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Background: Bone denudation after conventional relaxing incisions could be a critical factor in inhibiting maxillofacial growth. To address this, alternative relaxing incisions were designed. Thus, this study aimed to compare the effectiveness of palatal relaxing incisions versus nasopharyngeal relaxing incisions in enhancing postoperative outcomes. Materials and methods: A retrospective cohort study was conducted, involving a total of 120 patients divided into three groups: 40 patients have received modified Furlow palatoplasty with nasopharyngeal relaxing incisions (M.F + N.P.I palatoplasty), and 40 patients who received modified Furlow palatoplasty with palatal relaxing incisions (M.F + P.R.I palatoplasty). The other 40 patients received original Furlow palatoplasty without relaxing incisions (F palatoplasty). Data collected included gender, cleft type, cleft width, age at repair, velopharyngeal function, presence of palatal fistula, and follow-up. The chi-square test compared frequencies of sex, cleft type, postoperative fistula, and velopharyngeal outcomes across groups. The Mann–Whitney and independent t-tests compared mean values, with statistical significance set at p < 0.05. Results: The mean age at repair was similar across groups, with follow-up periods ranging from 5 to 11 years. No significant differences were found among the M.F + N.P.I and M.F + P.L.I groups regarding gender, cleft type, cleft width, and age at repair. However, the F group had a significantly narrowest cleft width compared to the other groups. Postoperative outcomes showed no significant differences in velopharyngeal function among the three groups, but the F group had a significantly higher rate of palatal fistula (32.5%) compared to the M.F + P.L.I (10%) and M.F + N.P.I (7.5%) groups. A comparison of the two modified Furlow techniques revealed no significant differences in velopharyngeal closure rates or the incidence of velopharyngeal insufficiency and persistent palatal fistula across different Veau classifications. Conclusions: While both incisions showed similar impacts on palatoplasty outcomes, palatal relaxing incisions may expose more bone and pose a higher risk of secondary healing issues. Therefore, nasopharyngeal relaxing incisions are recommended as an effective and potentially preferable technique in palatoplasty whenever feasible. Clinical relevance: The current study suggests that, whenever feasible, nasopharyngeal relaxing incisions are advised as an effective and potentially superior technique in palatoplasty. [ABSTRACT FROM AUTHOR]

Surgical robotic tools are being developed for a variety of surgical procedures that are executed within small workspaces. Novel designs of miniaturized cable-actuated surgical tools for cleft palate repair have previously been developed. However, the behavior and significance of friction within these tools are largely unknown. A study was conducted to investigate the friction in a pulleyless 3 mm diameter wristed instrument. The wrist utilizes cable guide channels that allow for miniaturization at the cost of increased friction. An experimental rig was developed to measure friction within the wrist link mechanism when the tool is positioned at various pitch angles. A strong relationship between the cable tension and the tool's pitch angle was found as a result of friction. The cable tension increased as the pitch angle approached extreme values (percent increases in the cable tension of 33% and 67.3% at a pitch of 90° and −90°, respectively). However, the resultant cable tension was below the failure strength of the cable, indicating that the design is feasible. The results of this study would be useful to those considering the design of miniature robotic surgical tools that are cable-driven. Significant tool reduction can be achieved by employing static guide channels for the cables, forgoing the use of additional moving components like pulleys while maintaining cable tension well within its break strength. Future work in the design and optimization of novel miniaturized wrist mechanisms should consider frictional effects and their impact on mechanism function. [ABSTRACT FROM AUTHOR]

Objectives: After cleft lip and/or palate (CL/P) repair, children may develop velopharyngeal insufficiency (VPI) leading to speech imperfections, necessitating additional speech correcting surgery. This study examines the incidence of VPI and speech correcting surgery after Sommerlad’s palatoplasty for CL/P, and its association with various clinical features. Materials and methods: A retrospective cohort study was performed in the Wilhelmina Children’s Hospital in Utrecht and child records from 380 individuals with CL/P registered from 2008 to 2017 were retrospectively reviewed. Inclusion criteria comprised the diagnosis of CL/P, primary palatoplasty according to Sommerlad’s technique, and speech assessment at five years or older. Association between cleft type and width, presence of additional genetic disorders and postoperative complications (palatal dehiscence, fistula) were assessed using odds ratios and chi squared tests. Results: A total of 239 patients were included. The VPI rate was 52.7% (n = 126) and in 119 patients (49.8%) a speech correcting surgery was performed. Severe cleft type, as indicated by a higher Veau classification, was associated with a significant higher rate of speech correcting surgeries (p = 0.033). Significantly more speech correcting surgeries were performed in patients with a cleft width >10 mm, compared to patients with a cleft width ≤10 mm (p < 0.001). Patients with oronasal fistula underwent significantly more speech correcting surgeries than those without fistula (p = 0.004). No statistically significant difference was found in the incidence of speech correcting surgery between patients with and without genetic disorders (p = 0.890). Conclusions/clinical relevance: Variations in cleft morphology, cleft width and complications like oronasal fistula are associated with different speech outcomes. Future research should focus on creating a multivariable prediction model for speech correcting surgery in CL/P patients. [ABSTRACT FROM AUTHOR]

