We sought to identify differences in 30-day medical and surgical complications in unilateral versus bilateral palatoplasty.
Design
The NSQIP-P 2015-2020 database was queried to identify cleft palate repairs using CPT codes. Cases were stratified as unilateral (Veau III) and bilateral (Veau IV) using ICD-9 and −10 codes.
Setting
A nationally representative random sample.
Patients/Participants
A total of 3791 cases were identified with 2608 undergoing unilateral repair and 1183 undergoing bilateral repair.
Main Outcomes/Measures
The postoperative outcomes of interest included surgical complications (surgical site infections, wound dehiscence), medical complications (pneumonia, urinary tract infection, seizure, cardiac arrest, bleeding/transfusions, systemic sepsis, unplanned intubation), readmission, and reoperation.
Results
The bilateral cohort was older (696 days versus 619 days, P < .001) and had longer operative times (157.3 min versus 144.5 min, P < .001). The unilateral cohort had more comorbidities including developmental delay, structural CNS abnormalities, need for nutritional support, and bleeding disorders. The bilateral cohort had statistically significant higher occurrences of wound dehiscence (2.1% versus. 1.2%, P = .03) and readmission (3.2% versus 1.7%, P = .01). On multivariate analysis, bilateral cleft repair (OR: 1.83, CI: 1.176-2.840, P = .007) and ASA class 4 (OR: 13.1, CI 2.288- 62.586, P = .002) were associated with greater odds of readmission.
Conclusion
Patients who underwent bilateral cleft repair had a higher proportion of 30-day postoperative complications and a two-fold increased odds of readmission. While palatoplasty is generally regarded as a safe procedure in the pediatric population, identifying factors related to an increased risk of early postoperative complications can help surgical teams better manage high-risk individuals.
MaiCTIsenburgJLCanfieldMA, et al.National population-based estimates for major birth defects, 2010-2014. Birth Defects Res. 2019;111(18):1420‐1435. doi:10.1002/bdr2.1589.
2.
MillerCK. Feeding issues and interventions in infants and children with clefts and craniofacial syndromes. Semin Speech Lang. 2011;32(2):115‐126. doi:10.1055/s-0031-1277714.
3.
AlloriACMullikenJBMearaJGShustermanSMarcusJR. Classification of cleft lip/palate: then and now. Cleft Palate Craniofac J. 2017;54(2):175‐188. doi:10.1597/14-080.
4.
StarkR. Embryology, Pathogenesis and Classification of Cleft Lip and Cleft Palate. Congenital Anomalies of the Face and Associated Structure. Thomas; 1961.
5.
TrotmanCALongRERosensteinSWMurphyCJohnstonLE. Comparison of facial form in primary alveolar bone-grafted and nongrafted unilateral cleft lip and palate patients: intercenter retrospective study. Cleft Palate Craniofac J. 1996;33(2):91‐95. doi:10.1597/1545-1569_1996_033_0091_coffip_2.3.co_2.
6.
KimENMossWDKunkelRPYamashiroDKGocimanBR. Simultaneous closure of the cleft alveolus and hard palate with concomitant bone grafting. Plast Reconstr Surg Glob Open. 2022;10(2):e4099. doi:10.1097/GOX.0000000000004099.
7.
OtsukiKYamanishiTEnomotoA, et al.Maxillary development and dental arch relationships following early two-stage palatoplasty: a comparative study. Cleft Palate Craniofac J. 2022:10556656221129751. doi:10.1177/10556656221129751.
8.
TacheAMommaertsMY. The need for maxillary osteotomy after primary cleft surgery: a systematic review framing a retrospective study. J Craniomaxillofac Surg. 2020;48(10):919‐927. doi:10.1016/j.jcms.2020.07.005.
9.
XuXCaoCZhengQShiB. The influence of four different treatment protocols on maxillofacial growth in patients with unilateral complete cleft lip, palate, and alveolus. Plast Reconstr Surg. 2019;144(1):180‐186. doi:10.1097/PRS.0000000000005711.
