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Incidence of palatal fistula after palatoplasty with levator veli palatini retropositioning according to Sommerlad
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British Journal of Oral and Maxillofacial Surgery 48 (2010) 637–640
Incidence of palatal fistula after palatoplasty with levator veli palatini retropositioning according to Sommerlad Lu Yong a,∗ , Shi Bing b , Zheng Qian b , Hu Qinggang a,1 , Wang Zhiyong a,1 a
Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital, Medical School of Nanjing University, No. 30 Zhong Yang’s Road, Xuan Wu, Nanjing 210008, Jiangsu Province, China b Department of Cleft Lip and Palate Surgery, West China College of Stomatology, Sichuan University, Chengdu 610041, Sichuan Province, China Accepted 19 October 2009 Available online 27 November 2009
Abstract The purpose of this study was to find out the incidence of palatal fistula and study the factors that influence its development after palatoplasty with repositioning of the levator veli palatini. We retrospectively reviewed 176 consecutive repairs of cleft palates during a 2-year period (2004–2006). The age of the patients at the time of repair ranged from 12 to 30 months (mode 17 months). All the palatoplasties were done either by a senior surgeon or a resident surgeon. The chi square test was used to assess whether the development of postoperative fistulas was influenced by sex, extent of cleft (as estimated by the Veau classification), age at repair, and operating surgeon. There were 12 palatal fistulas (7%), 8 of which were at the junction of the hard and soft palate, 3 in the hard palate, and 1 in the soft palate. There was no evidence to suggest that sex or age were associated with their development. Patients whose clefts had been treated by the senior surgeon had fewer fistulas (2/82, 2%) than those by the resident surgeon (10/94, 11%) (p = 0.04). The incidences of palatal fistulas in patients with clefts of the hard and soft cleft palate (7/44, 21%), and bilateral cleft lip or palate (2/21,10%), were significantly higher than those in patients with cleft soft palate (1/37, 3%), and unilateral cleft lip or palate (2/74, 3%) (p = 0.03). Our results show that palatal fistula after repair is related mainly to the extent of the cleft and the experience of the operating surgeon. © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Fistula; Cleft palate; Levator veli palatini retropositioning
Introduction Palatal fistula, an epithelialised opening in the repair between the mouth and nasal cavity, is a potential complication after primary palatoplasty that has serious functional consequences. It usually has an adverse effect on patients’ speech, oral hygiene, and even mental health. Even though currently there are many techniques for the repair of palatal fistulas, the recurrence rate is still as high as 37–50%.1,2 Avoidance ∗
Corresponding author. Tel.: +86 25 83620320; fax: +86 25 83620173. E-mail addresses: cleft [email protected] (Y. Lu), [email protected] (B. Shi). 1 Tel.: +86 25 83620320.
of palatal fisulas in the treatment of cleft palates is therefore critical. We reviewed and analysed the clinical data about palatoplasty with repositioning of the levator veli palatini as described by Sommerlad3 between 2004 and 2006 (when it was first done in China), and studied the postoperative incidence of palatal fistula and the factors that might have influenced it.
