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Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 151-155

Learning curve in performing palatoplasty: A retrospective study

Charles Pinto Centre for Cleft Lip, Palate, and Craniofacial Anomalies, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India

Date of Submission25-Jan-2022
Date of Acceptance06-Jun-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Dr. P Varun Menon
Charles Pinto Centre for Cleft Lip, Palate, and Craniofacial Anomalies, Jubilee Mission Medical College and Research Institute, Thrissur - 680 005, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_2_22

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Objectives: The aim of the study was to assess the influence of the experience of the surgeon on the occurrence of fistulas and breakdowns following palatoplasty. Materials and Methods: A retrospective review on the outcomes of palatoplasty done by a young surgeon in his initial 3 years of operating cleft palate was done. Cleft palate repair was performed using the Pinto's modification of Wardill–Kilner palatoplasty, Veau-Wardill-Kilner V-Y Pushback in both the techniques radical levator muscle dissection was carried out. Data were collected for age, sex, date of birth, syndrome, cleft palate type, type of repair, cleft width, length of soft palate, quality and quantity of muscle, fistula occurrence, and location of fistula. Results: Retrospective analysis was done on the outcomes of palatoplasty performed by a young surgeon in his initial 3 years at Charles pinto center for cleft lip palate and craniofacial on 220 cleft palate children which included all variants and dimensions of cleft palates. Postoperatively, the incidence of palatal fistulas occurred in 12 patients, three patients had bifid uvula, however, out of 12 patients who had fistulas only four needed fistula closure and one required a uvula re-repair; the rest healed well. Conclusion: We believe there is a learning curve in performing cleft palate repair. Our technique and principles followed in palatoplasty appear to have a low or zero fistula rate even in the initial period of learning. Furthermore, effective mentorship and guidance help in reducing errors and providing a better outcome.

Keywords: Cleft palate, palatoplasty, technique, learning curve

How to cite this article:
Menon P V, Radhakrishnan V, Narayanan P V, Adenwalla H S. Learning curve in performing palatoplasty: A retrospective study. J Cleft Lip Palate Craniofac Anomal 2022;9:151-5

How to cite this URL:
Menon P V, Radhakrishnan V, Narayanan P V, Adenwalla H S. Learning curve in performing palatoplasty: A retrospective study. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2022 Dec 8];9:151-5. Available from: https://www.jclpca.org/text.asp?2022/9/2/151/354292

  Introduction Top

Orofacial clefting (OFC) describes a range of abnormalities which manifest in the newborn infant, OFC involves structures around the oral cavity which can extend onto the facial structures resulting in oral, facial, and craniofacial deformity. A palatoplasty is a surgical procedure used to correct or reconstruct the palate in a person with a cleft palate. Primary objectives in the surgical repair of a cleft palate are the development of normal speech, hearing, and feeding, with minimal maxillary growth restriction.[1],[2]

One of the complications of palatoplasty is the occurrence of fistulas. A cleft palate fistula can result as a failure of healing or a breakdown in the primary surgical repair of the palate.[3] Several factors may influence the occurrence of fistulas, including type of cleft palate,[3],[4],[5] type of cleft repair,[6] cleft width,[6],[7],[8] and age at the time of palatal closure[4],[6] and surgical experience.[9]

The aim of the study was to assess the influence of experience of the young surgeon on the occurrence of fistulas following palatoplasty.

  Materials and Methods Top

A retrospective review was performed of consecutive children treated for cleft palate by a young surgeon who had no previous experience in treating clefts was done. All children undergoing cleft palate operations from January 1, 2017, to December 31, 2019, at the Charles Pinto center for cleft lip palate and craniofacial anomalies, Jubilee Mission Medical College, Thrissur, were included in the study. Data were collected for sex, date of birth, syndrome, cleft palate type, type of repair, date of cleft repair, cleft width, fistula, and location of fistula. All children were operated on by the same surgeon.

We follow the classification of Kernahan and Stark. He calls everything in front of the incisive foramen as the primary palate and everything behind the incisive foramen as the secondary palate. There are five main types of cleft palates that we come across:

  1. A partial cleft of the secondary palate with a central vomer
  2. A complete cleft of the secondary palate going up to the incisive foramina with a central vomer
  3. A complete cleft of the primary and secondary palate which includes the alveolus. In this case, the vomer is attached to the maxilla on the noncleft side
  4. A bilateral complete cleft of the primary and secondary palate with a central free vomer
  5. The submucous and submucous occult clefts.

