American Association of Plastic Surgeons

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Reducing Fistula: A Retrospective Cohort Study Of 1000 Cleft Palate Repairs By A Single Surgeon
Dale Podolsky, MD, PhD, FRCSC, Karen Wong Riff, MD, PhD, FRCSC, David Fisher, FACS, FRCSC;
The Hospital for Sick Children, Toronto, ON, Canada

PURPOSE: Fistula is a significant complication following cleft palate repair. However, the incidence of fistula varies considerably with high rates still frequently reported. This study demonstrates techniques that reduce the rate of fistula formation and exemplifies the minimization of its incidence using a single surgeonís experience.
METHODS: A retrospective review of prospectively collected data of patients who underwent cleft palate repair by a single surgeon was performed. Techniques involved meticulous handling of tissue in particular along the medial oral and nasal mucosal edges. Nasal mucosal release involved elevation of the mucosa from the medial pterygoid plate and hard palate and division of the tensor to offload tension during nasal mucosal closure. The type of cleft palate and technique performed as well as the incidence and size of post-operative fistula was determined.
RESULTS: The surgeon performed 1000 consecutive cleft palate repairs. A Furlow was performed 103 and 48 times for all Veau I and submucous cleft palates, respectively. Straight line repairs involved 384 von Langenbeck palatoplastyís for Veau II, 297 Hybrid repairs for Veau III and 167 three flap repairs for Veau IV cleft palates. There were 9 post-operative fistulas following straight line repairs (incidence of 0.9%). Eight of the 9 fistulas were 2.5 mm or less in size. There were no post-operative fistulas following Furlow palatoplasty.
CONCLUSION: This study demonstrates a very low fistula rate with a large series of patients. Meticulous tissue handling as well as extensive release of the mucosa during palatoplasty minimizes the risk of post-operative fistula.
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