Patients and methods We retrospectively reviewed the case notes of 176 patients with non-syndromic cleft palate who were treated at the
0266-4356/$ – see front matter © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2009.10.018
638
Y. Lu et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 637–640
Table 1 Veau classification. Class
Site involved
I II III IV
Soft cleft palate Hard and soft cleft palate Unilateral cleft lip or palate Bilateral cleft lip or palate
Department of Cleft Lip and Palate Surgery, West China College of Stomatology, Sichuan University, between June 2004 and March 2006. The study group included 108 boys and 68 girls; mean (SD) age at the time of repair was 17 (5) months (range 12–30). According to the Veau classification (Table 1),4,5 there were 37 patients with cleft soft palate, 44 with clefts of the hard and soft palate, 74 with unilateral cleft lip or palate, and 21 with bilateral cleft lip or palate. All the patients studied were treated by palatoplasty as described by Sommerlad.3 Two surgeons did the primary operation: one senior surgeon who had operated on more than 200 patients, and 1 resident surgeon who had operated on fewer than 10. The operation was done under general anaesthesia (Fig. 1). First, the oral mucosa was incised in the marginal cleft of the soft palate and the mucosal flaps were raised. Suturing the nasal layer before dissection of the muscle makes the dissection easier (Fig. 2). Then the more rigid muscle and tendon was divided without perforating the nasal mucosa with the knife. The muscle complex (levator and other muscles) was displaced, passed backwards, and then sutured across the midline (Fig. 3).6,7 Finally, the oral layer was closed with no lateral incisions (Langenbeck flaps) close to the alveolar processes (Fig. 4). The mean (SD) follow-up time after palatal closure was 16 (6) months (range 1 week to 3 years). All palatal suture lines and wounds were examined before the patient was discharged from hospital. Each patient was examined at least once and usually on several occasions by members of the cleft palate team during follow-up visits.
Fig. 1. Preoperative picture of a cleft of the hard and soft palate.
Fig. 2. Sutured nasal mucosa, and exposed velar muscle.
Fig. 3. Reconstruction of the muscle complex (levator veli palati muscle and other velar muscles).
Cohen et al.5 dealt with only those fistulas that developed after a primary surgical repair, and eliminated from their analysis any “nasal-alveolar fistulas and/or anterior palatal fistulas that were intentionally not repaired”. We defined all cleft palatal fistulas as failures of healing or breakdown in the primary repair of the palate. Clinically important fistulas were identified by the presence of either nasal leaks of fluids
Fig. 4. Postoperative picture of sutured oral mucosa without a lateral incision.
Y. Lu et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 637–640 Table 2 Langenbeck flaps from 2004 to 2006 in different clefts. Cleft palate
No of flaps
Soft (n = 37) Hard and soft (n = 44) Unilateral (n = 74) Bilateral (n = 21)
Flaps
No.
(%)
No.
27 18 4 0
73 41 5 0
10 26 70 21
(%) 27 59 95 100
or semisolids. Nine patients with unrepaired fistulas of the primary and secondary palate were excluded from the study group; a two-stage approach was used to repair their cleft palates, using vomer flaps to close the hard palates. The size of fistulas was graded as small (1–2 mm), medium (3–5 mm), and large (5 mm or more).8 The incidence was calculated and the chi square test used to assess whether it differed according to sex, the extent of the cleft (as estimated by the Veau classification), age at repair, and operating surgeon. Probabilities of less than 0.05 were accepted as significant. Limitation of the study The identification of small fistulas may be difficult, even for experts. Sometimes a palatal fistula that showed as a pinhole was not considered clinically relevant. So, a few missed small fistulas may have affected the overall rate.
Results No lateral incisions were made in 49/176 (28%) of all palatal repairs (Table 2). Sixteen patients had palatal perforations when they left hospital after operation. After a month’s follow-up, 4 dehiscences of the palatal oral mucosa in the soft
Table 3 Patients’characteristics, and extent of cleft together with outcome among 176 patients. Variable
No. of No. (%) of patients fistulas
Chi square
P value
Sex Male Female
108 68
8 (7) 4 (6)
4.34
0.77
Age (months) <18 18 or more
57 119
3 (%) 9 (8)
4.56
0.75
Extent of cleft Soft palate only Hard and soft palate Unilateral lip or palate Bilateral lip or palate
37 44 74 21
1 (3) 7 (21) 2 (3) 2 (10)
14.67
0.03
Operating surgeon Senior Resident
82 94
18.74
0.04
2 (2) 10(11)
639
palate had healed spontaneously, so the overall rate of true palatal fistulas in this series was 12/176 (7%). Five fistulas were classified as small, four as large, and three as medium. Most fistulas had developed at the junction of the hard and soft palate (8/12); the next most common site was the hard palate (3/12), followed by the soft palate (1/12) (p = 0.03). Table 3 shows the rest of the results.
