Semin Plast Surg 2020; 34(02): 120-128
DOI: 10.1055/s-0040-1709429
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Revision Surgery of the Cleft Palate

Shirley Hu
1   Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
,
Jared Levinson
2   Department of Otolaryngology-Head and Neck Surgery, SUNY Downstate Medical Center, Brooklyn, New York
,
Joseph J. Rousso
1   Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
3   Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, Icahn School of Medicine, New York, New York
› Author Affiliations
Further Information

Publication History

Publication Date:
06 May 2020 (online)

Abstract

Cleft palate repairs often require secondary surgeries and/or revisions for a variety of reasons. The most common causes are symptomatic oronasal fistulas and velopharyngeal insufficiency. Complications from primary surgery, such as wound dehiscence, infection, and hematomas, contribute to the relatively high rate of revision surgery. Prevention of postoperative complications that may lead to fistula or velopharyngeal insufficiency is key, and many techniques have been described that have reportedly decreased the incidence of secondary surgery. Management varies depending on the nature of the fistulous defect and the type of velopharyngeal insufficiency. Numerous surgical options exist to fix this deficiency.

 
  • References

  • 1 Parker SE, Mai CT, Canfield MA. , et al; National Birth Defects Prevention Network. Updated National Birth Prevalence estimates for selected birth defects in the United States, 2004-2006. Birth Defects Res A Clin Mol Teratol 2010; 88 (12) 1008-1016
  • 2 van Aalst JA, Kolappa KK, Sadove M. MOC-PSSM CME article: nonsyndromic cleft palate. Plast Reconstr Surg 2008; 121 (1, Suppl): 1-14
  • 3 Bardach J, Morris H, Olin W, McDermott-Murray J, Mooney M, Bardach E. Late results of multidisciplinary management of unilateral cleft lip and palate. Ann Plast Surg 1984; 12 (03) 235-242
  • 4 Maeda K, Ojimi H, Utsugi R, Ando S. A T-shaped musculomucosal buccal flap method for cleft palate surgery. Plast Reconstr Surg 1987; 79 (06) 888-896
  • 5 Senders CW, Sykes JM. Modifications of the Furlow palatoplasty (six- and seven-flap palatoplasties). Arch Otolaryngol Head Neck Surg 1995; 121 (10) 1101-1104
  • 6 Hardwicke JT, Landini G, Richard BM. Fistula incidence after primary cleft palate repair: a systematic review of the literature. Plast Reconstr Surg 2014; 134 (04) 618e-627e
  • 7 Monson LA, Khechoyan DY, Buchanan EP, Hollier Jr LH. Secondary lip and palate surgery. Clin Plast Surg 2014; 41 (02) 301-309
  • 8 Smith DM, Vecchione L, Jiang S. , et al. The Pittsburgh Fistula Classification System: a standardized scheme for the description of palatal fistulas. Cleft Palate Craniofac J 2007; 44 (06) 590-594
  • 9 Bykowski MR, Naran S, Winger DG, Losee JE. The rate of oronasal fistula following primary cleft palate surgery: a meta-analysis. Cleft Palate Craniofac J 2015; 52 (04) e81-e87
  • 10 Kahraman A, Yuce S, Kocak OF. , et al. Comparison of the fistula risk associated with rotation palatoplasty and conventional palatoplasty for cleft palate repair. J Craniofac Surg 2014; 25 (05) 1728-1733
  • 11 Lu Y, Shi B, Zheng Q, Hu Q, Wang Z. Incidence of palatal fistula after palatoplasty with levator veli palatini retropositioning according to Sommerlad. Br J Oral Maxillofac Surg 2010; 48 (08) 637-640
