ADVERTISEMENT
Cleft Palate Fistula: A Review
Abstract
Background. The development of postoperative oronasal fistulae (ONF) is a complication that plagues all cleft surgeons to varying degrees. There is extensive literature discussing the incidence, functional impact, and treatment of ONF. The goal of this article is to provide an extensive review of the literature discussing the incidence, causative factors, functional impact, classification systems, and treatment of ONF.
Methods. A literature review was performed using PubMed using the Medical Subject Heading terms “cleft palate” AND “fistula” OR “palatal fistula” OR “oronasal fistula”. After review, a total of 356 articles were deemed relevant for this study.
Results. Information regarding ONF care, prevention, and management in patients with cleft palate was collected from the articles included in this review. Treatment of ONF remains a challenging problem as there is not a consensus in the available literature on the best palatoplasty techniques for their prevention and treatment. A myriad of reconstructive options and adjunctive therapies exist, and their use is guided by the size and location of the fistula.
Conclusions. Fistula treatment should be tailored to the specific needs of the patient, and consideration must be given to not only the ONF itself but also the patient’s stage of growth and development. Large-scale, multicenter studies are needed in which ONF are described using standardized nomenclature, and improved outcomes reporting is necessary to better define an algorithm for a truly holistic approach to palate surgery and reduce the incidence of palatal fistula.
Introduction
The primary goal of cleft palate repair is the successful partition of the oral and nasal cavities with reorientation of the levator veli palatini (LVP) musculature, allowing for appropriate velar function during speech development and preventing nasal regurgitation during feeding. Numerous palatoplasty techniques have been described and are employed by cleft surgeons; nonetheless, the development of postoperative oronasal fistula (ONF) is a complication that plagues all cleft surgeons to varying degrees.1 A postoperative ONF develops as a result of failure of healing of palatal structures following palatoplasty. When the alveolus or anterior hard palate are purposely left open as a part of a prescribed algorithm for a staged repair, these fistulae are intentional and should not be considered pathologic, although functional impairment may persist until those structures are repaired.2,3 ONF may remain asymptomatic or represent a minor nuisance in some patients; in other cases, ONF may cause significant functional impairment that impacts speech and/or feeding in a socially stigmatizing way.
Regardless of their size and location, repair of palatal fistulae presents a technical challenge for the cleft surgeon. There is extensive literature discussing the incidence, functional impact, and treatment of ONF. However, this body of literature is composed mainly of limited case series that describe a wide variety of techniques with unstandardized nomenclature, making it difficult to identify meaningful trends and lessons for evidence-based practice. The goal of this article is to provide an extensive review of the literature discussing the incidence, causative factors, functional impact, classification systems, and treatment of ONF.
Methods
A literature review was performed using PubMed using the Medical Subject Heading terms “cleft palate” AND “fistula” OR “palatal fistula” OR “oronasal fistula”. The search yielded 962 publications. Exclusion criteria included irrelevance to the subject matter, nonhuman studies, lack of full-text article availability, and non-English language publications. A total of 223 articles were deemed relevant for this study. Publication dates ranged from 1962 through 2022.
These articles focused on a wide range of topics, including the causes and incidence of ONF after cleft palate repair; the role of ONF in velopharyngeal dysfunction; preventive strategies employed for fistulae prevention; and various repair techniques. The information collected from these articles was then compiled to provide a comprehensive guide to ONF care, prevention, and management in patients with cleft palate.
Results
Causative Factors
Many factors are associated with an increased risk for development of an ONF, including surgeon experience, the cleft “phenotype” (ie, the degree of clefting along with the soft tissue availability for reconstruction), surgical technique, and timing of the palatal repair.4-8 One early review by Campbell et al cited 4 main causes of palatal fistula: tension, hemorrhage/infection, postoperative anemia, and ischemic necrosis.9 The primary cause of ONF is widely considered to be tension, which implies that both cleft phenotype and surgical technique play a role in their formation.
