The influence of surgical technique and surgical skill on outcomes of cleft palate repair

Background: There remains significant uncertainty about the fistula rate following palate repair with the Furlow double opposing Z-plasty (Furlow) technique compared to a straight-line mucosal incision with intravelar veloplasty (straight-line/IVVP) technique. Moreover, the relative impact of technique and surgical skill on fistula incidence remains unclear. Methods: A prospective, observational study of cleft palate repair was conducted. Enrollment occurred at 18 U.S.-based cleft centers, including 64 cleft surgeons. The primary outcome was postoperative fistula. Results: Overall, 1219 participants underwent cleft palate repair, 1178 of whom presented for follow-up. Of these, 581 (49.3%) underwent palate repair with the Furlow technique, 483 (41.0%) with the straight-line/IVVP technique, and 114 (9.7%) with an alternative technique. The overall fistula incidence was 5.3% (62/1162 analyzed for fistula occurrence). The fistula incidence was significantly lower in the Furlow group (2.4% [14/564]) than the straight-line/IVVP group (7.8% [37/427]) with a propensity-score-weighted risk difference of 5.7% (95% CI, 1.6%-9.9%; p=0.007). The fistula incidence varied substantially among surgeons: the top quartile's fistula rate was 0% (0 fistula among 417 repairs), while the bottom quartile's fistula rate was 18.9% (31 fistulas among 164 repairs). Conclusions: Fistula incidence following cleft palate repair was significantly lower when using the Furlow technique, compared to the straight-line/IVVP technique. The effect of surgical technique was smaller, however, than the variation observed between the top and bottom quartiles of surgeons. These findings suggest that changing surgical technique may lead to small changes in fistula incidence, but greater opportunities exist to improve outcomes by improving surgical skill.