Discussion The actual reported incidence of palatal fistula varies widely, ranging from 3.4% to 15% in published reports.3,8–10 Our incidence of 7% after palatoplasty done by Sommerlad’s technique, was lower than that reported by Sommerlad himself in 2003.3 Our palatal fistulas usually developed at the junction of the soft and hard palate, followed by the hard palate, with the least in the soft palate. This may be explained by tissue breakdown as a result of tension at the site of wound closure.10 Controversy exists about the possible predisposing factors for fistulas developing after palatoplasty, but we concluded that the most important were age at operation, sex, extent of the cleft (as estimated by the Veau classification), surgical management, and skill of the surgeon.5,8–10 The optimal age at which to close the palate is also controversial, and the benefits of speech development have to be weighed against the possible risks of disturbing facial growth.11 Some authors have advocated closure of the cleft lip and soft palate before 9 months of age, and of the hard palate at 12–14 months of age.12 Conversely, a one-stage palatoplasty (simultaneous closure of defects in both the hard and soft palates) is not done until between 12 and 18 months of age.13 At our centre the lip is repaired at 3–6 months of age, and we recommend repair of the entire palate at 12–18 months to avoid possible disturbances in maxillofacial growth. We therefore divided the patients into two groups (less than 18 months old, and 18 months and older), but there was no significant difference between them. Sex was not a significant variable, which confirms the work of Muzaffar et al.8 and Emory et al.9 Extent of clefting,4,5 however, did make a difference, with patients with clefts of the hard and soft palate, and those with bilateral clefts, being more likely to develop a fistula than these with clefts of the soft palate alone and those with unilateral clefts. Wilhelmi et al.10 also noted that the type of cleft affected the rate of fistulation, but in their study, all palatal fistulas developed in the unilateral and bilateral groups. This may be explained by the technical difficulties in closing wider clefts, and the greater the extent of the cleft, the greater the rate of fistulation.5 In our study, we tried to avoid lateral incisions (Langenbeck flaps) close to the alveolar processes. Because an incomplete cleft palate is not as serious as a complete one, the tension needed to close the oral mucosa layer was less, so unilateral or bilateral mucoperiosteal flaps were not necessary as they are for complete cleft palates.
640
Y. Lu et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 637–640
Seven of 8 fistulas occurred at the junction of the hard and soft palate in patients with clefts of both hard and soft palate, which suggests that we must separate the nasal mucosa thoroughly at the back of the hard palate. Four patients developed dehiscences (about 0.5–1 cm in diameter) in the oral mucosal layer after operation, all of which had healed spontaneously by the one-month follow-up, which can be attributed to the intact layer of nasal mucosa. The skill of the operating surgeon also had a significant effect on the incidence of fistulas,14 as the senior surgeon had fewer than did the resident surgeon. The reason may be that the surgical technique required to reposition the levator veli palatini, having been only recently introduced to China, demanded the skill and care of an experienced surgeon during the velar muscular dissection. In conclusion, when compared with other procedures used for primary palatoplasty,8,9,13 palatoplasty using Sommerlad’s technique did not increase the incidence of postoperative palatal fistula after repair of a cleft. We think that palatal fistulas after such a repair are more likely to be associated with the extent of the cleft and the skill of the operating surgeon.
Conflict of interest The authors declare that they have no conflict of interest.
Acknowledgement The study was supported by the Medical Science and Technology Development Foundation, Nanjing Department of Health (YKK08049).
