Comparative Outcomes Assessment of Velopharyngeal Dysfunction and Oronasal Fistula: Implications of Muscle Repair in Palatoplasty
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Published on: September 8, 2023
David Y Cao1, Morgan I Lucero1, Jose Lucas Zepeda1
1Medical College of Wisconsin.
Objective:
To shed light on a clinical concern common to surgeries performed on muscles namely does more extensive muscle dissection during palatoplasty lead to excessive scarring, which would impair rather than improve subsequent muscle function?
Design:
Retrospective cohort study.
Setting:
Cleft lip and palate clinic within a single tertiary care academic institution.
Participants:
Nonsyndromic infants with cleft lip and palate or cleft palate only undergoing primary palatoplasty by 3 fellowship-trained craniofacial surgeons, assisted by plastic surgery resident physicians between 2001 and 2021 were reviewed. Inclusion criteria included primary surgery under 21 months of age, and at least 7 years of follow-up.
Interventions:
A comparison of 2 palatoplasty techniques-the von Langenbeck (VL), which consisted of coaptation of the levator muscle with minimal dissection and no actual levator muscle reconstruction and the Bardach Two-Flap (BTF) with Intravelar Veloplasty (IVVP) and levator palatini suture muscle repair.
Main Outcomes Measured:
Incidence of velopharyngeal dysfunction (VPD), defined by preoperative and postoperative Velopharyngeal Function Assessment Score (VFAS), need for secondary VPD surgery, and incidence of Oronasal Fistula (ONF).
Results:
One hundred fifty-seven patients were included, n=66 subjects underwent VL repair (mean age 12.5 mo) and n=91 subjects underwent BTF repair (mean age 12.8 mo), with similar age at surgery (P<0.33). Preoperative VFAS (8.8 VL versus 9.7 BTF, P<0.09) and postoperative VFAS (5.3 VL versus 4.2 BTF, P<0.10) did not differ significantly between groups. However, the VL group had significantly higher rates of adverse outcomes: VPD (59% VL versus 42% BTF, P<0.04), secondary speech surgery (59% VL versus 32% BTF, P<0.001), and postoperative ONF (64% VL versus 29% BTF, P<0.001). Analysis of surgeon factors showed that the single attending surgeon performing VL (without IVVP) had more years of experience than the BTF surgeons, yet the VL technique still yielded higher rates of secondary surgery and ONF (P<0.01, P<0.001). Resident physician experience level was similar across study groups.
Conclusions:
Levator muscle repair is associated with markedly improved outcomes after palatoplasty, challenging the notion that significant dissection and suture repair of the muscle would lead to subsequent scarring and compromise of clinical outcomes.