Cleft palate repair is a common reconstructive procedure that can involve significant blood loss. Tranexamic acid (TXA) has been proposed to minimise blood loss during various surgical procedures, but its effectiveness in cleft palate repair remains unclear. This systematic review and meta-analysis aimed to assess the effectiveness of TXA to reduce postoperative blood loss. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive search across multiple databases, including PubMed, Cochrane, and Web of Science, to identify relevant studies published up to September 2023. Only randomised controlled trials (RCTs) were included. Primary outcomes measured were total blood loss, transfusion rates, and postoperative complications. We identified four relevant RCTs, which included 275 cleft palate patients with a mean (range) age of 28.7 (6–65) months. The pooled analysis found no significant difference in duration of surgery (MD -18.40 minutes, p = 0.09), preoperative haemoglobin (MD 0.46 g/dl, p = 0.27), or postoperative haemoglobin (MD 0.07 g/dl, p = 0.86) between TXA and control groups. Intraoperative blood loss was lower with TXA, but with TXA, the difference was not statistically significant (MD -16.63 ml, p = 0.15). TXA significantly improved surgical field visibility (p = 0.004). No adverse events occurred with its use. While no significant differences were found in surgical outcomes with TXA, surgical field visibility significantly improved, and TXA showed a promising safety profile. Larger and higher-quality RCTs are still needed to validate these preliminary findings before TXA can be considered as a standard treatment. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to compare the incidence of palatal fistula formation between cleft palate (CP) repair with collagen matrix graft and conventional repair without collagen matrix graft. Patients and Methods: This was a preliminary randomized controlled study of patients with CP who underwent primary palatoplasty (two-flap palatoplasty technique) at the Lagos University Teaching Hospital. Patients were randomly allocated to either the test group (palatoplasty with collagen graft) or the control group (palatoplasty without collagen graft). The primary outcome was palatal fistula, and secondary outcomes were wound dehiscence, surgical site inflammation, surgical site infection, and surgeon satisfaction up to 3 months postoperative (PO). Results: Ten patients were recruited, five in each group. Only one patient in the control group developed a palatal fistula at 1 month PO on the soft palate which extended to the junction of hard and soft palate at 3 months PO. Eight patients developed wound dehiscence, five in the test group and three in the control group. Surgical site inflammation persisted up to at least 7 days PO in nine patients (five in the test group and four in the control group). All persistent wound dehiscence and surgical site inflammation resolved at 3 months PO. No patient developed surgical site infection. No significant difference was seen between the study group and wound dehiscence, surgery time, and difficulty of the procedure (P > 0.05 for all associations). Conclusion: Collagen graft may have a protective effect against fistula formation without significantly increasing surgery time and difficulty. However, due to the small sample size, the study failed to draw definite conclusions. Results from this study may inform future designs of larger randomized controlled studies.

Abstract Background Cleft palate repair surgery may result in severe pain in the immediate postoperative period. The aim of this study is to compare the effects of different doses of nalbuphine for postoperative analgesia in children with cleft palate. Methods From November 2019 to June 2021, 90 children (45 males and 45 females, age 9–20 months old, ASA class I—II) were selected for palatoplasty. They were randomly divided into three groups: the control group (Group C), the N1 group (postoperative analgesia with 0.05 mg/kg/h nalbuphine) and the N2 group (postoperative analgesia with 0.075 mg/kg/h nalbuphine). Each group had 30 cases. Nalbuphine was not continuously infused in Group C but was continuously infused in Groups N1 and N2 at rates of 0.05 mg/kg/h and 0.075 mg/kg/h, respectively, for 24 h for postoperative analgesia. The FLACC analgesia score and Ramsay Sedation score were recorded at 10 min (T1), 30 min (T2), 2 h (T3), 12 h (T4) and 24 h (T5) after the operation. Adverse reactions such as nausea, vomiting and respiratory depression were observed and recorded. Results Compared with those in Group C, the FLACC scores in the N1 and N2 groups decreased significantly at T1-T5 (p

Objectives: In cleft palate patients, the soft palate is commonly closed using straight-line palatoplasty, Z-palatoplasty, or palatoplasty with buccal flaps. Currently, it is unknown which surgical technique is superior regarding speech outcomes. The aim of this review is to study the incidence of speech correcting surgery (SCS) per soft palatoplasty technique and to identify variables which are associated with this outcome. Materials and methods: A systematic literature search was carried out according to the PRISMA guidelines. Inclusion and exclusion criteria were applied to focus on the incidence of SCS after soft palatoplasty. Additional variables like surgical modification, cleft morphology, syndrome, age at palatoplasty, fistula and assessment of velopharyngeal function were reported. A modified New-Ottawa Scale (NOS) was used for quality appraisal. Pooled estimates from the meta-analysis were calculated using a random-effects model. Results: One thousand twenty-nine studies were found of which 54 were included in the analysis. The pooled estimate proportion of SCS after straight-line palatoplasty was 19% (95% CI 15–24), after Z-palatoplasty 6% (95% CI 4–9), and after palatoplasty with buccal flaps 7% (95% CI 4–11). Conclusions: A lower SCS rate was found in patients receiving Z-palatoplasty when compared to straight-line palatoplasty. We propose a minimum set of outcome parameters which ideally should be included in future studies regarding speech outcomes after cleft palate repair. Clinical relevance: Current literature reports highly heterogenous data regarding cleft palate repair. Our recommended set of parameters may address this inconsistency and could make intercenter comparison possible and of better quality. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to compare the incidence of palatal fistula formation between cleft palate (CP) repair with collagen matrix graft and conventional repair without collagen matrix graft. Patients and Methods: This was a preliminary randomized controlled study of patients with CP who underwent primary palatoplasty (two‑flap palatoplasty technique) at the Lagos University Teaching Hospital. Patients were randomly allocated to either the test group (palatoplasty with collagen graft) or the control group (palatoplasty without collagen graft). The primary outcome was palatal fistula, and secondary outcomes were wound dehiscence, surgical site inflammation, surgical site infection, and surgeon satisfaction up to 3 months postoperative (PO). Results: Ten patients were recruited, five in each group. Only one patient in the control group developed a palatal fistula at 1 month PO on the soft palate which extended to the junction of hard and soft palate at 3 months PO. Eight patients developed wound dehiscence, five in the test group and three in the control group. Surgical site inflammation persisted up to at least 7 days PO in nine patients (five in the test group and four in the control group). All persistent wound dehiscence and surgical site inflammation resolved at 3 months PO. No patient developed surgical site infection. No significant difference was seen between the study group and wound dehiscence, surgery time, and difficulty of the procedure (P > 0.05 for all associations). Conclusion: Collagen graft may have a protective effect against fistula formation without significantly increasing surgery time and difficulty. However, due to the small sample size, the study failed to draw definite conclusions. Results from this study may inform future designs of larger randomized controlled studies. [ABSTRACT FROM AUTHOR]