  • 12 Thompson JA, Heaton PC, Kelton CM, Sitzman TJ. National estimates of and risk factors for inpatient revision surgeries for orofacial clefts. Cleft Palate Craniofac J 2017; 54 (01) 60-69
  • 13 Tse RW, Siebold B. Cleft palate repair: description of an approach, its evolution, and analysis of postoperative fistulas. Plast Reconstr Surg 2018; 141 (05) 1201-1214
  • 14 Swanson JW, Smartt Jr JMJ, Saltzman BS. , et al. Adopted children with cleft lip and/or palate: a unique and growing population. Plast Reconstr Surg 2014; 134 (02) 283e-293e
  • 15 Stewart TL, Fisher DM, Olson JL. Modified Von Langenbeck cleft palate repair using an anterior triangular flap: decreased incidence of anterior oronasal fistulas. Cleft Palate Craniofac J 2009; 46 (03) 299-304
  • 16 Reddy RR, Reddy SG, Banala B. , et al. Placement of an antibiotic oral pack on the hard palate after primary cleft palatoplasty: a randomized controlled trial into the effect on fistula rates. Clin Oral Investig 2018; 22 (05) 1953-1958
  • 17 Kane AA, Lo LJ, Yen BD, Chen YR, Noordhoff MS. The effect of hamulus fracture on the outcome of palatoplasty: a preliminary report of a prospective, alternating study. Cleft Palate Craniofac J 2000; 37 (05) 506-511
  • 18 Horton CE, Irish TJ, Adamson JE, Mladick RA. The use of vomerine flaps to cover the raw area on the nasal surface in cleft palate pushbacks. Preliminary report. Plast Reconstr Surg 1973; 51 (04) 421-423
  • 19 Agrawal K, Panda KN. Use of vomer flap in palatoplasty: revisited. Cleft Palate Craniofac J 2006; 43 (01) 30-37
  • 20 Millard DR. Methods of handling the neurovascular bundles. In: Millard DR, ed. Cleft Craft: The Evolution of Its Surgery. Vol 3: Alveolar and Palatal Deformities. Boston, MA: Little Brown & Co; 1980: 467-472
  • 21 Kirschner RE, Cabiling DS, Slemp AE, Siddiqi F, LaRossa DD, Losee JE. Repair of oronasal fistulae with acellular dermal matrices. Plast Reconstr Surg 2006; 118 (06) 1431-1440
  • 22 Hudson JW, Pickett DO. A 5-year retrospective review of primary palatoplasty cases utilizing an acellular collagen interpositional graft. J Oral Maxillofac Surg 2015; 73 (07) 1393.e1-1393.e3
  • 23 Rohleder NH, Loeffelbein DJ, Feistl W. , et al. Repair of oronasal fistulae by interposition of multilayered amniotic membrane allograft. Plast Reconstr Surg 2013; 132 (01) 172-181
  • 24 Winters R, Carter JM, Givens V, St Hilaire H. Persistent oro-nasal fistula after primary cleft palate repair: minimizing the rate via a standardized protocol. Int J Pediatr Otorhinolaryngol 2014; 78 (01) 132-134
  • 25 Li J, Gerety PA, Johnston J, Taylor JA. Gelfoam interposition minimizes risk of fistula and postoperative bleeding in modified-Furlow palatoplasty. J Craniofac Surg 2017; 28 (08) 1993-1996
  • 26 Henningson G, Isberg A. Oronasal fistulas and speech production. In: Bardach J, Morris HL. , eds. Multidisciplinary Management of Cleft Lip and Palate. 1st ed. Philadelphia, PA: W B Saunders Co; 1990: 787-791
  • 27 Berkman MD. Early non-surgical closure of postoperative palatal fistulae. Plast Reconstr Surg 1978; 62 (04) 537-541
  • 28 Millard DR. Cleft Craft: The Evolution of Its Surgery. Vol 1: The Unilateral Deformity. Boston, MA: Little, Brown; 1976
