contradictory. Previous studies have examined speech outcomes and the relationship with surgical intervention in 5-year-olds. What this study adds to the existing knowledge Speech outcomes based on standardized assessment in a large group of 10-year-old children born with UCLP and surgically treated according to different protocols are presented. While speech therapy had been provided, a large proportion of the children across treatment protocols still needed further speech therapy. What are the potential or actual clinical implications of this work? Aspects other than surgery and speech function might add to the understanding of what affects speech outcome. Effective speech therapy should be available for children in addition to primary surgical repair of the cleft and secondary surgeries if needed.

The Evaluation of Hospital Social Responsibility Services in Gatot Soebroto Indonesia Central Army Hospital in 2015 – 2019 of Cleft Lip and Palate Patients

Background : Cleft lip and cleft palate are the most common congenital craniofacial anomalies treated by plastic surgeons. The incidence of cleft lip and palate is higher at lower socioeconomic levels. Hospital Social Responsibility (HSR) in Gatot Soebroto Central Army Hospital provides free cleft lip and palate surgeries to those who need it the most. The HSR services still need to be evaluated, to get an overview of epidemiologic profile of cleft lip and palate patients, and to improve the services itself. Materials and Method: The authors conducted a retrospective descriptive study based on online data of Smile Train HSR RSPAD Cleft Center from period of January 2015 to December 2019. All patients presented with cleft lip and/or palate were included. Results : Of all 713 patients in total; The gender distribution male 62.2% (444/713) was higher than female 37.7% (269/713). Most of the patients came from Java Island 77.5% (553/713). 685 were primary surgeries, 28 secondary surgeries. Among the primary surgeries, lip repair has the highest numbers 71.6% (491/685), followed by palate repair 27.2% (187/685), and alveolar bone grafting 1% (7/685). The most widely used surgical technique in lip surgery was the Millard 50% (345/685), while the most widely used surgical technique in palate surgery was the Bardach technique 22.9% (157/685). The median age for the primary lip repair patients was 1 year (range, 3 months to 60 years), and the median age for the primary palate repair patients was 4 year (range, 7 months to 26 years). Among secondary surgeries, lip revision with Millard technique was the highest (82.1%), followed by scar revision 3.57%, fistula repair (7.1%). The most common diagnosis was unilateral cleft lip (left 34.4%, right 13.2%) and followed by complete cleft palate (22.7%) Conclusion : Male patients were more dominant than females. The most common diagnosis was unilateral cleft lip. Incomplete diagnostic data and clinical photos of patients make it difficult to determine the complete diagnose of cleft lip and palate.

25-year Follow-up of Primary Tibial Periosteal Graft for Hard Palate Repair in Cleft Lip and Palate: Outcomes, Concerns and Controversies.

This study evaluates long-term outcomes in adults with Unilateral and Bilateral Cleft Lip and Palate (UCLP/BCLP) treated during the period 1992 to 1995 with tibial periosteal graft in primary repair. Retrospective study. Department of Plastic and Maxillofacial Surgery, Children's Hospital Bambino Gesù (Italy). The study included 52 patients with non-syndromic BCLP/UCLP who met the inclusion criteria. All patients underwent a standardized surgical protocol using a tibial periosteal graft as primary repair of the hard palate. Long-term outcomes on maxillary growth, residual oronasal fistula, and leg length discrepancy. About <2% of patients showed oral-nasal communication. Mean value of maxillary depth was 86° ± 4.5°. The lower value for maxillary retrusion was 76.8° in relation to the Frankfurt plane. At the x-ray control, 12.2% of patients showed leg discrepancy with a difference of always <2 cm. The rate of maxillary retrusion obtained was the same if compared to other techniques. Tibial periosteal graft reduces the risk of fistula and the need for reintervention after secondary bone graft. The study did not observe negative impacts on leg growth after 25 years.

Unplanned Intensive Care Unit Admission Following Cleft Palate Repair by Head and Neck Surgeons.