Surgical robotic tools are being developed for a variety of surgical procedures that are executed within small workspaces. Novel designs of miniaturized cable-actuated surgical tools for cleft palate repair have previously been developed. However, the behavior and significance of friction within these tools are largely unknown. A study was conducted to investigate the friction in a pulleyless 3 mm diameter wristed instrument. The wrist utilizes cable guide channels that allow for miniaturization at the cost of increased friction. An experimental rig was developed to measure friction within the wrist link mechanism when the tool is positioned at various pitch angles. A strong relationship between the cable tension and the tool’s pitch angle was found as a result of friction. The cable tension increased as the pitch angle approached extreme values (percent increases in the cable tension of 33% and 67.3% at a pitch of 90° and −90°, respectively). However, the resultant cable tension was below the failure strength of the cable, indicating that the design is feasible. The results of this study would be useful to those considering the design of miniature robotic surgical tools that are cable-driven. Significant tool reduction can be achieved by employing static guide channels for the cables, forgoing the use of additional moving components like pulleys while maintaining cable tension well within its break strength. Future work in the design and optimization of novel miniaturized wrist mechanisms should consider frictional effects and their impact on mechanism function.

Objective To observe the effect of different doses of ε-aminocaproic acid （EACA） on wound bleeding in infants undergoing cleft palate repair. Methods One hundred and twenty infants scheduled to undergo cleft palate repair， aged from 6 to 36 months， ASA status Ⅰ or Ⅱ， were randomly divided into the control （group C）， conventional-dose EACA （group E1） and low-dose EACA groups （group E2）， 40 cases in each group. Infants in groups E1 and E2 were administrated with a loading dose of EACA （40 mg/kg） for 20 min before incision， followed by continuous infusion of 30 mg/（kg·h） and 10 mg/（kg·h） in two groups， respectively. In group C， continuous infusion of normal saline was applied. Same anesthesia regimen was delivered for all patients among three groups. Wound bleeding scores during operation， before extubation and 24 h after operation， intraoperative blood loss， anesthesia time， operation time， and fibrinogen concentration before and 24 h after surgery， and the incidence of delayed haemorrhage， deep vein thrombosis and epilepsy were recorded. Results Compared with group C， the wound bleeding scores during operation and before extubation in group E1 and E2 were significantly lower， the amount of intraoperative blood loss was significantly less， and the fibrinogen concentration at postoperative 24 h was significantly increased （all P < 0.05）， while no significant statistical difference was observed between groups E1 and E2 （all P > 0.05）. There were no statistically significant differences in operation time， anesthesia time and the incidence of delayed hemorrhage among three groups （all P > 0.05）. No deep vein thrombosis or epilepsy occurred among three groups. Conclusion The application of EACA in infants with cleft palate repair can mitigate perioperative wound bleeding and lower the incidence of delayed hemorrhage. Low-dose EACA yields favorable hemostatic effect. These findings provide reference for drug use in clinical practice.

Purpose: The current pilot study aimed to collect craniofacial surgeon's personal perspectives regarding the timing of cleft palate surgical repair, medical considerations for surgical repair (i.e., age, weight, type of cleft, and potential for surgical complications), and social considerations (i.e., speech--language development, socioeconomic status, and familial support). Materials and Methods: Fifteen plastic surgeons currently practicing cleft palate repair participated in this study. Surveys were distributed electronically to team coordinators of the American Cleft Palate-Craniofacial Association-accredited craniofacial teams and included a combination of Likert scales, closed multiple-choice questions, and open-ended qualitative questions for free-text responses. Results: Preliminary data obtained in this study suggest that the most common age range for palate repair in nonmedically complex infants is 10-11 months of age (n = 10). Notably, 20% of respondents (n = 3) reported a typical surgical repair time of 7-9 months of age. While medical and social priorities differed, all surgeons rated speech--language development as an important factor when determining the timing of surgical intervention. Conclusion: Given the limited consensus on surgical timing and intervention for children with cleft palate, further research is needed to determine the optimal timing of palate repair that considers both medical safety and near age-appropriate speech sound acquisition and production. [ABSTRACT FROM AUTHOR]

Purpose: The current pilot study aimed to collect craniofacial surgeon's personal perspectives regarding the timing of cleft palate surgical repair, medical considerations for surgical repair (i.e., age, weight, type of cleft, and potential for surgical complications), and social considerations (i.e., speech–language development, socioeconomic status, and familial support). Materials and Methods: Fifteen plastic surgeons currently practicing cleft palate repair participated in this study. Surveys were distributed electronically to team coordinators of the American Cleft Palate-Craniofacial Association-accredited craniofacial teams and included a combination of Likert scales, closed multiple-choice questions, and open-ended qualitative questions for free-text responses. Results: Preliminary data obtained in this study suggest that the most common age range for palate repair in nonmedically complex infants is 10–11 months of age (n = 10). Notably, 20% of respondents (n = 3) reported a typical surgical repair time of 7–9 months of age. While medical and social priorities differed, all surgeons rated speech–language development as an important factor when determining the timing of surgical intervention. Conclusion: Given the limited consensus on surgical timing and intervention for children with cleft palate, further research is needed to determine the optimal timing of palate repair that considers both medical safety and near age-appropriate speech sound acquisition and production.