At our center, we use the two long-flap techniques popularized in India by Charles Pinto and the world over by Bardach for the complete palate and for partial cleft palates Veau-Wardill-Kilner V-Y palatoplasty.[10]

Routinely in Group A, Veau-Wardill-Kilner V-Y palatoplasty is done, and in Groups B, C, and D, a Pinto's modification of Wardill–Kilner two-layer palatoplasty is performed in both these techniques standard radical levator muscle dissection was done.

Cleft palate fistula in our study was defined as a failure of healing or a breakdown in the primary surgical repair of the palate. The primary outcome was measured by clinical evaluation based on the incidence of a fistula after cleft palate repair that required secondary surgery.

To evaluate for a possible “learning curve,” we separated patients into groups based on the year of the cleft palate operation.

  Results Top

A total of 808 palatoplasties were done at our center. Among that 220 were done by the young surgeon of the department. [Table 1] shows the number of cases done each year by the young surgeon and the number of complications encountered. In the early years, there were 20% complications in 2017 which gradually reduced to 5.8% in 2019 [Figure 1].
Figure 1: Percentage of fistula in each year

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Table 1: Number of cases done in each year and respective complications

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Type of technique versus fistula

Out of the total 220 palatoplasties done 141 were partial cleft palate, for this Veau-Wardill- Kilner V-Y palatoplasty was done and the number of complete cleft palates was 79 and Pinto's modification of Wardill–Kilner two-layer palatoplasty was performed in this. Percentage-wise the incidence of fistulas was more or less in equal proportions in both the groups [Figure 2].
Figure 2: Incidence of fistulas with complete and partial clefts

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Type of cleft palate versus fistula

Compared to the usual thought process of bilateral complete cleft repair being more technique sensitive to unilateral complete cleft, we found more complications in unilateral as compared to bilateral [Figure 3].
Figure 3: Incidence of fistula in complete cleft palates

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Cleft palate width versus fistula

The cleft width was measured between the median edges of the cleft at the hard and soft palate junction. In this series of cleft palates, the maximum width of the cleft noted was 23 mm and minimum was 4 mm. We observed more fistulas in the moderate width group 9–13 mm [Figure 4].
Figure 4: Incidence of fistula in different cleft width

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Length of cleft palate versus fistula

The length of soft palate was arbitrarily made based on young surgeons' intraoperative assessment of the length of soft palate and the distance between the uvula and pharyngeal wall. When it comes to the correlation of the length of soft palate and incidence of fistulas [Figure 5], the fistula was noted more in short and moderate groups as compared to the longer palate.
Figure 5: Comparison of length of soft palate with the incidence of fistula

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Muscle bulk of cleft palate versus fistula

Standard radical levator muscle dissection was performed in all cases and the quality and quantity of muscle were made based on the intraoperative clinical judgment of the surgeon. No microscopes or loupes were used by the surgeon in the above procedure. It was grouped to poor, moderate, and good. The incidence of the fistula was noted more in the moderate group as compared to poor and good muscle groups [Figure 6].
Figure 6: Comparison of muscle bulk with the incidence of fistula

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Each patient was closely monitored for a week till they were discharged and also in their follow-up visits at 2 weeks and 3 months postoperative. The late presentations of any complications were noted in annual follow-up visits. In this review, out of 20 cases that had complications; six were pinpoint fistulas, five were in soft palate, one in the junction of hard and soft palate, and eight were complete soft palate breakdowns [Figure 7]. Each complication was noted and assessed along with the senior surgeons.
Figure 7: Number of fistula and breakdowns based on location

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During this period, 808 palatoplasties done in the department, 588 cases were done by senior surgeons of the department, among these there was only one breakdown which was a complete soft palate breakdown that was subsequently re-repaired and there was no fistula. [Figure 8].
Figure 8: Comparison of a young surgeon with department outcome

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  Discussion Top

It was Kilner who made that profound statement. He said “Gentlemen when you evaluate your cleft palate repairs ask not for a spatula and torch but give your patient your ear and listen to him speak. There is just one aim and one purpose of a good cleft palate repair that is good speech, but an immediate evaluation of a successful palate repair is still using a spatula and torch that is without having fistulas and breakdowns.