References 1. Schultz RC. Management and timing of cleft palate fistula repair. Plast Reconstr Surg 1986;78:739–47. 2. Rohrich RJ, Rowsell AR, Johns DF, Drury MA, Grieg G, Watson DJ, et al. Timing of hard palatal closure: a critical long-term analysis. Plast Reconstr Surg 1996;98:236–46. 3. Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg 2003;112:1542–8. 4. Veau V. Division palatine. Paris: Masson; 1931. 5. Cohen SR, Kalinowski J, LaRossa D, Randall P. Cleft palate fistulas: a multivariate statistical analysis of prevalence, etiology, and surgical management. Plast Reconstr Surg 1991;87:1041–7. 6. Boorman JG, Sommerlad BC. Musculus uvulae and levator palati: their anatomical and functional relationship in velopharyngeal closure. Br J Plast Surg 1985;38:333–8. 7. Sommerlad BC, Gault DT. Space obliterating skin suture (letter). Plast Reconstr Surg 1998;102:2277–8. 8. Muzaffar AR, Byrd HS, Rohrich RJ, Johns DF, LeBlanc D, Beran SJ, et al. Incidence of cleft palate fistula: an institutional experience with two-stage palatal repair. Plast Reconstr Surg 2001;108:1515–8. 9. Emory Jr RE, Clay RP, Bite U, Jackson IT. Fistula formation and repair after palatal closure: an institutional perspective. Plast Reconstr Surg 1997;99:1535–8. 10. Wilhelmi BJ, Appelt EA, Hill L, Blackwell SJ. Palatal fistulas rare with the two-flap palatoplasty repair. Plast Reconstr Surg 2001;107:315–8. 11. Nguyen PN, Sullivan PK. Issues and controversies in the management of cleft palate. Clin Plast Surg 1993;20:671–82. 12. Chait L, Gavron G, Graham C, Noik E, De Aquier G. Modifying the two-stage cleft palate surgical correction. Cleft Palate Craniofac J 2002;39:226–32. 13. 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;45:172–8. 14. Andersson EM, Sandvik L, Semb G, Abyholm F. Palatal fistulas after primary repair of clefts of the secondary palate. Scand J Plast Reconstr Surg Hand Surg 2008;42:296–9.
British Journal of Oral and Maxillofacial Surgery 48 (2010) 637–640
Incidence of palatal fistula after palatoplasty with levator veli palatini retropositioning according to Sommerlad Lu Yong a,∗ , Shi Bing b , Zheng Qian b , Hu Qinggang a,1 , Wang Zhiyong a,1 a
Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital, Medical School of Nanjing University, No. 30 Zhong Yang’s Road, Xuan Wu, Nanjing 210008, Jiangsu Province, China b Department of Cleft Lip and Palate Surgery, West China College of Stomatology, Sichuan University, Chengdu 610041, Sichuan Province, China Accepted 19 October 2009 Available online 27 November 2009
Abstract The purpose of this study was to find out the incidence of palatal fistula and study the factors that influence its development after palatoplasty with repositioning of the levator veli palatini. We retrospectively reviewed 176 consecutive repairs of cleft palates during a 2-year period (2004–2006). The age of the patients at the time of repair ranged from 12 to 30 months (mode 17 months). All the palatoplasties were done either by a senior surgeon or a resident surgeon. The chi square test was used to assess whether the development of postoperative fistulas was influenced by sex, extent of cleft (as estimated by the Veau classification), age at repair, and operating surgeon. There were 12 palatal fistulas (7%), 8 of which were at the junction of the hard and soft palate, 3 in the hard palate, and 1 in the soft palate. There was no evidence to suggest that sex or age were associated with their development. Patients whose clefts had been treated by the senior surgeon had fewer fistulas (2/82, 2%) than those by the resident surgeon (10/94, 11%) (p = 0.04). The incidences of palatal fistulas in patients with clefts of the hard and soft cleft palate (7/44, 21%), and bilateral cleft lip or palate (2/21,10%), were significantly higher than those in patients with cleft soft palate (1/37, 3%), and unilateral cleft lip or palate (2/74, 3%) (p = 0.03). Our results show that palatal fistula after repair is related mainly to the extent of the cleft and the experience of the operating surgeon. © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Fistula; Cleft palate; Levator veli palatini retropositioning
Introduction Palatal fistula, an epithelialised opening in the repair between the mouth and nasal cavity, is a potential complication after primary palatoplasty that has serious functional consequences. It usually has an adverse effect on patients’ speech, oral hygiene, and even mental health. Even though currently there are many techniques for the repair of palatal fistulas, the recurrence rate is still as high as 37–50%.1,2 Avoidance ∗
Corresponding author. Tel.: +86 25 83620320; fax: +86 25 83620173. E-mail addresses: cleft [email protected] (Y. Lu), [email protected] (B. Shi). 1 Tel.: +86 25 83620320.