In some studies, cleft width and severity have been named as factors that influence the rate of fistula formation,2,4,10-14 whereas others disagree, citing no difference in the rate of fistula formation with regards to Veau classification and cleft width.10,15-19 Perhaps the more accurate predictor of fistula formation would be the ratio of cleft width to the surrounding palatal tissues available for reconstruction, which several studies have shown to be the case.12,14,20,21
Many studies found that fistula rate was unrelated to age at the time of palate repair,10,16,17 although a study by Al-Nawas et al did cite lower preoperative weight as a risk factor, which could be associated with younger age at the time of repair.22 On the other hand, Emory et al reported a small but significant decrease in fistula rate when cleft palate repair was performed on patients younger than 12 months of age, and several other studies also noted a decreased fistula rate with earlier repair.5,23,24 However, 1 study did note that palate repair in patients younger than 6 months of age is associated with a higher fistula rate.25 Overall, it appears that age 6 to 12 months may be an ideal time to perform palate repair to decrease the likelihood of postoperative ONF. This observation should not be considered in a vacuum, however, as timing of cleft palate repair also dramatically impacts the effectiveness of speech development and subsequent facial growth restriction, factors that are paramount in the overall development of children with cleft palate.
While confounded by surgeon experience and cleft phenotype, surgical technique can have an impact on the incidence of palatal fistula. The 2-stage palate repair technique has been associated with fistula formation after definitive closure in some studies, although others showed no statistically significant difference when compared with 1-stage repair.13,26-29 The 2-stage technique is known to have a negative impact on speech outcomes, with 1 study by Funayama et al showing a higher incidence of malarticulations at 4 years of age in patients who had undergone only soft palate repair around age 18 months compared with those who underwent repair in a single stage. Those patients in the 2-stage group still showed a higher rate of malarticulations at age 8 years following the second procedure to close the residual cleft in the hard palate.30 With no apparent reduction in fistula formation and a higher rate of speech difficulties, the benefit of the 2-stage technique is questionable.
With regard to 1-stage palatoplasty techniques, there is no clear consensus regarding which strategy is optimal for ONF prevention. The majority of studies are inherently limited in that they describe either a single-surgeon technique or a comparison of 2 techniques. Furthermore, these observations are often heavily influenced by patient, surgeon, and cleft phenotype. For example, Amartunga et al noted a higher fistula rate with a Langenbeck hard palate repair; conversely, Cohen et al demonstrated better outcomes with a Langenbeck repair with than the Wardill closure.2,31 The Sommerlad repair technique has a published fistula rate of 5% to 16%.32-34 Bekerecioglu et al found no difference in fistula rate between 2- and 4-flap palatoplasty,35 whereas Dong et al found no difference in outcomes between Furlow and 2-flap palatoplasty.36 A novel “rotation flap” method published by Kahrama et al showed a significantly lower fistula rate than was seen in a traditional V-to-Y pushback group,16 whereas a modified approach by Ogata et al dubbed “the 3M flap” produced a fistula rate of 6%.37
The nuanced differences in how each procedure is described and performed probably means that the outcomes of each study have meaning only for the surgeon whose patients are examined. That being said, overall trends and principles can be inferred. One study by Wilhelmi et al reinforced the broader principle that techniques to minimize midline tension, including 2-flap palatoplasty and lateral relaxing incisions, can decrease fistula rates.17 At the same time, one must consider the impact that secondary healing of donor sites can have on transverse, anteroposterior, and vertical maxillary growth. Though other techniques demonstrating low fistula rates have also been reported,38,39 many of these studies are inherently limited due to small sample size and describe only 1 technique or compare 2 methods.
Regardless of the specific preferred technique, surgeons should utilize techniques that they are comfortable performing to achieve a watertight, tension-free closure of both the soft and hard palate and maintain a robust vascular supply for optimal healing and fistula avoidance. Most importantly, the correct operation must be chosen to complete an intravelar veloplasty and achieve functional speech outcomes.