In this retrospective study, the correlation between learning curve and the reduction in the incidence of fistula rate over a period was noted. Moreover, no significant association between the incidence of palate fistula and sex, age at repair, nature of cleft palate, type of repair, or cleft width was observed.[9]

In our study, we found that the incidence of the fistula was less in the wider groups as compared to moderate or lesser wide clefts. Logical explanation for this could be surgeons tend to be more careful while performing wider clefts. Furthermore, the young surgeon had less complication while operating long palates, the above explanation when it comes to width may hold true in this scenario as well.

The one junctional fistula and the breakdowns noted in our review needed re-repair; the rest all eventually healed over 1 year. In our observations in this series, there were no anterior and posterior alveolar fistula the possible explanation could be the fact at the time of lip repair every effort is made to close this region well behind the lesser segment, and we do try to obtain a two-layer closure at the time of palate repair as well.

There are numerous inconsistencies in the medical literature about the association between cleft type and fistula formation.[11] It seems that higher fistula rates are reported in patients with more severe clefts,[1],[3],[6],[7],[8],[12],[13],[14] however, some studies do not find the association.[10] It should be noted that the lack of significance in our series may have been due to the small percentage of palate fistulas.

It is assumed that surgical experience improves over time. There are some studies[4],[5] supporting this and other studies[15],[16] contradicting this assumption. Lu et al.,[5] for instance, demonstrated that the cleft surgeon has a fistula rate of 2% and the resident (under supervision) of 11%. In this study, there was a significant difference in palatal fistula incidence over the observed period. One possible important factor is that our young surgeon had a day-to-day exposure in cleft palate surgery. This can influence a potential learning curve.

We believe the three commandments for the cleft palate surgeon are complete mobilization, gentle handling of tissues, and meticulous suturing.

It would be worthwhile in keeping the following points in mind while performing palatoplasty to reduce or eliminate fistulas and breakdowns.

  • The mobilization of the flaps must be so complete that the repair is free of all tension
  • Tissue handling must be so gentle that there is a minimum of fibrosis in the repair
  • The suturing should be meticulous, the palate should not be over stitched nor should the knots be overtightened
  • All dead space should be obliterated
  • The repair should be fistula-free and for this, the floor of the nose should be repaired far back at the time of the lip repair. This prevents an anterior oronasal fistula
  • In a complete cleft of the secondary palate use the vomer if there is tension on the nasal layer. If there is no tension avoid using the vomer as this causes further damage to maxillary growth. When in doubt use the vomer. Do not accept tension in the repair
  • If there is a shortage of the lining in a wide defect one is advised to borrow 2 mm from the oral layer on either side to give it to the nasal side – 4 mm is a lot of tissue in a palate
  • It is advisable to anchor the oral layer to the nasal layer so that you avoid a hanging palate.

At present, many centers are able to produce fistula-free palates in a majority of patients. Tension-free closure of the palate and meticulous suturing are the key factors in the prevention of fistulas. A review of the literature reveals a huge range in the incidence of fistula after cleft palate repair. The range is from 2.6% to 58%. In between these extremes, many have reported around 10%, some 15%, and 23%.[17],[18]

It is important to learn cleft surgery from a man who knows his principles and then master a technique until you know it better than the back of your hand; after that explore possibilities of technical improvement, innovating always toward a functional goal and that goal is – better and better speech.

The role of mentorship and guidance in the learning phase is very much important.

