Nine Years, 293 Cases: Advancing Wide Cleft Palate Repair: Insights, Techniques, and Outcomes From Cleft Lip and Palate Association of Pakistan's Institutional Experience.

BACKGROUND

Wide cleft palate repair poses a considerable challenge due to the potential for closure under tension, and an elevated risk of postoperative oronasal fistula and velopharyngeal insufficiency (VPI). Preoperative cleft width and Cleft Palate Index (CPI) are recognized as key predictors of outcome. This study presents Cleft Lip And Palate Association of Pakistan's (CLAPP) institutional experience with wide cleft palate repair, analyzing the influence of anatomical severity, surgical technique, and other variables on fistula formation and speech outcomes.

METHODS

A retrospective review was conducted of patients undergoing repair at CLAPP Hospital between January 2015 and December 2023. Data collected included demographics, cleft width, palatal shelf width, CPI, surgical technique, fistula location and rate, speech outcomes, and need for secondary speech-correcting surgery. Cleft width and CPI were stratified into predefined categories. Univariate and multivariate logistic regression were performed to identify predictors of postoperative fistula formation.

RESULTS

A total of 293 patients (mean age 8 years, range 9 months-48 years) were included. Nearly one-third (35.5%) had cleft widths greater than the combined right and left palatal shelf widths. CPI distribution revealed progressive fistula rates from 12.1% in the narrowest group to 28.2% in the widest. The overall postoperative fistula rate was 21.2%, most frequently at the soft palate (27.4%) and hard-soft junction (12.9%). In univariate analysis, left palate width ≥ 1.1 cm and von Langenbeck repair were associated with significantly lower fistula rates, although only the latter remained significant in multivariate analysis (adjusted odds ratio = 0.34; 95% confidence interval = 0.16-0.72; P = 0.004). Bardach repair was preferentially performed in more severe, wider clefts, accounting for its higher unadjusted fistula rate. Preoperative and postoperative speech assessments (N = 173) showed a mean composite score improvement of 13.4%, with 8.9% requiring secondary speech-correcting surgery.

CONCLUSIONS

Wide cleft palate repair outcomes are strongly influenced by cleft morphology, with CPI emerging as a key prognostic tool. While von Langenbeck repair demonstrated lower adjusted fistula rates, technique selection remains contingent on preoperative assessment, with Bardach repair favored in severe cases. Long-term monitoring for VPI is crucial, with early repair and tailored technique selection critical for optimizing functional outcomes in this challenging subset.