To examine the incidence of pediatric intensive care unit (PICU) admission following primary repair of cleft palate by otolaryngologist-head and neck surgeons at 2 tertiary centers. To identify potential diagnoses associated with admission or unanticipated PICU transfer. Multi-institutional case series with chart review. Two tertiary pediatric medical centers. Children who underwent primary repair of cleft palate at 2 cleft centers over a 10-year period were identified. Charts were reviewed for demographics, comorbidities, and whether PICU admission was required. From 2009 to 2019, 464 patients underwent primary repair of a cleft palate by 1 of 6 otolaryngologist-head and neck surgeons with subspecialty training in cleft surgery; 459 patients had sufficient postoperative documentation and 443 children met inclusion criteria. The incidence of PICU admission was 9.3% (41/443), with 33 (7.4%) planned admissions and 8 (1.8%) unexpected PICU transfers. Syndromic conditions were associated with both planned and unanticipated PICU admissions. The incidence of unanticipated postoperative PICU admission following cleft palate repair by otolaryngologist-head and neck surgeons was low. Risk stratification by surgeons with expertise in airway management may inform decisions regarding postoperative disposition of patients with medical or airway complexity who are undergoing cleft palate repair.

Perioperative Pain Management After Primary Palate Repair: A 3-Surgeon Retrospective Study.

Pain management strategies following palatoplasty vary substantially. Despite efforts to reduce narcotic utilization, specific analgesic regimens are typically guided by surgeon preference. Our aim was to define analgesic variables that affect postoperative narcotic use and time to resumption of oral intake. This is a retrospective review from 2015 to 2018. Nonsyndromic patients undergoing primary palate repair. Analgesic variables included: local anesthetic, pterygopalatine ganglion nerve block, palatal pack, and postoperative use of ketorolac, dexamethasone, and nursing-controlled analgesia (NCA) opioid dosing. Proxy measures for pain included time to resumption of oral intake and morphine equivalence (mg/kg/h) administered. Veau phenotypes for the 111 patients included were: I (28%), II (19%), III (33%), IV (16%), and submucous (4%). Age, weight, local anesthetic, and postoperative use of ketorolac, dexamethasone, and palatal pack had no effect on either proxy measure (P > .05). Postoperative narcotic usage was significantly lower in patients who had an intraoperative suprazygomatic peripheral nerve block and significantly higher when NCA was utilized (P < .05). Neither variable had a significant impact on time to resumption of oral intake (P > .05). Several perioperative analgesic strategies lead to comparable postoperative consumption of narcotic and time to resume oral intake. The authors advise careful consideration of NCA due to the potential for increased narcotic utilization that we found in our institution. Based on our promising findings, further studies are warranted to assess risks, benefits, and costs of performing peripheral nerve blocks at the time of palatoplasty.

Primary Palatoplasty: A Comparison of Results by Various Techniques - A Retrospective Study.

Introduction:To identify a better method for primary cleft palate (CP) repairs with respect to velopharyngeal function.Materials and Methods:A retrospective, longitudinal review of medical charts of patients with congenital CP who underwent four different techniques of palatoplasty, performed by three different surgeons in the Department of Maxillofacial Surgery of the National Center for Maternal and Child Health. Nasopharyngoscopy (NPS) was used for velopharyngeal function evaluation. CP was classified according to the Veau system and the “Golding-Kushner” scale for NPS results was used for assessing the patient’s velopharyngeal function and its association with cleft types and the primary palatoplasty techniques. Pearson’s Chi-square analysis and binary logistic regression were used for statistical analysis.Results:A total of 335 patients were included in the study. The mean age at primary palate repair was 22.9 ± 13.6 months. There were 56, 42, 177, and 60 patients with Veau-I, Veau-II, Veau-III, and Veau-IV types, respectively, whereas for primary palatoplasty 65 patients underwent Furlow, 148 patients – Mongolian, 108 patients – two flap, 34 patients – von Langenbeck technique. NPS assessment of adequate velopharyngeal function was followed by Furlow’s technique in 89.4% of cases, Mongolian technique in 62.2% of cases but by “two flap” only in 48.1% and von Langenbeck in 47.1% of cases.Discussion:The Furlow and Mongolian techniques were superior for maintaining velopharyngeal function after primary palatoplasty.