  • 29 Ohsumi N, Onizuka T, Ito Y. Use of a free conchal cartilage graft for closure of a palatal fistula: an experimental study and clinical application. Plast Reconstr Surg 1993; 91 (03) 433-440
  • 30 Obermeyer P. [Early closure of suture dehiscence after uranoplasty by means of a conservative method]. Dtsch Stomatol 1967; 17 (03) 168-173
  • 31 Diah E, Lo LJ, Yun C, Wang R, Wahyuni LK, Chen YR. Cleft oronasal fistula: a review of treatment results and a surgical management algorithm proposal. Chang Gung Med J 2007; 30 (06) 529-537
  • 32 Ardehali MM, Farshad A. Repair of palatal defect with nasal septal flap. Int J Oral Maxillofac Surg 2007; 36 (01) 77-78
  • 33 Liu DZ, Latham K, Gruss JS. Nasal lining mobilization for primary and secondary palatoplasty. J Craniofac Surg 2011; 22 (06) 2241-2243
  • 34 Guerrero-Santos J, Altamirano JT. The use of lingual flaps in repair of fistulas of the hard palate. Plast Reconstr Surg 1966; 38 (02) 123-128
  • 35 Jenq TF, Hilliard SM, Kuang AA. Novel use of osmotic tissue expanders to treat difficult anterior palatal fistulas. Cleft Palate Craniofac J 2011; 48 (02) 217-221
  • 36 Chen HC, Ganos DL, Coessens BC, Kyutoku S, Noordhoff MS. Free forearm flap for closure of difficult oronasal fistulas in cleft palate patients. Plast Reconstr Surg 1992; 90 (05) 757-762
  • 37 Goiato MC, dos Santos DM, Moreno A. , et al. Prosthetic treatments for patients with oronasal communication. J Craniofac Surg 2011; 22 (04) 1445-1447
  • 38 Mattos BS, Sousa AA, Magalhães MH, André M, Brito E Dias R. Candida albicans in patients with oronasal communication and obturator prostheses. Braz Dent J 2009; 20 (04) 336-340
  • 39 Thaller SR. Staged repair of secondary cleft palate deformities. J Craniofac Surg 1995; 6 (05) 375-380 , discussion 381
  • 40 Bureau S, Penko M, McFadden L. Speech outcome after closure of oronasal fistulas with bone grafts. J Oral Maxillofac Surg 2001; 59 (12) 1408-1413 , discussion 1413–1414
  • 41 Conley SF, Gosain AK, Marks SM, Larson DL. Identification and assessment of velopharyngeal inadequacy. Am J Otolaryngol 1997; 18 (01) 38-46
  • 42 Perry JL. Anatomy and physiology of the velopharyngeal mechanism. Semin Speech Lang 2011; 32 (02) 83-92
  • 43 Fisher DM, Sommerlad BC. Cleft lip, cleft palate, and velopharyngeal insufficiency. Plast Reconstr Surg 2011; 128 (04) 342e-360e
  • 44 Chorney SR, Commesso E, Tatum S. Incidence of secondary surgery after modified furlow palatoplasty: a 20-year single-surgeon case series. Otolaryngol Head Neck Surg 2017; 157 (05) 861-866
  • 45 Phua YS, 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 2008; 45 (02) 172-178
  • 46 Zhao S, Xu Y, Yin H. , et al. Incidence of postoperative velopharyngeal insufficiency in late palate repair. J Craniofac Surg 2012; 23 (06) 1602-1606
  • 47 Rudnick EF, Sie KC. Velopharyngeal insufficiency: current concepts in diagnosis and management. Curr Opin Otolaryngol Head Neck Surg 2008; 16 (06) 530-535
  • 48 Kummer AW, Briggs M, Lee L. The relationship between the characteristics of speech and velopharyngeal gap size. Cleft Palate Craniofac J 2003; 40 (06) 590-596
  • 49 Kummer AW, Curtis C, Wiggs M, Lee L, Strife JL. Comparison of velopharyngeal gap size in patients with hypernasality, hypernasality and nasal emission, or nasal turbulence (rustle) as the primary speech characteristic. Cleft Palate Craniofac J 1992; 29 (02) 152-156
