Cleft palate repair: description of an approach, its evolution, and analysis of post-operative fistulas

Background: Fistulas following cleft palate repair impair speech, health, and hygiene and occur in up to 35% cases. The purpose of this study was to (1) describe the evolution of a surgical approach to cleft palate repair; (2) assess the rates, causes, and predictive factors of fistulas; (3) assess the temporal association of modifications to fistula rates during six years of a single surgeon experience. Methods: Consecutive patients (N=146) undergoing cleft palate repair were included. The technique of repair was based on cleft type and a common surgical approach was used for all repairs. Modifications to the approach were made around specific anatomic features including peri-articular bony hillocks, maxilla-palatine suture, velopalatine pits, and tensor insertion. Results: Fistula rate after primary repair was 2.4% (N=125) and after secondary repair was 0% (N=22). All complications occurred in patients with Type 3 or 4 clefts. Cleft width and cleft:total palatal width were associated with fistulas whereas syndromes, age, and adoption were not. Traumatic dissection and inadequate release were suspected in cases of delayed healing and flap necrosis during the first 2 years. Modifications were introduced following these complications. The fistula rate declined by one half in subsequent years. Conclusions: We describe a surgical approach to cleft palate repair and its evolution. Fistulas were rare but associated with increasing cleft severity (type, width). A reduction in frequency and severity of fistulas was consistent with a learning curve and may in part be associated with modifications to the surgical approach. Funding support: None Commercial associations and financial disclosures: None Conflicts of interest: None Acknowledgements: Thanks to Jemère Ruby for illustrating the figures; to Erik Stuhaug for intra-operative photography; to Joseph Gruss, Richard Hopper, and Craig Birgfeld for their mentorship, feedback, and assistance with this manuscript; to David Fisher for the training in cleft palate repair; to Shane Morrison for assistance in revision; and to the residents and fellows for suggesting this study. Corresponding author: Raymond Tse, Seattle Children's Hospital, M/S OB.9.527, 4800 Sand Point Way NE , Seattle, WA,98105 ©2018American Society of Plastic Surgeons