Given the complexity of cleft palate surgery and the nuances of repair, surgeon experience would seem to be a predictor of success and ONF prevention. One high-powered study reported a statistically significant increase in all-cause reoperation rates for cleft palate repair in surgeries performed by residents versus attending physicians.40 However, multiple smaller studies found no statistically significant difference in fistula rate by surgeon experience, whether that be defined by title (resident versus attending) or by number of procedures performed.22,41,42 Moreover, the degree of improvement as surgeons progress through training can vary greatly, with additional experience not always correlating with improved outcomes.40 The setting in which surgeons operate also plays a role, as multiple studies have noted higher fistula rates in patients who underwent palatoplasty in a mission-trip setting43,44 and after repairs performed in third-world countries.45 Regardless of surgeon experience, continuity of care may play a factor, as Connolly et al reported a higher incidence of fistula when care was provided by multiple teams.46
Whereas discrepancies between the sexes are known to exist in the rates of cleft lip and palate and cleft palate alone, the likelihood of fistula formation based on patient sex is less clear. Multiple studies indicate no difference in fistula formation with regard to patient sex.10,15-17 However, 1 study noted that fistulae occur twice as often in male patients,31 while another study found a higher fistula recurrence rate in female patients.2 Hosseinabed et al found no difference in rate of occurrence but did note that male patients with fistulae were more likely to experience symptomatic hypernasality.47
In regard to other patient factors, internationally adopted children occupy a unique and common subset of patients. In patients presenting to US craniofacial centers after cleft palate repairs performed abroad, Swanson et al noted a 34% incidence of fistula. In addition, secondary palatoplasty or pharyngoplasty was performed more frequently for patients who underwent primary palatoplasty before adoption than after.48 Similarly, a fistula rate of only 14% was found by Hansson et al in internationally adopted patients who underwent palate repair after adoption.49 However, a patient cohort studied by Werker et al noted just an 8% rate of postpalatoplasty fistulae in need of revision after adoption.50 Regardless of their age and location at time of palatoplasty, internationally adopted children can be successfully treated with the various methods of fistula repair discussed later in this manuscript.
Another subset of patients of special interest is those with cleft-associated syndromes. A 2015 study by Ahmed et al found palatal fistulae to be reliably associated with cleft severity but not with cleft-associated syndromes.51 Though not a syndrome itself, Pierre Robin sequence has been found in multiple studies to be associated with poor speech outcomes following cleft repair but not with increased fistula rates.52-54 This is interesting given the underlying syndromic associations and the wide, U-shaped nature of the prototypical Pierre Robin cleft palate. The findings of these large, single-center studies were corroborated by a later systematic review that also showed no increase in fistula rate in patients with Pierre Robin sequence.55
Functional Impact
The most important outcome of palatoplasty is a well-healed palate repair without excessive scarring and fistulation.56-58 The primary functional impacts of symptomatic ONF are excessive nasal air escape during speech and nasal regurgitation of food contents during oral intake. One study found the critical limit of fistula size to have an adverse effect on speech is considered to be around 5 mm59; however, some authors report that a fistula of only a few millimeters in size can affect speech and resonance, especially if the fistula disrupts the levator mechanism.2,31,60 Studies have shown that even partial closure of fistulae can improve speech intelligibility and nasality. Clinically, patients with symptomatic fistulae can demonstrate hypernasality, audible nasal escape, and weakness of pressure consonants during speech examination. A diagnostic maneuver to aid in determining the extent of fistula impact during the speech evaluation is to use a custom device, soft candy, or gum to obturate the fistula and compare speech samples with and without the obturating material present.61-63
The treatment and timing of surgery should be based on the magnitude of impact that the fistula has on feeding and speech. Surgery at a younger age is indicated in cases of severe nasal regurgitation as this may negatively impact caloric intake in young children and ultimately result in poor nutritional status or diminished growth, as well as poor dental hygiene.64 Not only can later surgical intervention result in delayed speech development, but the adverse effects on speech can also be socially stigmatizing to the patient. Management of asymptomatic fistulae can be deferred to minimize risks of additional scarring, growth restriction, and dental injury.