  • 50 Golding-Kushner KJ, Argamaso RV, Cotton RT. , et al. Standardization for the reporting of nasopharyngoscopy and multiview videofluoroscopy: a report from an International Working Group. Cleft Palate J 1990; 27 (04) 337-347 , discussion 347–348
  • 51 Sie KC, Starr JR, Bloom DC. , et al. Multicenter interrater and intrarater reliability in the endoscopic evaluation of velopharyngeal insufficiency. Arch Otolaryngol Head Neck Surg 2008; 134 (07) 757-763
  • 52 Tieu DD, Gerber ME, Milczuk HA. , et al. Generation of consensus in the application of a rating scale to nasendoscopic assessment of velopharyngeal function. Arch Otolaryngol Head Neck Surg 2012; 138 (10) 923-928
  • 53 Chen Q, Li Y, Shi B, Yin H, Zheng GN, Zheng Q. Analysis of the correlative factors for velopharyngeal closure of patients with cleft palate after primary repair. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 116 (06) e424-e428
  • 54 Sullivan SR, Marrinan EM, LaBrie RA, Rogers GF, Mulliken JB. Palatoplasty outcomes in nonsyndromic patients with cleft palate: a 29-year assessment of one surgeon's experience. J Craniofac Surg 2009; 20 (Suppl. 01) 612-616
  • 55 Mahoney MH, Swan MC, Fisher DM. Prospective analysis of presurgical risk factors for outcomes in primary palatoplasty. Plast Reconstr Surg 2013; 132 (01) 165-171
  • 56 Chen PK, Wu JT, Chen YR, Noordhoff MS. Correction of secondary velopharyngeal insufficiency in cleft palate patients with the Furlow palatoplasty. Plast Reconstr Surg 1994; 94 (07) 933-941 , discussion 942–943
  • 57 Yuan N, Dorafshar AH, Follmar KE, Pendleton C, Ferguson K, Redett III RJ. 3. Effects of cleft width and Veau type on incidence of palatal fistula and velopharyngeal insufficiency after cleft palate repair. Ann Plast Surg 2016; 76 (04) 406-410
  • 58 Jodeh DS, Nguyen ATH, Rottgers SA. Outcomes of primary palatoplasty: an analysis using the pediatric health information system database. Plast Reconstr Surg 2019; 143 (02) 533-539
  • 59 Ha S, Koh KS, Moon H, Jung S, Oh TS. clinical outcomes of primary palatal surgery in children with nonsyndromic cleft palate with and without lip. BioMed Res Int 2015; 2015: 185459
  • 60 Leclerc JE, Godbout A, Arteau-Gauthier I, Lacour S, Abel K, McConnell EM. We can predict postpalatoplasty velopharyngeal insufficiency in cleft palate patients. Laryngoscope 2014; 124 (02) 561-569
  • 61 Rossell-Perry P, Caceres Nano E, Gavino-Gutierrez AM. Association between palatal index and cleft palate repair outcomes in patients with complete unilateral cleft lip and palate. JAMA Facial Plast Surg 2014; 16 (03) 206-210
  • 62 McWilliams BJ, Philips BJ. Velopharyngeal Incompetence: Audio Seminars in Speech Pathology. Philadelphia, PA: W.B. Saunders Company; 1979
  • 63 Lam DJ, Starr JR, Perkins JA. , et al. A comparison of nasendoscopy and multiview videofluoroscopy in assessing velopharyngeal insufficiency. Otolaryngol Head Neck Surg 2006; 134 (03) 394-402
  • 64 Gosain AK, Arneja JS. Management of the black hole in velopharyngeal incompetence: combined use of a Furlow palatoplasty and sphincter pharyngoplasty. Plast Reconstr Surg 2007; 119 (05) 1538-1545
