Study Examines Factors Leading to Secondary Palate Surgery

Alyssa KirkmanJournal

CHAPEL HILL, N.C. / May 21, 2019 – Factors that are specific to the child, surgeon, and/or hospital at the time of primary cleft palate repair may lead to a need for secondary palate surgery, according to the article “Five-Fold Variation Among Surgeons and Hospitals in the Use of Secondary Palate Surgery” from the May 2019 issue of The Cleft Palate-Craniofacial Journal (CPCJ).

For children born with a cleft palate, palate repair is performed early in life to prevent food from exiting the nose and to enable normal speech development. If the initial procedure is unsuccessful, an oronasal fistula or velopharyngeal insufficiency (VPI) can occur. Both fistula and VPI indicate a need for secondary palate surgery, a procedure that accounts for 37 percent of cleft palate operations.

“If we can identify factors that contribute to the development of fistula and VPI after a child’s primary cleft palate repair, we can minimize the need for a second procedure. This would improve outcomes for children with cleft palate and reduce treatment costs,” noted lead researcher Thomas J. Sitzman, MD, MPH.

The study analyzed risk factors for secondary palate surgery among 17,772 children who received their primary repair at one of 49 free-standing children’s hospitals in the United States between 1998 and 2015. Child-, surgeon-, and hospital-specific factors that are known to lead to secondary cleft palate surgery were identified at the time of the primary cleft palate repair. Researchers also estimated the magnitude of variation in secondary surgery that is attributable to differences in practice among surgeons and hospitals.

“Our study expanded upon prior research of secondary palate surgery by evaluating the effect of cleft type and additional medical comorbidities, and by estimating secondary surgery occurrence for each surgeon and each hospital in the study,” Sitzman said.

After controlling for cleft type and age at primary repair, researchers observed a relationship between a child’s demographic, medical, and surgical factors and the probability of undergoing secondary surgery. Children who had their primary palate repair performed before 9 months of age had a 4-fold higher risk of requiring secondary surgery, compared with children who underwent palate repair between 9 and 24 months of age. The largest difference in secondary surgery, however, was due to differences among the individual surgeons and hospitals. After adjusting for cleft type, age at repair, surgeon specialty, and procedure volume, the predicted proportion of children undergoing secondary palate surgery ranged from 9% to 46% across surgeons and 9% to 49% across hospitals.

Causes for this 5-fold variation in secondary surgery rates among surgeons and hospitals were not immediately clear. Among surgeons, both surgical technique and expertise may contribute to the occurrence of fistula or VPI after primary palate repair. Differences in secondary surgery among hospitals may be attributed to anesthesia expertise, nursing care, postoperative care instructions, and some long-range components of care, like treatment protocols or hospital-specific thresholds for offering secondary palate surgery.

Overall, this study found substantial variation in the occurrence of secondary palate surgery based on child-, surgeon-, and hospital-specific factors. A 5-fold difference in secondary surgery use across surgeons and an independent 5-fold difference in secondary surgery use across hospitals were noted.

“These results suggest that, by identifying the causes of this variation among surgeons and hospitals, we can reduce the need for secondary palate surgery,” Sitzman said. “By learning how centers with the best outcomes are achieving their results and spreading those practices among all cleft centers, we may be able to improve patient care and reduce medical costs.”

“Surgical outcomes vary. For decades, researchers have found that not all palate repairs are the same – some surgeons and hospitals do much better than others. The cause of this wide variation is multifactorial and, like findings from studies dating back to the 1980s, the quality of the surgeon is one of the most important determinant,” states Jack C. Yu, DMD, MD, MS ED, Editor of CPCJ.  “In addition to each surgeon striving to self-evaluate and improve, a key finding from this study is to delay the palate repair until the baby is older than 9 months of age.”

To learn more about the American Cleft Palate-Craniofacial Association and cleft and craniofacial conditions, please visit

About the American Cleft Palate-Craniofacial Association
The American Cleft Palate-Craniofacial Association (ACPA) is a nonprofit 501(c)(3) association of interested individuals and health care professionals who treat and/or perform research on oral cleft and craniofacial conditions. Since 1943, ACPA has worked to optimize outcomes for individuals with oral cleft and craniofacial conditions through education, support, research, advocacy and interdisciplinary team care. ACPA also provides information to affected individuals and families and seeks to educate the public about facial differences through its ACPA Family Services program. For more information, please visit