  Conclusion Top

Looking at the incidence of fistulas following cleft palate repair, this study demonstrated evidence of a learning curve during the first few years of performing cleft palate repair. Our techniques and principles followed in palatoplasty; when practiced meticulously give a fistula-free palate repair.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Phua YS, de Chalain T. Incidence of oronasal fistulae and velopharyngeal insufficiency after cleft palate repair: An audit of 211 children born between 1990 and 2004. Cleft Palate Craniofac J 2008;45:172-8.  Back to cited text no. 1
Losken HW, van Aalst JA, Teotia SS, Dean SB, Hultman S, Uhrich KS. Achieving low cleft palate fistula rates: Surgical results and techniques. Cleft Palate Craniofac J 2011;48:312-20.  Back to cited text no. 2
Muzaffar AR, Byrd HS, Rohrich RJ, Johns DF, LeBlanc D, Beran SJ, et al. Incidence of cleft palate fistula: An institutional experience with two-stage palatal repair. Plast Reconstr Surg 2001;108:1515-8.  Back to cited text no. 3
Andersson EM, Sandvik L, Semb G, Abyholm F. Palatal fistulas after primary repair of clefts of the secondary palate. Scand J Plast Reconstr Surg Hand Surg 2008;42:296-9.  Back to cited text no. 4
Lu Y, Shi B, Zheng Q, Hu Q, Wang Z. Incidence of palatal fistula after palatoplasty with levator veli palatini retropositioning according to Sommerlad. Br J Oral Maxillofac Surg 2010;48:637-40.  Back to cited text no. 5
Landheer JA, Breugem CC, van der Molen AB. Fistula incidence and predictors of fistula occurrence after cleft palate repair: Two-stage closure versus one-stage closure. Cleft Palate Craniofac J 2010;47:623-30.  Back to cited text no. 6
Parwaz MA, Sharma RK, Parashar A, Nanda V, Biswas G, Makkar S. Width of cleft palate and postoperative palatal fistula – Do they correlate? J Plast Reconstr Aesthet Surg 2009;62:1559-63.  Back to cited text no. 7
de Agostino Biella Passos V, de Carvalho Carrara CF, da Silva Dalben G, Costa B, Gomide MR. Prevalence, cause, and location of palatal fistula in operated complete unilateral cleft lip and palate: Retrospective study. Cleft Palate Craniofac J 2014;51:158-64.  Back to cited text no. 8
Smarius B, Breugem C. Surgical learning curve in performing palatoplasty: A retrospective study in 200 patients. J Craniomaxillofac Surg 2015;43:1868-74.  Back to cited text no. 9
Narayanan PV, Adenwalla HS. Cleft palate. In: Bonanthaya K, Panneerselvam E, Manuel S, Kumar VV, Rai A, editors. Oral and Maxillofacial Surgery for the Clinician. Singapore: Springer; 2021. [doi: 10.1007/978-981-15-1346-6_73].  Back to cited text no. 10
Mahoney MH, Swan MC, Fisher DM. Prospective analysis of presurgical risk factors for outcomes in primary palatoplasty. Plast Reconstr Surg 2013;132:165-71.  Back to cited text no. 11
Schultz RC. Management and timing of cleft palate fistula repair. Plast Reconstr Surg 1986;78:739-47.  Back to cited text no. 12
Amaratunga NA. Occurrence of oronasal fistulas in operated cleft palate patients. J Oral Maxillofac Surg 1988;46:834-8.  Back to cited text no. 13
Cohen SR, Kalinowski J, LaRossa D, Randall P. Cleft palate fistulas: A multivariate statistical analysis of prevalence, etiology, and surgical management. Plast Reconstr Surg 1991;87:1041-7.  Back to cited text no. 14
Sullivan SR, Marrinan EM, LaBrie RA, Rogers GF, Mulliken JB. Palatoplasty outcomes in nonsyndromic patients with cleft palate: A 29-year assessment of one surgeon's experience. J Craniofac Surg 2009;20 Suppl 1:612-6.  Back to cited text no. 15
Al-Nawas B, Wriedt S, Reinhard J, Keilmann A, Wehrbein H, Wagner W. Influence of patient age and experience of the surgeon on early complications after surgical closure of the cleft palate – A retrospective cohort study. J Craniomaxillofac Surg 2013;41:135-9.  Back to cited text no. 16
Lindsay WK, Witzel MA. Cleft palate repair: Von Langenbeck technique. In: Bardach J, Morris HL, editors. Multidisciplinary Management of Cleft Lip and Palate. Philadelphia: W.B. Saunders Company; 1990. p. 303.  Back to cited text no. 17
Pomerantz JH, Hoffmann WM. In: Nelegan P, editor. Chapter 23 Cleft Palates in Plastic Surgery. 4th ed. Philadelphia: Elsevier; 2010. p. 579.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1]


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