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Thirty Year Experience with the Modified Furlow Cleft Palate Repair
Carrie A. Stransky, MD, Oksana Jackson, MD, Marten Basta, BS, Nirav Desai, BS, Cynthia Solot, MA, CCC, Marilyn Cohen, BA, LSLP, Richard Kirschner, MD, David Low, MD, Peter Randall, MD, Don LaRossa, MD.
Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Purpose: The purpose of this study was to evaluate the long-term outcomes following modified Furlow double-opposing z-palatoplasty in a large series of nonsyndromic patients over 30 years of experience at a single institution.
Methods: A retrospective review was performed of all nonsyndromic patients undergoing primary cleft palate repair by the modified Furlow technique at a single institution between 1980 and 2011. Surgical success was evaluated by speech outcomes assessed at a minimum of age 5 by the Pittsburgh Weighted Values for Speech Symptoms Associated with Velopharyngeal Incompetence (VPI), the need for secondary pharyngeal surgery to correct VPI, and the rate of postoperative oronasal fistula. Results were analyzed by surgeon, Veau cleft type, and age at repair, and grouped into three time periods: early (1980-1985), middle (1985-1995), and late (1995-2006).
Results: 1350 patients were identified who underwent the modified Furlow double-opposing z-palatoplasty for primary cleft palate repair from January 1980 to January 2011. Patients with identified syndromes and hearing loss were excluded, and 745 patients met the inclusion criteria. The overall fistula rate was 5.5%. Repairs were performed by 11 different surgeons; 42.3% of the repairs were performed by a single surgeon, and 49.8% by one of three other surgeons. All speech evaluations were performed by one of two senior speech pathologists with documented inter-rater reliability. Speech results at age 5 or older were available for 559 patients. In this group, the mean length of follow-up was 8.8 yrs, and the mean age at last exam was 9.8 years. 72.3% of these patients were found to have a competent velopharyngeal mechanism, 21.7% had a borderline velopharyngeal mechanism that was consistent with socially acceptable speech, and 6.1% had an incompetent VP mechanism. 85.3% of patients demonstrated no or inaudible nasal emission, 90.2% demonstrated no or mild hypernasality, and 96.8% of patients had no errors in articulation related to VPI. Secondary pharyngeal surgery was performed or recommended to correct VPI in 8.1% of patients. Oronasal fistula rates were higher in Veau class 3 and 4 clefts (p=.03), and speech scores were worse in Veau class 1 and 2 clefts (p=.002), as well as in patients who underwent repair at greater than 18 months of age (p=.009). There was significant improvement in the oronasal fistula rate over time, occurring in 14.93% of patients in the early period, 5.6% in the middle period, and 5.4% in the later period (p=.014). Speech results were stable over time (p=.10), and rates of secondary surgery declined, occurring in 14.9% in the early period, 10.7% in the middle period, and 4.8% in the later period (p=.005).
Conclusion: 30 years experience with the modified Furlow double-opposing z-palatoplasty at a single institution shows stable speech results over time, decreasing rates of secondary surgery, and an acceptable rate of post-operative oronasal fistula.
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