of palatal fisulas in the treatment of cleft palates is therefore critical. We reviewed and analysed the clinical data about palatoplasty with repositioning of the levator veli palatini as described by Sommerlad3 between 2004 and 2006 (when it was first done in China), and studied the postoperative incidence of palatal fistula and the factors that might have influenced it.
Patients and methods We retrospectively reviewed the case notes of 176 patients with non-syndromic cleft palate who were treated at the
0266-4356/$ – see front matter © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2009.10.018
638
Y. Lu et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 637–640
Table 1 Veau classification. Class
Site involved
I II III IV
Soft cleft palate Hard and soft cleft palate Unilateral cleft lip or palate Bilateral cleft lip or palate
Department of Cleft Lip and Palate Surgery, West China College of Stomatology, Sichuan University, between June 2004 and March 2006. The study group included 108 boys and 68 girls; mean (SD) age at the time of repair was 17 (5) months (range 12–30). According to the Veau classification (Table 1),4,5 there were 37 patients with cleft soft palate, 44 with clefts of the hard and soft palate, 74 with unilateral cleft lip or palate, and 21 with bilateral cleft lip or palate. All the patients studied were treated by palatoplasty as described by Sommerlad.3 Two surgeons did the primary operation: one senior surgeon who had operated on more than 200 patients, and 1 resident surgeon who had operated on fewer than 10. The operation was done under general anaesthesia (Fig. 1). First, the oral mucosa was incised in the marginal cleft of the soft palate and the mucosal flaps were raised. Suturing the nasal layer before dissection of the muscle makes the dissection easier (Fig. 2). Then the more rigid muscle and tendon was divided without perforating the nasal mucosa with the knife. The muscle complex (levator and other muscles) was displaced, passed backwards, and then sutured across the midline (Fig. 3).6,7 Finally, the oral layer was closed with no lateral incisions (Langenbeck flaps) close to the alveolar processes (Fig. 4). The mean (SD) follow-up time after palatal closure was 16 (6) months (range 1 week to 3 years). All palatal suture lines and wounds were examined before the patient was discharged from hospital. Each patient was examined at least once and usually on several occasions by members of the cleft palate team during follow-up visits.
Fig. 1. Preoperative picture of a cleft of the hard and soft palate.
Fig. 2. Sutured nasal mucosa, and exposed velar muscle.
Fig. 3. Reconstruction of the muscle complex (levator veli palati muscle and other velar muscles).
Cohen et al.5 dealt with only those fistulas that developed after a primary surgical repair, and eliminated from their analysis any “nasal-alveolar fistulas and/or anterior palatal fistulas that were intentionally not repaired”. We defined all cleft palatal fistulas as failures of healing or breakdown in the primary repair of the palate. Clinically important fistulas were identified by the presence of either nasal leaks of fluids
Fig. 4. Postoperative picture of sutured oral mucosa without a lateral incision.
Y. Lu et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 637–640 Table 2 Langenbeck flaps from 2004 to 2006 in different clefts. Cleft palate
No of flaps
Soft (n = 37) Hard and soft (n = 44) Unilateral (n = 74) Bilateral (n = 21)
Flaps
No.