Objective To observe the effect of different doses of ε-aminocaproic acid (EACA)on wound bleeding in infants undergoing cleft palate repair. Methods One hundred and twenty infants scheduled to undergo cleft palate repair, aged from 6 to 36 months, ASA status Ⅰ or Ⅱ, were randomly divided into the control (group C), conventional-dose EACA (group E1)and low-dose EACA groups (group E2), 40 cases in each group. Infants in groups E1 and E2 were administrated with a loading dose of EACA (40 mg/kg)for 20 min before incision, followed by continuous infusion of 30 mg/(kg · h)and 10 mg/(kg · h)in two groups, respectively. In group C, continuous infusion of normal saline was applied. Same anesthesia regimen was delivered for all patients among three groups. Wound bleeding scores during operation, before extubation and 24 h after operation, intraoperative blood loss, anesthesia time, operation time, and fibrinogen concentration before and 24 h after surgery, and the incidence of delayed haemorrhage, deep vein thrombosis and epilepsy were recorded. Results Compared with group C, the wound bleeding scores during operation and before extubation in group E1 and E2 were significantly lower, the amount of intraoperative blood loss was significantly less, and the fibrinogen concentration at postoperative 24 h was significantly increased (all P < 0.05), while no significant statistical difference was observed between groups E1 and E2 (all P > 0.05). There were no statistically significant differences in operation time, anesthesia time and the incidence of delayed hemorrhage among three groups (all P > 0.05). No deep vein thrombosis or epilepsy occurred among three groups. Conclusion The application of EACA in infants with cleft palate repair can mitigate perioperative wound bleeding and lower the incidence of delayed hemorrhage. Low-dose EACA yields favorable hemostatic effect. These findings provide reference for drug use in clinical practice. [ABSTRACT FROM AUTHOR]

The purpose of this study was to assess the effect of tongue−lip adhesion (TLA) on the long-term speech and articulation outcomes of patients with Robin sequence (RS) after cleft palate repair. Outcomes were compared to those in patients with RS who required positioning alone and to patients with isolated cleft palate (ICP). All consecutive patients with RS (with or without TLA) versus isolated cleft palate (ICP) who underwent cleft palate repair were retrospectively reviewed. Speech and articulation included all assessments between the age of 3–6 years. Secondary speech operations, velopharyngeal insufficiency (VPI), hypernasality, and articulation errors by cleft-type characteristics (CTC), including 4 categories (passive), non-oral, anterior-oral, and posterior-oral. A total of 41 RS patients and 61 ICP patients underwent repair with sufficient follow-up. Of them, 23 patients underwent a TLA at median age of 12 days. Rates of hypernasality (p = 0.004), secondary speech operations (p = 0.004), and posterior oral CTC (p = 0.042) were higher in RS compared to ICP. Isolated RS had speech outcomes similar to those of ICP; however, syndromic RS patients needed more secondary speech operations compared to isolated RS (p = 0.043). TLA-RS patients did not demonstrate differences in speech outcomes or any CTCs (all p > 0.05) compared to non−TLA-RS patients, except for the anterior oral CTC (74% TLA-RS vs 28% non−TLA-RS, p = 0.005). Within the limitations of the study, it seem that TLA does not affect long-term velopharyngeal function in patients with RS. However, TLA-RS patients demonstrated higher rates of anterior-oral CTC, which might be related to a different positioning of the tongue after TLA. Every effort should be taken to treat patients with RS conservatively instead of with TLA because of this demonstrated a negative effect on one type of articulation error. However, if conservative therapy fails, a TLA is still a valuable adjunct in the treatment of RS, and cleft speech pathologists who treat such patients should be more aware of this phenomenon in order to improve long-term articulation outcomes. [ABSTRACT FROM AUTHOR]

Background: Although the United Kingdom (UK) cleft surgeons follow a similar training pathway, and cleft centers adhere to similar protocols regarding the timing of palate surgery and surgical technique, speech outcomes still vary between centers. Objective: To explore the training experiences of consultant cleft lip and palate (CL/P) surgeons, performing a Sommerlad radical intravelar veloplasty (IVVP) and their approach to teaching others. Design: An exploratory, qualitative approach was adopted to understand the views of UK cleft surgeons performing a Sommerlad radical IVVP and discuss what was important during training and upon qualifying as a consultant. Method: A semi-structured interview schedule was designed, interviews were conducted in-person or via videoconferencing, depending on preference and availability, with interested surgeons. The interviews were recorded, transcribed, and checked for accuracy. Analysis involved inductive thematic analysis. Results: Fourteen cleft consultants from the UK participated (3F:11M). Seven of the consultants were trained in plastic surgery and four in maxillofacial surgery. Seven themes were identified from the thematic analysis. Three themes, namely Learning to perform palate repair, Teaching others to perform palate repair, and Ongoing learning as a consultant are discussed. Conclusions: Cleft palate repair is clearly a technically challenging procedure to learn and teach with the potential to cause harm if performed incorrectly. Positive changes have been made to improve exposure to palate surgery, encourage practice away from the patient, and increase supervised practical experience. The role of colleagues in providing mentorship and support appears invaluable. We provide some simple recommendations that may improve the training experience and ensure parity for all trainees. [ABSTRACT FROM AUTHOR]

Cleft lip and palate are the most frequent congenital anomalies of the face. They may be either unilateral or bilateral and involve either lip or palate or both lip and palate. These orofacial clefts can occur as a part of a syndrome or isolated clefts. Multidisciplinary management should be considered in cleft lip and palate patients to fully ensure speech and hearing, the continuation of occlusion and maxillofacial growth. All branches of dentistry treat cleft lip and palate sequentially at various stages of life. [ABSTRACT FROM AUTHOR]