  • 65 Gart MS, Gosain AK. Surgical management of velopharyngeal insufficiency. Clin Plast Surg 2014; 41 (02) 253-270
  • 66 Abdel-Aziz M, Nassar A, Rashed M, Naguib N, El-Tahan AR. Furlow palatoplasty for previously repaired cleft palate with velopharyngeal insufficiency. Int J Pediatr Otorhinolaryngol 2015; 79 (10) 1748-1751
  • 67 Noorchashm N, Dudas JR, Ford M. , et al. Conversion Furlow palatoplasty: salvage of speech after straight-line palatoplasty and “incomplete intravelar veloplasty”. Ann Plast Surg 2006; 56 (05) 505-510
  • 68 Chim H, Eshraghi Y, Iamphongsai S, Gosain AK. Double-opposing Z-palatoplasty for secondary surgical management of velopharyngeal incompetence in the absence of a primary furlow palatoplasty. Cleft Palate Craniofac J 2015; 52 (05) 517-524
  • 69 Reddy RR, Reddy SG, Banala B. , et al. Use of a modified Furlow Z-plasty as a secondary cleft palate repair procedure to reduce velopharyngeal insufficiency. Int J Oral Maxillofac Surg 2016; 45 (02) 170-176
  • 70 Ysunza A, Pamplona MC, Molina F. , et al. Surgery for speech in cleft palate patients. Int J Pediatr Otorhinolaryngol 2004; 68 (12) 1499-1505
  • 71 Marsh JL. Management of velopharyngeal dysfunction: differential diagnosis for differential management. J Craniofac Surg 2003; 14 (05) 621-628 , discussion 629
  • 72 Liao YF, Chuang ML, Chen PK, Chen NH, Yun C, Huang CS. Incidence and severity of obstructive sleep apnea following pharyngeal flap surgery in patients with cleft palate. Cleft Palate Craniofac J 2002; 39 (03) 312-316
  • 73 Ettinger RE, Oppenheimer AJ, Lau D. , et al. Obstructive sleep apnea after dynamic sphincter pharyngoplasty. J Craniofac Surg 2012; 23 (07) (Suppl. 01) 1974-1976
  • 74 Abdel-Aziz M. Palatopharyngeal sling: a new technique in treatment of velopharyngeal insufficiency. Int J Pediatr Otorhinolaryngol 2008; 72 (02) 173-177
  • 75 Lau D, Oppenheimer AJ, Buchman SR, Berger M, Kasten SJ. Posterior pharyngeal fat grafting for velopharyngeal insufficiency. Cleft Palate Craniofac J 2013; 50 (01) 51-58
  • 76 Kelly DA, Plikatitis C, Blalock D, Argenta LC, David LR. AlloDerm revision for failed pharyngoplasty. J Craniofac Surg 2012; 23 (03) 645-649
  • 77 Rashed M, Naguib N, Abdel-Aziz M. Trans-oral endoscopic cerclage pharyngoplasty for treatment of velopharyngeal insufficiency. Int J Pediatr Otorhinolaryngol 2014; 78 (06) 934-937
  • 78 Liao YF, Noordhoff MS, Huang CS. , et al. Comparison of obstructive sleep apnea syndrome in children with cleft palate following Furlow palatoplasty or pharyngeal flap for velopharyngeal insufficiency. Cleft Palate Craniofac J 2004; 41 (02) 152-156
  • 79 Thurston JB, Larson DL, Shanks JC, Bennett JE, Parsons RW. Nasal obstruction as a complication of pharyngeal flap surgery. Cleft Palate J 1980; 17 (02) 148-154
  • 80 Valnicek SM, Zuker RM, Halpern LM, Roy WL. Perioperative complications of superior pharyngeal flap surgery in children. Plast Reconstr Surg 1994; 93 (05) 954-958
  • 81 Katzel EB, Shakir S, Naran S. , et al. Speech outcomes after clinically indicated posterior pharyngeal flap takedown. Ann Plast Surg 2016; 77 (04) 420-424
  • 82 Por YC, Tan YC, Chang FC, Chen PK. Revision of pharyngeal flaps causing obstructive airway symptoms: an analysis of treatment with three different techniques over 39 years. J Plast Reconstr Aesthet Surg 2010; 63 (06) 930-933