Classification
Classification of palatal fistulae has traditionally been described in terms of size and location. When subdivided based on size, fistulae are classified as small (<2 mm), medium (3-5 mm), or large (>5 mm).2,3 When subdivided based on location, fistulae can be described as anterior, mid-palate, junctional (ie, at the border of the hard and soft palates), and soft palate. The greatest contribution to the classification and management of ONF is the Pittsburgh Fistula Classification System.65 This system offers standardized, anatomically based nomenclature to describe fistula location to improve clinical communication and the study of anatomically similar fistulae. First described by Smith et al in 2007, the Pittsburgh Fistula Classification System is shown in Figure 1.65
Incidence and Prevention Strategies
Analysis of the current body of literature suggests that the incidence of ONF is difficult to characterize, largely due to lack of uniform definition and surgeon reporting bias. Whereas some studies include unrepaired alveolar clefts in their reporting, this does not fit the more appropriate definition of a palatal fistula, which is a failure of healing or breakdown of the primary surgical repair of the palate.66 Consequently, the published incidence of palatal fistula varies widely, from 3.4% to 78%.2,10,15-17,30,31,41,47,66-80 Multiple meta-analyses likely provide the best estimates of incidence of ONF, which lies between 6.4% and 8.6%.66,81,82 Reports of fistula location also vary widely; 1 study reported that 87% occur within the hard palate,2 whereas other studies report higher rates occurring at the junction of the hard and soft palate.31,66 Still other studies report that ONF occur in equal distributions across the hard palate, soft palate, and the junctional region.10,15
As previously discussed, a paucity of literature exists regarding the exact causes of ONF formation as it is likely multifactorial in most cases. The ultimate goal of palatoplasty is to achieve a watertight, tension-free closure of both the oral and nasal layers while achieving the anatomic realignment of the levator mechanism. During this pursuit, excess tension or a large amount of dead space between the nasal and oral layers may lead to wound breakdown.
There has been concern over whether bacterial colonization of the oral cavity may predispose certain patients to infection, particularly in patients who are less likely to maintain diligent oral hygiene postoperatively. However, the infection rates following palatoplasty are very low, and the use of preoperative antibiotics has not been shown to significantly impact fistula rates.83,84 However, 1 study by Tuna et al did note significantly higher counts of methicillin-sensitive Staphylococcus aureus in saliva samples of patients with larger ONF.85 Regarding topical antimicrobials, 1 repair method favored by Mulliken involved the securing of a gauze pack soaked in balsam of Peru to the alveolar ridges postoperatively.86 Brignardello-Peterson et al studied a similar method and found a decreased incidence of fistula formation in patients who had an antibiotic pack sutured over their palate repair for 5 days postoperatively, although the correlation may be confounded by the fact that this pack also provided a physical barrier to protect the suture lines.87 Nevertheless, current evidence does not support the use of protracted antibiotic regimens in primary palatoplasty, and one must consider the potential for increased length of stay and patient discomfort when using these topical treatment modalities.84
Surgical relief of tension in mobilization of the palate is crucial for ONF prevention. One study by Dec et al suggested that the use of presurgical infant orthopedics, such as nasoalveolar molding, before palatoplasty may lead to a decreased fistula rate by bringing the palatal segments in closer proximity.88 While this makes sense empirically, a subsequent meta-analysis found no statistically significant evidence of this, possibly because repair of the lip serves as a form of orthopedic and leads to subsequent collapse of the palatal segments after primary cheiloplasty.89 A prospective study performed by Losken et al showed a dramatic reduction in fistula rate by using a systematic approach to palatoplasty repair technique based on cleft width. His study also reinforced the importance of skeletonization of the vascular pedicle during medialization of the mucoperiosteal flaps, aggressive undermining and mobilization of musculature, and meticulous 2-layer mattress suture closure.90 In cases where further medialization of the pedicle is required after those maneuvers, surgeons have also advocated performing greater palatine foraminal osteotomies.91
Another important maneuver to improve soft tissue mobilization during palatoplasty is to make lateral relaxing incisions at the crease between the lateral buccal wall and soft palate.70,92 Wilhelmi et al advocated leaving these relaxing incisions open to avoid undue tension on the midline closure and prevent incisional breakdown.17 Additional surgical manueuvers that can be preventive against ONF formation include various modifications of relaxing incisions, local flaps, back cuts, and vomer flaps; these strategies are well described in a review by Butow et al.93