Study Objective: The study aimed to evaluate the efficacy of ropivacaine in providing postoperative analgesia for children undergoing cleft palate repair., Methods: A double-blinded, randomized controlled trial was conducted on sixty-four children scheduled for cleft palate repair. The patients received either local infiltration with 1% lidocaine or 0.2% ropivacaine before incision. The primary outcome was the postoperative average pain score, and secondary outcomes included pain scores at various time points, consumption of flurbiprofen and hydromorphone, effectiveness of nurse-controlled analgesia pump, and incidence of bradycardia, vomiting, and respiratory depression., Main Results: The results showed that the postoperative average pain score was significantly lower in the ropivacaine group compared to the lidocaine group (1.27±0.28 vs. 1.75±0.29, P<0.001). Pain scores at multiple postoperative time points were also lower in the ropivac:aine group. Additionally, consumption of flurbiprofen and hydromorphone was lower, and ineffective compressions of the nurse-controlled analgesia pump were reduced in the ropivacaine group. The incidence of vomiting, bradycardia, and respiratory depression did not show significant differences between the two groups., Conclusion: Local infiltration with ropivacaine effectively provided postoperative analgesia for children undergoing cleft palate repair without major side effects. It was found to be superior to lidocaine in reducing the need for additional rescue analgesia., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Masson SAS.)

Objective: To determine predictors of success following Veau 1 and 2 cleft palate repair in patients with and without syndromes. Study Design: Retrospective review of prospectively collected data. Setting: Tertiary care children's hospital. Methods: All children <18 months of age undergoing Furlow palatoplasty for Veau 1 and 2 cleft repair between 2000 and 2014 with postoperative perceptual speech assessment (PSA). Results: In total, 368 consecutive patients were identified; 95 were excluded, resulting in 273 patients. Median age at surgery was 13.0 months (interquartile range [IQR], 11-15 months) with postoperative PSA at a median of 32.3 months (IQR, 26.3-44.5 months). Fifty patients (18.3%) had syndrome diagnosis; 59 patients (21.6%) had nonsyndromic Robin sequence. Velopharyngeal insufficiency (VPI) occurred in 27 patients (10.5%); 13 underwent secondary speech surgery. Cleft-related speech errors occurred in 46 patients (17.6%). Non-cleft-related speech errors occurred in 155 patients (59.6%) and reduced intelligibility in 127 patients (47.9%). Oronasal fistula occurred in 23 patients (8.8%) and was exclusive to Veau 2 clefts. In multivariate analysis, age >13 months at palatoplasty demonstrated a 6-fold higher rate of VPI (hazard ratio [HR], 6.64; P <.01), worse speech outcomes (HR, 6.04; P <.01; HR, 1.60; P <.01; HR, 1.57; P =.02), and greater speech therapy utilization (HR, 2.18; P <.01). Conclusion: VPI occurred in 10% of patients undergoing Furlow palatoplasty repair of Veau 1 or 2 clefts. Age <13 months at palatoplasty was associated with improved speech outcomes and lower VPI incidence (2.8% vs 16.2%). Syndromic diagnosis was associated with noncleft speech errors and reduced intelligibility on univariate analysis but not velopharyngeal function after palatoplasty. [ABSTRACT FROM AUTHOR]

Objective: The mainstay of palatal repair in the United Kingdom is the intravelar veloplasty (IVVP). It is not always possible to align the oral mucosa in the midline to achieve tension-free repair. The addition of lateral relieving incisions may aid transposition of the oral mucosa to allow closure. The aim of this study was to explore cleft features that may predispose to a requirement for relieving incisions in order to allow palate closure. Design: We performed a national multiinstitutional retrospective study using data from the UK Cleft Collective cohort study. Patients: The study sample consisted of 474 patients who had undergone IVVP at the time of palatal closure across all 16 of the UK cleft units. Results: We found strong evidence for the requirement for relieving incisions in patients with an increased degree of clefting per the Veau classification (P <.001), increasing palatal soft-edge width (P <.001) and moderate evidence of an associated use in patients with Pierre Robin sequence (P =.015). Insufficient data were available to explore the relationship between intertuberosity distance and the presence of fistula formation with the use of relieving incisions. Conclusions: The results of this study identify cleft features that increase the likelihood for requiring lateral relieving incisions to allow palatal closure. The degree to which the addition of relieving incisions to IVVP affects maxillary growth and speech outcomes is unknown. Further study is required to answer this important question. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the development process and clinical impact of implementing a standardized perioperative clinical care pathway for cleft palate repair. Design: Medical records of patients undergoing primary cleft palate repair prior to pathway implementation were retrospectively reviewed as a historical control group (N = 40). The historical cohort was compared to a prospectively collected group of patients who were treated according to the pathway (N = 40). Patients: Healthy, nonsyndromic infants undergoing primary cleft palate repair at a tertiary care pediatric hospital. Interventions: A novel, standardized pathway was created through an iterative process, combining literature review with expert opinion and discussions with institutional stakeholders. The pathway integrated multimodal analgesia throughout the perioperative course and included intraoperative bilateral maxillary nerve blocks. Perioperative protocols for preoperative fasting, case timing, antiemetics, intravenous fluid management, and postoperative diet advancement were standardized. Main Outcome Measures: Primary outcomes include: (1) length of hospital stay, (2) cumulative opioid consumption, (3) oral intake postoperatively. Results: Patients treated according to the pathway had shorter mean length of stay (31 vs 57 hours, P <.001), decreased cumulative morphine consumption (77 vs 727 μg/kg, P <.001), shorter time to initiate oral intake (9.3 vs 22 hours, P =.01), and greater volume of oral intake in first 24 hours postoperatively (379 vs 171 mL, P <.001). There were no differences in total anesthesia time, total surgical time, or complication rates between the control and treatment groups. Conclusions: Implementation of a standardized perioperative clinical care pathway for primary cleft palate repair is safe, feasible, and associated with reduced length of stay, reduced opioid consumption, and improved oral intake postoperatively. [ABSTRACT FROM AUTHOR]