10.
ReddyRRGosla ReddySVaidhyanathanABergéSJKuijpers-JagtmanAM. Maxillofacial growth and speech outcome after one-stage or two-stage palatoplasty in unilateral cleft lip and palate. A systematic review. J Craniomaxillofac Surg. 2017;45(6):995‐1003. doi:10.1016/j.jcms.2017.03.006
11.
MikoyaTShibukawaTSusamiT, et al.Dental arch relationship outcomes in one- and two-stage palatoplasty for Japanese patients with complete unilateral cleft lip and palate. Cleft Palate Craniofac J. 2015;52(3):277‐286. doi:10.1597/13-285.
12.
SchönmeyrBWendbyLCampbellA. Early surgical complications after primary cleft lip repair: a report of 3108 consecutive cases. Cleft Palate Craniofac J. 2015;52(6):706‐710. doi:10.1597/14-158.
13.
Rossell-PerryPFigallo-HudtwalckerOVargas-ChanduviRCalderon-AyvarYRomero-NarvaezC. Risk factors leading to mucoperiosteal flap necrosis after primary palatoplasty in patents with cleft palate. J Plast Surg Hand Surg. 2017;51(5):348‐351. doi:10.1080/2000656X.2016.1270216.
14.
SaothonglangKPunyavongPWinaikosolKJenwitheesukKSurakunpraphaP. Risk factors of Fistula following primary palatoplasty. J Craniofac Surg. 2021;32(2):587‐590. doi:10.1097/SCS.0000000000007515.
15.
YuanNDorafsharAHFollmarKEPendletonCFergusonKRedettRJ. Effects of cleft width and veau type on incidence of palatal Fistula and velopharyngeal insufficiency after cleft palate repair. Ann Plast Surg. 2016;76(4):406‐410. doi:10.1097/SAP.0000000000000407.
16.
LiaoYFYangIYWangRYunCHuangCS. Two-stage palate repair with delayed hard palate closure is related to favorable maxillary growth in unilateral cleft lip and palate. Plast Reconstr Surg. 2010;125(5):1503‐1510. doi:10.1097/PRS.0b013e3181d5132a.
17.
YamanishiTNishioJKoharaH, et al.Effect on maxillary arch development of early 2-stage palatoplasty by modified furlow technique and conventional 1-stage palatoplasty in children with complete unilateral cleft lip and palate. J Oral Maxillofac Surg. 2009;67(10):2210‐2216. doi:10.1016/j.joms.2009.04.038.
18.
FriedeH. Maxillary growth controversies after two-stage palatal repair with delayed hard palate closure in unilateral cleft lip and palate patients: perspectives from literature and personal experience. Cleft Palate Craniofac J. 2007;44(2):129‐136. doi:10.1597/06-037.1.
19.
KumarAGabbayJSNikjooR, et al.Improved outcomes in cleft patients with severe maxillary deficiency after Le fort I internal distraction. Plast Reconstr Surg. 2006;117(5):1499‐1509. doi:10.1097/01.prs.0000206308.86089.86.
WuRCheraghlouSParsaeiYTraviesoRSteinbacherDM. Does cleft palate width correlate with veau classification and outcome?J Craniofac Surg. 2017;28(5):1369‐1374. doi:10.1097/SCS.0000000000003646.
22.
ChouairiFMetsEJGabrickKSAlperovichM. Veau III and veau IV cleft palate: do peri-operative complications differ?J Craniofac Surg. 2019;30(8):2372‐2374. doi:10.1097/SCS.0000000000005918.
23.
KalmarCLPatelVAZapateroZDKosykMSTaylorJA. Optimal timing of palatoplasty in infants with comorbidities. Cleft Palate Craniofac J. 2021;58(8):937‐942. doi:10.1177/1055665620976249.
24.