If there is concern for excess tension at the repair, interposing a third layer of tissue or soft tissue substitute may help improve healing. This serves the purpose of offsetting opposing suture lines to decrease fistula risk, as well as filling dead space between tissue planes as a means of optimizing healing.94-97 Losee advocated for the use of acellular dermal matrix (ADM) in the event of a tenuous palate repair.70 Though some argue against the insertion of avascular material into a region of already compromised vascularity, others use ADMs routinely in their repairs to obliterate dead space and allow for the ingrowth of healthy tissue.98 Hudson et al demonstrated no fistula formation in a series of 6 patients with the use of ADM and fibrin glue stabilization.99 The use of other adjuncts, such as the injection of platelet-rich plasma for its high concentration of growth factors, has also shown promising results in palatoplasty.100 The use of buccal fat flaps to fill the space between oral and nasal lining represents an autologous, vascularized alternative to ADM use. The use of buccal fat pad flaps for palatoplasty was originally described by Levi et al as an added soft tissue layer to cover exposed areas of the hard palate as well as midline areas of high tension.101 Other authors have advocated their use prophylactically to avoid fistula formation and have demonstrated lower fistula rates with their use.102,103
Cleft palate is not just a failure of fusion; in patients with cleft palate, there is overall hypoplasia of palatal tissue. The majority of repair techniques rely on the supposition that there is an adequate amount of tissue at the repair site, which is not true in all causes. More recently, there has been a trend toward recruitment of distant tissue into the palatal repair to optimize outcomes. If a paucity of tissue at the repair site is the issue, the recruitment of regional soft tissue via buccal myomucosal flaps may be indicated to provide healthy, well vascularized soft tissue for palatal closure. Mann has described and advocated for the use of this flap in both primary and secondary palatoplasty techniques and has demonstrated equivalent outcomes in phenotypes more severe than those for which this technique has been traditionally deployed.104 The buccal myomucosal flap is an axial pattern flap based on the buccinator muscle and can be used in combination with standard Furlow palatoplasty; a double-opposing buccal flap procedure can also be used to add additional soft tissue to a repair to minimize tension and lengthen the palate in patients with wide clefts.104-106 The flap pedicles can then be divided in a secondary procedure before eruption of the second molars. Hill et al also advocated utilizing this technique for any cleft in which the cleft width exceeds the sum of the width of the palatal shelves.107 The role and proper application of these techniques is currently under debate, but the logical value of adding tissue to minimize tension is appealing.
Postoperative palatoplasty management varies, and no specific routine has been shown to reduce the rate of ONF formation. The use of arm restraints is a commonly accepted practice and may be beneficial in preventing trauma to the repair, although evidence shows this benefit may not be statistically significant.108 Postoperative diet typically begins with clear liquids, with gradual advancement to a soft diet over several weeks. Some surgeons prefer a time period of feeding via sippy cup, whereas others allow for bottle-feeding immediately after surgery. There have not been any studies supporting a specific postoperative diet regimen for the prevention of ONF following palatoplasty.
Repair of Palatal Fistulae
Just as in primary palatoplasty, the goal of ONF repair is to perform a 2-layer, tension-free durable closure.1 Many surgical techniques have been used to fulfill this objective, ranging from local flaps to free tissue transfer.109-112
Local Flaps
First-line treatment for ONF repair involves the use of local tissue for closure.113,114 Locally available tissues include the nasal and oral mucosa and hard palate mucoperiosteum, which can be advanced, rotated, or turned over to close small defects of the palate. In many cases, the simplest method of local flap closure is total palatal elevation and primary closure.115,116 This repair technique was utilized by Denny et al in a series of 60 patients, with a success rate of 97% in previously unoperated palatoplasty fistulae.110 The use of local flaps is often limited by the size of the defect, as large donor sites or undue tension on the repair could ultimately result in a larger defect in the event of flap failure. The quality of local tissues available also plays a role in flap selection.