The study aimed to: (1) compare the occurrence of postoperative respiratory difficulties (PRD) following primary cleft palate repair (CPR) in infants with an isolated cleft palate (iCP) and infants with Robin sequence (RS), and (2) describe the possible benefit of preoperative analysis with palatal plate in infants with RS. All consecutive infants with an iCP and infants with RS who underwent CPR between January 2009 and June 2022 in the Wilhelmina Children's Hospital were retrospectively reviewed. A total of 127 infants were included of which 74 infants with an iCP and 53 infants with RS. The group of infants with RS consisted of 35 infants with non-isolated RS (niRS) and 18 infants with isolated RS (iRS). Significant more PRD were seen in infants with RS compared to infants with an iCP (14/53 versus 9/74; p = 0.04). Especially infants with niRS have a significant higher risk of developing PRD in comparison with infants with an iCP (OR = 4.16, 95% CI [1.17-15.99], p = 0.031). The preoperative palatal plate screening in infants with RS (n = 25) did not show abnormalities and had no effect on the perioperative policy. Within the limitations of this study it seems that infants with niRS are more prone to develop PRD following primary CPR when compared to infants with iRS or an iCP. No clear benefit was found in postponing surgery until 12 months or later in infants with RS to avoid PRD. The preoperative palatal plate screening did not demonstrate signs of UAO in infants with RS that developed PRD. These findings suggest that preoperative analysis with palatal plate has a low predictive value., Competing Interests: Declaration of competing interest The authors declare that there are no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: This study aims to reduce the waste generated from primary cleft lip and/or palate (CL/P) repair., Design: A retrospective chart review examined a single surgeon's experience with CL/P repair using standard draping technique and reduced draping technique. Fisher's exact tests were performed comparing complication rates between techniques., Setting: All procedures were conducted at a single academic medical center under the care of a board-certified pediatric plastic surgeon and fellowship-trained pediatric anesthesiologists., Patients: The study included all patients ≤ 24 months of age who underwent primary CL/P repair using a reduced draping technique at the senior author's institution. An equivalent number of patients who underwent CL/P repair by the senior author immediately prior to implementation of the reduced draping technique were included for comparison., Intervention: Patients undergoing CL/P repair before the change in technique were draped using the standard CL/P draping. The senior author then switched to using a reduced draping on all CL/P repairs afterwards., Main Outcome Measures: Weights and costs of both draping sets were obtained and differences calculated. A manual chart review was performed to assess rates of accidental intraoperative extubation, postoperative infection, fistula formation, and wound dehiscence., Results: The implementation of a reduced draping technique resulted in a 530 gram weight savings and $7.49 cost savings per procedure. Fisher's exact tests revealed no statistically significant differences in complication rates except for oral mucosal dehiscence, which was lower in the reduced draping group., Conclusions: Reduced draping in CL/P repairs significantly reduces operative waste without compromising surgical outcomes., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Although cleft surgeons in the United Kingdom follow a similar training pathway, and cleft centers adhere to similar protocols regarding timing of palate surgery and surgical technique, speech outcomes still vary significantly between centers. Objective: To explore if differences in technique exist between individual surgeons, performing a Sommerlad radical intravelar veloplasty (IVVP). Design: An exploratory, qualitative approach was adopted to understand the views of UK cleft surgeons performing a Sommerlad radical IVVP for primary cleft palate repair and to discuss what was important in the adoption, adaptation, and evolution of this technique within their own practice. Method: A semistructured interview schedule was designed. Interviews were conducted in person or via videoconferencing, with interested surgeons. The interviews were recorded, transcribed, and checked for accuracy. Analysis involved inductive thematic analysis. Results: Fourteen cleft consultants from the United Kingdom participated (3 females and 11 males). Seven of the consultants were trained in plastic surgery and 4 in oral and maxillofacial surgery. Eight themes were identified from the thematic analysis. One theme--Surgical Variation--is discussed. Conclusions: The findings provide insight into areas of variation seen within one surgical technique of cleft palate repair. These variations may have arisen to accommodate heterogeneity in the patient population or may have evolved in relation to different experiences of training or influences of colleagues. Further work is needed to explore the reasons for these differences in technique and to identify if any of these subtle differences contributed to variability in outcomes. [ABSTRACT FROM AUTHOR]

Objective: This study assesses the association between risk of secondary surgery for oronasal fistula following primary cleft palate repair and 2 hospital characteristics—cost-to-charge ratio (RCC) and case volume of cleft palate repair. Design: Retrospective cohort study. Setting: This study utilized the Pediatric Health Information System (PHIS) database, which consists of clinical and resource-utilization data from >49 hospitals in the United States. Patients and Participants: Patients undergoing primary cleft palate repair from 2004 to 2009 were abstracted from the PHIS database and followed up for oronasal fistula repair between 2004 and 2015. Main Outcome Measure(s): The primary outcome measure was whether patients underwent oronasal fistula repair after primary cleft palate repair. Results: Among 5745 patients from 45 institutions whom met inclusion criteria, 166 (3%) underwent oronasal fistula repair within 6 to 11 years of primary cleft palate repair. Primary palatoplasty at high-RCC facilities was associated with a higher rate of subsequent oronasal fistula repair (odds ratio [OR] = 1.84 [1.32-2.56], adjusted odds ratio [AOR] = 1.81 [1.28-2.59]; P ≤.001). Likelihood of surgery for oronasal fistula was independent of hospital case volume (OR = 0.83 [0.61-1.13], P =.233; AOR = 0.86 [0.62-1.20], P =.386). Patients with complete unilateral or bilateral cleft palate were more likely to receive oronasal fistula closure compared to those with unilateral-incomplete cleft palate (AOR = 2.09 [1.27-3.56], P =.005; AOR = 3.14 [1.80-5.58], P <.001). Conclusions: Subsequent need for oronasal fistula repair, while independent of hospital case volume for cleft palate repair, increased with increasing hospital RCC. Our study also corroborates complete cleft palate and cleft lip as risk factors for oronasal fistula. [ABSTRACT FROM AUTHOR]