(%)
No.
27 18 4 0
73 41 5 0
10 26 70 21
(%) 27 59 95 100
or semisolids. Nine patients with unrepaired fistulas of the primary and secondary palate were excluded from the study group; a two-stage approach was used to repair their cleft palates, using vomer flaps to close the hard palates. The size of fistulas was graded as small (1–2 mm), medium (3–5 mm), and large (5 mm or more).8 The incidence was calculated and the chi square test used to assess whether it differed according to sex, the extent of the cleft (as estimated by the Veau classification), age at repair, and operating surgeon. Probabilities of less than 0.05 were accepted as significant. Limitation of the study The identification of small fistulas may be difficult, even for experts. Sometimes a palatal fistula that showed as a pinhole was not considered clinically relevant. So, a few missed small fistulas may have affected the overall rate.
Results No lateral incisions were made in 49/176 (28%) of all palatal repairs (Table 2). Sixteen patients had palatal perforations when they left hospital after operation. After a month’s follow-up, 4 dehiscences of the palatal oral mucosa in the soft
Table 3 Patients’characteristics, and extent of cleft together with outcome among 176 patients. Variable
No. of No. (%) of patients fistulas
Chi square
P value
Sex Male Female
108 68
8 (7) 4 (6)
4.34
0.77
Age (months) <18 18 or more
57 119
3 (%) 9 (8)
4.56
0.75
Extent of cleft Soft palate only Hard and soft palate Unilateral lip or palate Bilateral lip or palate
37 44 74 21
1 (3) 7 (21) 2 (3) 2 (10)
14.67
0.03
Operating surgeon Senior Resident
82 94
18.74
0.04
2 (2) 10(11)
639
palate had healed spontaneously, so the overall rate of true palatal fistulas in this series was 12/176 (7%). Five fistulas were classified as small, four as large, and three as medium. Most fistulas had developed at the junction of the hard and soft palate (8/12); the next most common site was the hard palate (3/12), followed by the soft palate (1/12) (p = 0.03). Table 3 shows the rest of the results.
Discussion The actual reported incidence of palatal fistula varies widely, ranging from 3.4% to 15% in published reports.3,8–10 Our incidence of 7% after palatoplasty done by Sommerlad’s technique, was lower than that reported by Sommerlad himself in 2003.3 Our palatal fistulas usually developed at the junction of the soft and hard palate, followed by the hard palate, with the least in the soft palate. This may be explained by tissue breakdown as a result of tension at the site of wound closure.10 Controversy exists about the possible predisposing factors for fistulas developing after palatoplasty, but we concluded that the most important were age at operation, sex, extent of the cleft (as estimated by the Veau classification), surgical management, and skill of the surgeon.5,8–10 The optimal age at which to close the palate is also controversial, and the benefits of speech development have to be weighed against the possible risks of disturbing facial growth.11 Some authors have advocated closure of the cleft lip and soft palate before 9 months of age, and of the hard palate at 12–14 months of age.12 Conversely, a one-stage palatoplasty (simultaneous closure of defects in both the hard and soft palates) is not done until between 12 and 18 months of age.13 At our centre the lip is repaired at 3–6 months of age, and we recommend repair of the entire palate at 12–18 months to avoid possible disturbances in maxillofacial growth. We therefore divided the patients into two groups (less than 18 months old, and 18 months and older), but there was no significant difference between them. Sex was not a significant variable, which confirms the work of Muzaffar et al.8 and Emory et al.9 Extent of clefting,4,5 however, did make a difference, with patients with clefts of the hard and soft palate, and those with bilateral clefts, being more likely to develop a fistula than these with clefts of the soft palate alone and those with unilateral clefts. Wilhelmi et al.10 also noted that the type of cleft affected the rate of fistulation, but in their study, all palatal fistulas developed in the unilateral and bilateral groups. This may be explained by the technical difficulties in closing wider clefts, and the greater the extent of the cleft, the greater the rate of fistulation.5 In our study, we tried to avoid lateral incisions (Langenbeck flaps) close to the alveolar processes. Because an incomplete cleft palate is not as serious as a complete one, the tension needed to close the oral mucosa layer was less, so unilateral or bilateral mucoperiosteal flaps were not necessary as they are for complete cleft palates.