Local flap repair techniques can be useful for Pittsburgh type III, IV, and V fistulae as the hard palate mucoperiosteum can, in some cases, provide adequate soft tissue for closure. Often these flaps are well illustrated and conceptualized using ingenious principles of plastic surgery, but their clinical efficacy may be limited due to scarring, poor vascularity, and lack of tissue availability. Jackson et al described the use of mucoperiosteal turn-in flaps for closure of the nasal layer, as well as buccal mucosal flaps for oral closure in a series of 68 patients with ONF, with recurrence in only 2 cases.117 Bilateral mucoperiosteal advancement flaps have also been described for fistula repair, as well as palatal mucoperiosteal island flaps.118,119 Labial mucoperiosteal flaps have been described in the repair of type VI and VII fistulae.120
Another mainstay of local flap closure is a hinge flap. Though techniques can vary, incisions are typically made within the fistula at the approximate junction between the oral and nasal mucosa, being sure to include enough mucosa to allow for elevation and closure without undue tension. The mucosa is typically flipped superiorly to provide closure of the nasal layer. This technique is often used in conjunction with another local flap to close the oral mucosa layer and provide a 2-layered, watertight closure.59,121-123
While less common, other unique repair methods for ONF repair have been described in the literature. Similar to the hinge flap, Erdenetsogt et al described the repair of type IV fistulae in 3 patients using a local turn-down flap for nasal closure, followed by a traditional 2-flap technique for the oral repair.124 Ardehali et al described the use of a trilaminar nasal septal flap for repair of a large unrepaired fistula in an adult.125 Abdel-Aziz et al described a 2-layered V-Y repair for fistula types III, IV, and V with primary closure of the donor site.121 A double-layered repair of the oral mucosa using double-breasted mucoperiosteal flaps in a “vest-over-pants” fashion utilizes offset sutures lines and 1 to 2 cm of overlapping tissue to provide closure, with studies showing no fistula recurrence at an average of 33 months.74 An advancement flap based on the nasopalatine artery has also been described.126
Local flaps are considered advantageous in many ways compared with other regional flaps. They prevent changes in articulation and resonance that are often associated with tongue flaps and also avoid remote donor sites, such as the cheek.121 As subsequent sections will show, they can be utilized in conjunction with bone graft,110,117,119,120,127 distraction osteogenesis,128,129 ADMs, or even various tissue expanders to provide a durable closure of palatal tissues.130-133 Though there is a role for many of these flaps, scarring from previous surgeries and poor tissue quality can prevent them from being viable options. In these situations, other reconstructive methods are indicated.
Interposition of Graft Material
As with primary cleft palate repair, one of the difficulties with ONF repair is the creation of multiple layers of opposing suture lines, each of which must heal independently and presents an opportunity for fistula formation should it not. The use of various materials as an interposition graft has been advocated to decrease the risk of palatal fistula at the time of primary palatoplasty.134 For the same reason, many also advocate their use in formed palatal fistulae as this tissue has already demonstrated a propensity for poor healing.135 A multitude of graft materials have been described for use in the repair of palatal fistulae, including many types of ADMs.136-140 Although often costly, they are considered safe and are widely available for use. ADMs allow for vascular and tissue ingrowth over time; 1 study reported graft incorporation to be indistinguishable from host tissues after 4 weeks.141 Though a 2-layered watertight closure is ideal, multiple studies have shown success even when a portion of the matrix is left exposed. If sufficient tissue is present for a 2-layered closure, these matrices also demonstrate adequate ability to facilitate healing by secondary intention in the event of partial dehiscence of the closure, thus avoiding a return to the operating room.141-143
In addition to synthetic substances, autologous tissues have also been utilized as interposition grafts. As previously mentioned, buccal fat has been successfully utilized in palatal fistula repair, either as an interposition graft or as the oral layer of closure, with complete epithelialization typically achieved by 3 to 4 weeks.144,145 De Castro et al reported the successful use of buccal fat as a free graft.146 Autologous fascia has also been used successfully as a free graft,147 as has a mixture of platelet-rich plasma and bone graft.148
