Maxillary Growth and Speech Outcomes Following Staged Palatoplasty: A Single-Center Approach

INTRODUCTION: Cleft lip and palate are the most common craniofacial abnormalities in children. However, timing and staging of cleft palate repair remain controversial. Timing of palate repair depends on balancing the speech benefits of early repair with the improved maxillofacial growth of late palate repair. Both single stage and two staged palatoplasty have been proposed for optimizing growth and speech, each to varying success. In this study, we reviewed outcomes of the staged approach at a single center. METHODS: A retrospective chart review was performed for all patients who underwent staged palatoplasty for cleft palate at Children's Medical Center in Dallas between 2006-2012. All patients in the study underwent intra-velar veloplasty at 3 to 6 months and hard palate repair at 18 months. Exclusion criteria included patients undergoing single stage repair, initial treatment at an outside center, secondary surgery at an outside center, and inadequate follow up. 61 patients were eligible for final inclusion. Speech outcomes were evaluated based on Pittsburgh Weighted Speech Scores (PWSS) and rates of secondary operations indicated for correction of VPI. PWSS were collected after completion of staged palatoplasty, postoperatively after any surgical correction of VPI, and at latest available patient follow up. Maxillary growth outcomes were evaluated by rates of oronasal fistula, reoperation indicated for palate repair, Angle class malocclusion, and LeFort I advancement procedures. RESULTS: For the entire cohort, 26% of patients were determined to have clinical VPI. 28% required corrective VPI surgery. 11% were determined to have residual VPI refractory to corrective surgery. 31% were found to have a persistent oronasal fistula, with 30% requiring surgery. 50% had class III malocclusion. At the time of review, no patients required LeFort I advancement procedures. There were no significant differences when including syndromic patients. Compared to patient with CLP, patients with isolated CP had higher rates of clinical VPI (33% vs 24%), oronasal fistula (34% to 20%), and class III occlusion (54% to 27%). Compared to patient with complete CP, patients with incomplete CP had higher rates of clinical VPI (36% vs 23%) lower rates of oronasal fistula (14% to 36%), and lower rates of class III occlusion (29% to 53%). Compared to patients with UCLP, patients with bilateral CLP had higher rates of clinical VPI (43% vs 15%), oronasal fistula (57% to 27%), and class III occlusion (64% to 48%). CONCLUSION: In our cohort of 61 patients, speech and growth outcomes after staged palatoplasty are similar to what has been previously reported in the literature. Despite the lack of consensus on the appropriate surgical treatment for CP and a trend towards single stage palatoplasty, our data strongly suggests that staged palatoplasty is still a valuable surgical approach to the patient with cleft palate.