Quantitative Evaluation of Palatal Lengthening After Cleft Palate Repair When a Buccal Flap Is Routinely Combined With Furlow's Z-Plasty.

The use of a buccinator myomucosal flap in combination with Furlow's Z-plasty during primary and secondary palatal repairs has been proposed by many authors to overcome some of the limitations of Furlow's technique. However, there have been no studies that quantitatively measured the effective palatal lengthening when the buccal flap is added. The buccal flap is routinely used during primary palate repair in order to fill the gap between the hard palate and reoriented palatal muscle sling. The soft palatal length was measured in the midline from the posterior edge of the hard palate to the base of the uvula. All patients were measured before starting the surgery and just after palatal closure in the standard position for cleft palate repair. Seventy-three patients with cleft palate who were candidates for primary repair were included. The mean age at the time of operation was 11.4 ± 3.5 months. The mean preoperative palatal length was 21.36 ± 3.529 mm, whereas the mean postoperative palatal length was 29.64 ± 4.171) mm. The mean palatal length change was 8.29 ± 2.514 mm (P < 0.000). The Combined use of a buccinator myomucosal flap with modified Furlow's Z-plasty in primary cleft palate repair has proven effective for palatal lengthening and achieved tensionless closure without the need for relaxing incision. It also provided a pliable soft tissue attachment of the palatal muscles to the hard palate allowing for better muscle function and mobility.

Need for velopharyngeal surgery after primary palatoplasty in cleft patients. A retrospective cohort study and review of literature

BackgroundEnabling intelligible speech plays an important role in achieving social inclusion and a good quality of life of cleft patients. A crude measure of primary palatal repair quality is the incidence of operations to correct velopharyngeal insufficiency (VPI) after speech-language therapy has proven inadequate. This study assessed the necessity for surgery to correct velopharyngeal insufficiency following our standardized two-staged protocol, compared the results with the literature, and identified factors that may influence velopharyngeal competence. MethodsA review of the literature was performed. The outcome measure in our series was the necessity for a secondary procedure to correct velopharyngeal insufficiency. The results of literature review were compared with the results of our case series, which we treated using a standardized protocol. ResultsIn our retrospective study, 5 patients (2.5%) required secondary pharyngoplasty. In literature, the frequency of surgery to correct velopharyngeal insufficiency after one- and two-stage protocols were 13.6% and 24.5%, respectively. No statistical difference was found between bilateral and unilateral clefts. The frequencies of velopharyngeal surgery were 7.2% after Furlow palatoplasty, 17.5% after a 2-flap palatoplasty, 18.6% after a Wardill-Killner palatoplasty, and 35.6% after a Von Langenbeck palatoplasty. ConclusionThe literature reported that one-stage palatoplasty is correlated with a lower incidence of secondary pharyngeal surgery. Our standardized two-stage protocol proved successful in avoiding secondary velopharyngeal surgery but due to the reduced number of patients included in our study, more research is needed.

Prevention and management of oronasal fistulas.

The aim of this article is to present the current opinion on the prevention and management of oronasal fistulas in cleft palate patients. Though cleft palate repair has seen numerous modifications and improvements, oronasal fistulas remain one of the most common complications of palatoplasty. There are various techniques available for preventing and managing this complication. Oronasal fistulas can be minimized by employing proper principles for palatoplasty. Once a fistula occurs, the repair technique should be appropriate for the fistula type. Oronasal fistula classifications, various repair techniques, tissue adjuncts, and biomaterials used in both the primary palate repair and oronasal fistula repair are discussed in this review.

A Closer Look at Delayed Primary Cleft Surgery and Unrepaired Cleft Lip and/or Palate in 5 UK Cleft Centers.