PeckCJGowdaAUShultzBN, et al.The effect of surgical timing on 30-day outcomes in cleft palate repair. Plast Reconstr Surg. 2021;147(1):131‐137. doi:10.1097/PRS.0000000000007458.
25.
BastaMNFiadjoeJEWooASPeeplesKNJacksonOA. Predicting adverse perioperative events in patients undergoing primary cleft palate repair. Cleft Palate Craniofac J. 2018;55(4):574‐581. doi:10.1177/1055665617744065.
26.
OpdenakkerYSwennenGPottelLAbeloosJNagyK. Postoperative respiratory complications after cleft palate closure in patients with pierre robin sequence: operative considerations. J Craniofac Surg. 2017;28(8):1950‐1954. doi:10.1097/SCS.0000000000003995.
27.
HardwickeJTRichardsHCafferkyLUnderwoodIHorstBTSlatorR. Outcomes of cleft palate repair in patients with pierre robin sequence: a matched case-control study. Plast Reconstr Surg. 2016;137(3):927‐935. doi:10.1097/01.prs.0000475829.32402.a8.
28.
KantarRSCammarataMJRifkinWJPlanaNMDiaz-SisoJRFloresRL. Outpatient versus inpatient primary cleft lip and palate surgery: analysis of early complications. Plast Reconstr Surg. 2018;141(5):697e‐706e. doi:10.1097/PRS.0000000000004293.
29.
MetsEJChouairiFTorabiSJAlperovichM. Predictors of adverse events following cleft palate repair. J Craniofac Surg. 2019;30(5):1414‐1418. doi:10.1097/SCS.0000000000005542.
30.
CawthornTRToddARHardcastleNSpencerAOHarropARFraulinFOG. Optimizing outcomes after cleft palate repair: design and implementation of a perioperative clinical care pathway. Cleft Palate Craniofac J. 2022;59(5):561‐567. doi:10.1177/10556656211017409.
31.
WoodBCBoyajianMJZurakowskiDRogersGFOhAK. Evaluating the need for routine admission following primary cleft palate repair: an analysis of 100 consecutive cases. Plast Reconstr Surg. 2015;136(4):502e‐510e. doi:10.1097/PRS.0000000000001583.
32.
EsfahanianMMarcottSCHopkinsE, et al.Enhanced recovery after cleft palate repair: a quality improvement project. Paediatr Anaesth. 2022;32(10):1104‐1112. doi:10.1111/pan.14541.
33.
AsadourianPAWangLDemetresMImahiyeroboMROtterburnTAMD. Closing the gap: a systematic review and meta-analysis of enhanced recovery after surgery protocols in primary cleft palate repair. Cleft Palate Craniofac J. 2022:10556656221096631. doi:10.1177/10556656221096631.
34.
HushSEChenJTBradyCM, et al.Implementation of a modified enhanced recovery protocol in cleft palate repairs. J Craniofac Surg. 2019;30(7):2154‐2158. doi:10.1097/SCS.0000000000005718.
35.
GarlandKDworschak-StokanAMaticD. Patient and surgical factors that affect the development of velopharyngeal insufficiency. J Plast Reconstr Aesthet Surg. 2022;75(10):3813‐3816. doi:10.1016/j.bjps.2022.06.036.
36.
OthienoFTatumSA. Prevention and management of oronasal fistulas. Curr Opin Otolaryngol Head Neck Surg. 2021;29(4):320‐326. doi:10.1097/MOO.0000000000000732.
37.
HorswellBBChouJ. Does the children’s hospital of Philadelphia modification improve the Fistula rate in furlow double-opposing Z-plasty?J Oral Maxillofac Surg. 2020;78(11):2043‐2053. doi:10.1016/j.joms.2019.08.018.
38.
RichardsonSAgniNA. Palatal fistulae: a comprehensive classification and difficulty index. J Maxillofac Oral Surg. 2014;13(3):305‐309. doi:10.1007/s12663-013-0535-2.