The aim of this study is to compare speech outcomes, fistula rates, and rates of secondary speech surgeries after palatoplasty using Furlow palatoplasty or type 2b intravelar veloplasty for soft palate repair. Patients with unilateral cleft lip and palate who had either Furlow palatoplasty or intravelar veloplasty for soft palate repair were retrospectively evaluated for demographic and perioperative variables and speech outcomes. Fistula rate, secondary surgical intervention for improved speech results, and findings of speech assessment were further reviewed for the patients who met the inclusion criteria. A total of 76 patients, 36 in the Furlow palatoplasty group and 40 in the intravelar veloplasty group, were included in the study. In the speech assessment, nasalance values were statistically similar between the two groups. Also, there was no statistically significant difference between the groups in velopharyngeal motility (p = 0.103). The total rates of secondary surgeries and fistula were statistically similar between the groups (p = 0.347 and 0.105, respectively). The similar outcomes of speech and surgical evaluation between the two groups make the surgeon's preference determinant in the selection of the surgical technique for soft palate repair. [ABSTRACT FROM AUTHOR]

Objective: Delayed repair of cleft palate is associated with worse speech outcomes. Social determinants of health may influence the timing of surgery; however, there are no population health investigations to evaluate factors such as travel distance, language barriers, and payer. This study sought to identify factors that may interfere with timely cleft palate repair., Design: Retrospective cohort., Setting: National/multi-center., Patients/participants: All cleft palate repairs within California were extracted from 2000-2021., Main Outcomes Measures: The primary outcome was age at surgical repair, which was modeled with linear regression. Covariates included race, primary language, distance from patient home to hospital, socioeconomic status, primary payer, and managed care enrollment status., Results: 11 260 patients underwent surgical repair of a cleft palate. Black race was associated with delayed repair (22 additional days, P  = .004, 95% CI 67.00-37.7) along with Asian/Pacific-Islander race (11 additional days, P  = .006, 95% CI 3.26-18.9) compared to white race. Spanish-speaking patients had significantly later cleft palate repairs by 19 days, ( P  < .001, 95% CI 10.8-27.7) compared with English-speaking. Further distances from the hospital were significantly associated with later cleft surgeries with out-of-state patients undergoing surgery 52 days later ( P  < .001, 95% CI 11.3-24.3). Managed care plans and Medi-Cal were significantly associated with earlier surgical repair compared with private insurance., Conclusion: Black, Asian Pacific Islander, and Spanish-speaking patients and greater distance traveled to hospital were associated with delayed cleft palate repairs. These results underscore the importance of addressing structural and social barriers to care to improve outcomes and reduce health disparities for patients with cleft palate., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Congenital cleft of the secondary palate occurs when there is failure of one or both maxillary processes to fuse with the nasal septum during embryonic development. Palatal cleft severity can range from a simple focal fissure of the caudal soft palate to full-thickness defects of varied widths involving the entire soft and hard palate. A novel staged medially positioned single mucoperiosteal flap technique in 4 canine patients is reported. This flap technique is based on the major palatine and infraorbital arteries with strategic extractions of maxillary teeth and placement of allograft membrane in 3 of 4 cases for treatment of clefts wider than may be repaired effectively by traditional methods., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Grisel's syndrome is nontraumatic atlantoaxial subluxation secondary to inflammatory conditions or surgery in the head and neck region due to anomalous head posture. In this case report, a 6-year-old female patient, diagnosed as Grisel's syndrome following the surgery for the repair of cleft palate with velopharyngeal insufficiency is presented. This is to note the importance of perioperative positioning and postoperative stabilization. 6 years old female child, with a weight of 23 kg admitted to the hospital for speech disorders and velopharyngeal insufficiency associated with cleft palate. She underwent surgery for the repair of cleft palate and three weeks after surgery, she was readmitted to the hospital with abnormal head posture, pain and limitation in neck movements. After cervical CT scanning, atlantoaxial subluxation was confirmed. She was diagnosed as Grisel's syndrome and treated with conservative therapy by stabilization of the neck with a hard cervical collar and medical treatment. Extreme head positions are sometimes necessary for cleft lip and palate surgeries. Early diagnosis of Grisel's syndrome is critical for a successful treatment. INSET: 56. [ABSTRACT FROM AUTHOR]

Objective: To increase access to high-quality and multiregional databases in global epidemiology of cleft surgeries through partnership with an NGO. Design: The study retrospectively analyzes 34 801 primary palate surgeries in 70+ countries from the 2016 electronic health records of an non-governmental organization (NGO). The study also utilizes the Kids' Inpatient Database to compare the epidemiology of primary cleft palate surgeries in the United States. Participants: Patient records of those undergoing primary cleft palate surgeries only. Main Outcome Measures: Region, age, sex, type of cleft, laterality of cleft. Results: Key findings show that average age of those receiving primary cleft palate surgery in the low- and middle-income countries (LMICs) was 1.95 years. The distribution of males and females receiving surgery corresponds to the US national data. More hard cleft palates were on the left side (66.18%) than the right side (33.82%), independent of gender and region. Conclusions: Databases from an established NGO can be used to enhance our understanding of the disease characteristics in these regions. By increasing the information available regarding cleft surgeries in the LMIC, we hope to increase awareness of the similarities and differences in surgeries across various regions, as part of an effort to inform the goals set by Global Surgery 2030 initiative by the Lancet Commission. [ABSTRACT FROM AUTHOR]