Regional Flaps
Larger fistulae that cannot be closed with simpler methods benefit from the recruitment of regional tissue. One of the earliest regional flaps used for ONF reconstruction is the tongue flap, a versatile flap traditionally used for type IV or V fistulae up to 3.5 cm in width.149,157 Though design of the flap can vary, it is generally accepted that the base of a posteriorly based flap should lie beneath the posterior border of the defect with the tongue in neutral position. Anteriorly based tongue flaps may be more suitable for anterior fistulae to minimize tension on the repair.152,158 The width of the flap should be one-half to two-thirds the width of the tongue and, at minimum, equal to the width of the defect and up to 20% larger to allow for tension-free closure.159 Flap thickness should be great enough to include the submucosal vascular plexus to allow for adequate blood supply.150 This typically results in a flap that is 3 mm thick at the site of inset, with a slightly thicker (5 mm) base.149 A flap length of 5 to 6 cm should allow for adequate tongue mobility without maxillomandibular fixation.151,160 Timing of flap division varies in the literature from 10 days to 3 weeks.31,150,151,159-161
Because of its wide applications for use, numerous modifications of the tongue flap have been described. For large anterior palatal fistulae, the tongue tip may be divided into dorsal and ventral halves, with the dorsal tip sutured posteriorly and the ventral tip anteriorly. While this provides a large area of coverage, the flap can be bulky, and the loss of the tongue tip can affect articulation162; these effects, however, may be minimal as long as care is taken to appropriately contour the vault.163 Though typically used for oral closure, a posteriorly based flap may also be suspended by a palatal sling and used for nasal closure.164,165 The tongue flap has also been used in conjunction with a pharyngeal flap for closure of larger defects.166 Numerous operative techniques have been described, including the minimization of local anesthetic, design of the flap off midline to minimize tip distortion and articulation changes, and wide removal of scar and granulation tissue from the fistula.151,152
If one wishes to avoid the inherent drawbacks of the tongue flap, attention can be turned to the tissues of the cheek, where the previously mentioned buccal myomucosal flap can be utilized for fistula closure (Figure 2).167-174 Similarly, the facial artery myomucosal (FAMM) flap provides another option for fistula types III, IV, and V due to its ability to reach to the mid-palate (Figure 3). These are true axial pattern flaps with a reliable blood supply that may be harvested from 1 or both sides of the buccal mucosa for closure of larger anterior palatal fistulae.175,176 Though this operation can be performed in a single stage if there is a tooth gap for the flap to lie in, or if a passage is created in the retromolar trigone, it may require a period of forced occlusal opening before division at a second stage.122,177 The donor site is closed primarily but may be painful. Unfurling of the tubed pedicle has also been found to be useful for coverage of recurrent fistulae.178 While a myriad of other regional flaps have been described, ranging from inferior turbinate to modifications of the FAMM flap, these are less commonly used and may be of benefit in cases of multiple recurrent fistulae where more traditional techniques have been exhausted.58,126,167,179-182
Free Tissue Transfer
When local and regional options have been exhausted or do not provide enough tissue coverage of a large defect, a free tissue transfer is a reliable reconstructive option.183,184 Due to the nature of the intraoral tissues and their effects on speech and eating, a thin flap with a long pedicle is best suited for palatal reconstruction. A radial forearm free flap (RFFF) can provide this via the radial artery; a RFFF may even have a split-thickness skin graft secured to its deep side to provide a healthy fasciocutaneous flap with a built-in nasal and oral lining. Anastomosis to the facial vessels can typically be performed approximately 1 cm inferior to the mandibular margin, after the pedicle passes through the maxillary cleft and a subcutaneous tunnel.185 This can be supplemented by using mucoperiosteal flaps to cover a vascularized segment of the radius if an osteocutaneous flap is harvested or by using bone graft to bridge the bony defect.186 In larger chronic defects, osteotomies may be required for total reconstruction of the bony and soft tissue elements.187