640
Y. Lu et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 637–640
Seven of 8 fistulas occurred at the junction of the hard and soft palate in patients with clefts of both hard and soft palate, which suggests that we must separate the nasal mucosa thoroughly at the back of the hard palate. Four patients developed dehiscences (about 0.5–1 cm in diameter) in the oral mucosal layer after operation, all of which had healed spontaneously by the one-month follow-up, which can be attributed to the intact layer of nasal mucosa. The skill of the operating surgeon also had a significant effect on the incidence of fistulas,14 as the senior surgeon had fewer than did the resident surgeon. The reason may be that the surgical technique required to reposition the levator veli palatini, having been only recently introduced to China, demanded the skill and care of an experienced surgeon during the velar muscular dissection. In conclusion, when compared with other procedures used for primary palatoplasty,8,9,13 palatoplasty using Sommerlad’s technique did not increase the incidence of postoperative palatal fistula after repair of a cleft. We think that palatal fistulas after such a repair are more likely to be associated with the extent of the cleft and the skill of the operating surgeon.
Conflict of interest The authors declare that they have no conflict of interest.
Acknowledgement The study was supported by the Medical Science and Technology Development Foundation, Nanjing Department of Health (YKK08049).
References 1. Schultz RC. Management and timing of cleft palate fistula repair. Plast Reconstr Surg 1986;78:739–47. 2. Rohrich RJ, Rowsell AR, Johns DF, Drury MA, Grieg G, Watson DJ, et al. Timing of hard palatal closure: a critical long-term analysis. Plast Reconstr Surg 1996;98:236–46. 3. Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg 2003;112:1542–8. 4. Veau V. Division palatine. Paris: Masson; 1931. 5. Cohen SR, Kalinowski J, LaRossa D, Randall P. Cleft palate fistulas: a multivariate statistical analysis of prevalence, etiology, and surgical management. Plast Reconstr Surg 1991;87:1041–7. 6. Boorman JG, Sommerlad BC. Musculus uvulae and levator palati: their anatomical and functional relationship in velopharyngeal closure. Br J Plast Surg 1985;38:333–8. 7. Sommerlad BC, Gault DT. Space obliterating skin suture (letter). Plast Reconstr Surg 1998;102:2277–8. 8. Muzaffar AR, Byrd HS, Rohrich RJ, Johns DF, LeBlanc D, Beran SJ, et al. Incidence of cleft palate fistula: an institutional experience with two-stage palatal repair. Plast Reconstr Surg 2001;108:1515–8. 9. Emory Jr RE, Clay RP, Bite U, Jackson IT. Fistula formation and repair after palatal closure: an institutional perspective. Plast Reconstr Surg 1997;99:1535–8. 10. Wilhelmi BJ, Appelt EA, Hill L, Blackwell SJ. Palatal fistulas rare with the two-flap palatoplasty repair. Plast Reconstr Surg 2001;107:315–8. 11. Nguyen PN, Sullivan PK. Issues and controversies in the management of cleft palate. Clin Plast Surg 1993;20:671–82. 12. Chait L, Gavron G, Graham C, Noik E, De Aquier G. Modifying the two-stage cleft palate surgical correction. Cleft Palate Craniofac J 2002;39:226–32. 13. 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;45:172–8. 14. Andersson EM, Sandvik L, Semb G, Abyholm F. Palatal fistulas after primary repair of clefts of the secondary palate. Scand J Plast Reconstr Surg Hand Surg 2008;42:296–9.