Objective: To test the feasibility of implementing a high-fidelity cleft palate simulator during a workshop in Santiago, Chile, using a novel video endoscope to assess technical performance. Design: Sixteen cleft surgeons from South America participated in a 2-day cleft training workshop. All 16 participants performed a simulated repair, and 13 of them performed a second simulated repair. The repairs were recorded using a low-cost video camera and a newly designed camera mouth retractor attachment. Twenty-nine videos were assessed by 3 cleft surgeons using a previously developed cleft palate objective structured assessment of technical skill (CLOSATS with embedded overall score assessment) and global rating scale. The reliability of the ratings and technical performance in relation to minimum acceptable scores and previous experience was assessed. Results: The video setup provided acceptable recording quality for the purpose of assessment. Average intraclass correlation coefficient for the CLOSATS, global, and overall performance score was 0.69, 0.75, and 0.82, respectively. None of the novice surgeons passed the CLOSATS and global score for both sessions. One participant in the intermediate group, and 2 participants in the advanced group passed the CLOSATS and global score for both sessions. There were highly experienced participants who failed to pass the CLOSATS and global score for both sessions. Conclusions: The cleft palate simulator can be practically implemented with video-recording capability to assess performance in cleft palate repair. This technology may be of assistance in assessing surgical competence in cleft palate repair. [ABSTRACT FROM AUTHOR]

The prosthodontic rehabilitation of patients postcleft palate repair is an important part of the multidisciplinary approach to solving the many problems related to total health. One such problem is speech difficulties and articulation errors. High-arched palate associated with cleft palate repair affects phonation and articulation by affecting the approximation of its surface with the tongue. This results in unintelligible and hypernasal sound production. Palatogram is a fairly simple, yet highly efficacious clinical technique for the assessment of palatal contours, to improve the existent speech deficiencies of affected sounds. This case report demonstrates a multidisciplinary treatment approach to successfully improve the intelligibility of speech by fabrication of a speech appliance by making a palatogram and customizing the palatal contours. [ABSTRACT FROM AUTHOR]

Objectives: In cleft palate patients, the soft palate is commonly closed using straight-line palatoplasty, Z-palatoplasty, or palatoplasty with buccal flaps. Currently, it is unknown which surgical technique is superior regarding speech outcomes. The aim of this review is to study the incidence of speech correcting surgery (SCS) per soft palatoplasty technique and to identify variables which are associated with this outcome., Materials and Methods: A systematic literature search was carried out according to the PRISMA guidelines. Inclusion and exclusion criteria were applied to focus on the incidence of SCS after soft palatoplasty. Additional variables like surgical modification, cleft morphology, syndrome, age at palatoplasty, fistula and assessment of velopharyngeal function were reported. A modified New-Ottawa Scale (NOS) was used for quality appraisal. Pooled estimates from the meta-analysis were calculated using a random-effects model., Results: One thousand twenty-nine studies were found of which 54 were included in the analysis. The pooled estimate proportion of SCS after straight-line palatoplasty was 19% (95% CI 15-24), after Z-palatoplasty 6% (95% CI 4-9), and after palatoplasty with buccal flaps 7% (95% CI 4-11)., Conclusions: A lower SCS rate was found in patients receiving Z-palatoplasty when compared to straight-line palatoplasty. We propose a minimum set of outcome parameters which ideally should be included in future studies regarding speech outcomes after cleft palate repair., Clinical Relevance: Current literature reports highly heterogenous data regarding cleft palate repair. Our recommended set of parameters may address this inconsistency and could make intercenter comparison possible and of better quality., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Backgound Pierre Robin sequence (PRS) has worse speech outcomes than isolated cleft palate. We aimed to search for possible associations of phonological outcomes with PRS status (isolated vs syndromic), clinical severity, soft palate muscles deficiency, or surgical procedure. Methods We designed a retrospective study of 130 children (male/female ratio: 0.4) with isolated (96) or syndromic (34) PRS with cleft palate. Grading systems were used to classify retrognathia, glossoptosis, and respiratory and feeding disorders. Electromyography was used to investigate levator veli palatini muscles. Hard cleft palate was measured using maxillary casts. Intravelar veloplasty was performed using the Sommerlad's technique. Phonological outcomes were assessed using the Borel-Maisonny classification. Results Cleft palate was repaired in one stage (65.5%) or hard palate closure was postponed (34.5%). Velopharyngeal insufficiency was more frequent in syndromic PRS (53%) vs. isolated PRS (30.5%) ( p = 0.01), but was not statistically associated with clinical grade, hard cleft palate width, soft palate electromyography, and surgical procedure. Conclusions In children with PRS, anatomic variables, initial clinical severity, and soft palate muscle deficiency are not predictors of speech prognosis. [ABSTRACT FROM AUTHOR]

Background:The aim of this study was to investigate speech outcomes in children with clefts in the hard and/or soft palate only (CPH/CPS), in order to determine the prevalence of cleft speech characteristics, the change between 5 and 10 years of age, and the difference in occurrence between CPH and CPS. Methods:A consecutive series of 88 children born with CPH or CPS were included in a retrospective cohort. All participants were treated with one-stage palatal repair using a minimal incision technique with muscle reconstruction (mean age 13 months). Twelve children (14%) received a velopharyngeal flap. Cleft speech variables were rated at 5 and 10 years of age independently by three experienced external speech-language pathologists. Inter- and intra-rater agreements were determined, and the prevalence of cleft speech characteristics was calculated. Results:Moderate-to-severe hypernasality and weak pressure consonants were present in 5%–10% of the children at 5 years, with marginal but statistically significant improvement at 10 years of age. Frequently or always occurring audible nasal air leakage was detected in 20% of children at age 5, and increased to ∼35% of the children at 10 years. Ten per cent had compensatory articulation at age 5, and 25% demonstrated s-distortions, whereas few had these problems at age 10. Conclusions:The results demonstrate low occurrence of compensatory articulation problems in this cohort, even by 5 years of age. The high presence of symptoms of velopharyngeal insufficiency at 10 years of age suggests a need for additional secondary velopharyngeal surgery. [ABSTRACT FROM PUBLISHER]