There may be many reasons for delays to primary cleft surgery. Our aim was to investigate the age of children undergoing primary cleft lip or primary cleft palate repair in 5 cleft centers within the United Kingdom. Identify the reasons for delayed primary cleft lip repair (beyond 6 months) and delayed primary palate repair (beyond 13 months). Identify children who had a cleft lip and/or palate (CL±P) that was intentionally unrepaired and the reasons for this. A retrospective, multicenter review of patients born with a CL±P between December 1, 2012, and December 31, 2016. Three regional cleft centers, comprising of 5 cleft administrative units in the United Kingdom participated. In all, 1826 patients with CL±P were identified. Of them, 120 patients had delayed lip repair, outside the expected standard of 183 days. And, 178 patients in total had delayed palate repair, outside the expected standard of 396 days. Twenty (1%) patients had an unrepaired cleft palate. This large retrospective review highlights variations between centers regarding the timing of lip and palate surgery and details the reasons stated for delayed primary surgery. A small number of patients with an unrepaired cleft palate were identified. All had complex medical problems or comorbidities listed as a reason for the decision not to operate and 50% had a syndromic diagnosis. The number of patients receiving delayed surgery due to comorbidities, being underweight or prematurity, highlights the importance of the cleft specialist nurse and pediatrician within the cleft multidisciplinary team.

Fistula incidence after primary repair and correlation with cleft width-to-palatum width ratio: A prospective cohort study

BackgroundCleft lip with or without cleft palate is one of the most common birth defects and is certainly the most visible. Fistula rate after primary palatoplasty was ranging between 10 and 23% and could be detected in the first three weeks after surgery. The cleft width is the frequent factor which was assumed to correspond to fistula occurrence. This study aimed to find correlation between fistula occurrence with cleft width and palatum width ratio after primary palate repair. MethodsA prospective cohort study was conducted on 16 subjects, which consisted of 10 males and 6 females. We measured width of cleft palate, width of rest palate and width of palate arch on three level measurements (posterior, junction and anterior). The surgery was performed using the two-flap and three layers suturing technique. ResultsSixteen patients were enrolled in this study during January and February 2008 . Ten patients were diagnosed with unilateral cleft palate while six patients had bilateral cleft palate. Mean of age was 22.31 ± 5.86 month. Correlation analysis between fistula occurrence and cleft width, cleft width-remnant palate width ratio and cleft width-palate arch width ratio using logistic regression did not show statistical correlation, and the same result was found between fistula occurrence and hemoglobin level, white blood count, nutritional status, cleft type and caries dentis factors (p > 0.05). ConclusionWidth of the cleft is not a factor associated with fistula occurrence. Two-flap three layers technique could be considered as a simple technique and gives a low rate of fistula occurrence.

Perceptual Speech Outcomes After Early Primary Palatal Repair in Ugandan Patients With Cleft Palate.

To provide speech outcomes of English-speaking Ugandan patients with a cleft palate with or without cleft lip (CP±L). Prospective case-control study. Referral hospital for patients with cleft lip and palate in Uganda. Twenty-four English-speaking Ugandan children with a CP±L (15 boys, 9 girls, mean 8.4 years) who received palatal closure prior to 6 months of age and an age- and gender-matched control group of Ugandan children without cleft palate. Comparison of speech outcomes of the patient and control group. Perceptual speech outcomes including articulation, resonance, speech understandability and acceptability, and velopharyngeal composite score (VPC-sum). Information regarding speech therapy, fistula rate, and secondary surgery. Normal speech understandability was observed in 42% of the patients, and 38% were judged with normal speech acceptability. Only 16% showed compensatory articulation. Acceptable resonance was found in 71%, and 75% of the patients were judged perceptually to present with competent velopharyngeal function based on the VPC-sum. Additional speech intervention was recommended in 25% of the patients. Statistically significant differences for all these variables were still observed with the control children (P < .05). Overall, acceptable speech outcomes were found after early primary palatal closure. Comparable or even better results were found in comparison with international benchmarks, especially regarding the presence of compensatory articulation. Whether this approach is transferable to Western countries is the subject for further research.

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

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. 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. Incidence of ONFs. 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. 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.