Other free flaps are less commonly utilized but are worth noting. The lateral arm flap, supplied by branches of the profunda brachii artery, can be utilized for larger palatal defects.188 Similarly, a dorsalis pedis free flap can provide thin, pliable tissue for reconstruction of any defect of the hard or soft palate.189 For type VI and VII fistulae, an osteocutaneous second toe free flap, supplied by the first dorsal metatarsal pedicle from the dorsalis pedis artery, can provide a vascularized bone bridge for the alveolar gap and a cutaneous lining of both the labial and lingual portions of the defect.190 The laminated nature of this flap provides a long pedicle with adequate bone stock for osseointegrated implants and skin on both sides while also allowing for primary donor site closure without long-term morbidity.191
No matter what type of free tissue transfer is performed, the importance of a tension-free anastomosis, as well as the prevention of torsion on the pedicle, cannot be overstated. Traditional approaches to prevent tension and torsion of the pedicle include burring or deepening of the piriform rim to allow for passage of the vessels or utilizing a posterior approach that passes the vessels behind the maxillary tuberosity. An additional method to prevent pedicle tension is to pass the flap pedicle through a maxillary antrostomy and to the facial vessels in the cheek via a subcutaneous dissection.192
Osteotomies and Bone Grafts
An in-depth discussion of the routine management of alveolar clefts goes beyond the scope of this article. Bone grafting to repair a Pittsburgh class VI or VII alveolar cleft is an integral part of treatment for patients with clefts of the primary palate and alveolus.193-196 The typical management of alveolar clefts and residual ONF is to fill the bony defect with autologous bone graft with closure of all perialveolar ONF at each cleft site during the period of mixed dentition just before canine eruption.197,198 This approach occasionally requires surgical repositioning of a locked-out premaxilla in patients with malposition so severe that it cannot be treated with orthodontics alone.199
A very trying and vexing problem is the Pittsburgh class V fistula at the incisive foramen in the bilateral complete cleft lip and palate. In these cases, premaxillary osteotomies and repositioning with or without bone grafting can be used to address this problem. Various sources of bone graft include autogenous bone from the calvarium, iliac crest, ribs, and tibia. The highest success rate has been reported with calvarial grafts. This is attributed to the membranous origin, which is similar to that of the maxilla.200-202 However, the high success of grafts obtained from the iliac crest,193,203 along with the ability to provide large quantities of both cortical and cancellous bone,204 have resulted in the ubiquitous popularity of this donor site. Regardless of donor site, bone grafting may also be used as an adjunct in closure of hard palate defects posterior to the alveolus.197,205
For closure of ONF, segmental osteotomies can be used to manipulate palatal segments and bring them into closer proximity to facilitate easier closure of the soft tissue fistula. Surgeons' resistance to the use of segmental maxillary osteotomies has persisted due to concerns of whether segmentation of the maxilla can be performed with enough safety to justify its routine use and whether a stable occlusion will be maintained.206 A technique that can be employed to reconstruct ONF associated with larger bony defects is to perform maxillary osteotomies in conjunction with distraction osteogenesis. This can be utilized for large alveolar gaps or hard palate fistulae. The segment of alveolar bone adjacent to the maxillary defect can be distracted along the track of the original alveolar bone to reconstruct the defect. The downfall with this technique is that the ONF often remains open after distraction has finished, requiring a secondary procedure for definitive soft tissue closure.
Prosthetics
In patients who are not ideal surgical candidates or where surgical measures have proven unsuccessful, the use of palatal obturators may provide the best outcome. These may also be used to assist or complement surgical treatment, such as a temporary obturator for the protection of suture lines following cleft palate or alveolar fistula repair.203,207,208 Goals of prosthetic use are to obturate the palate, divide the oral and nasal cavities, establish proper speech, and allow for proper mastication and swallowing. When these goals are accomplished, certain speech measures and quality of life have been shown to improve.209,210
Prosthetics vary widely in design and use. In some cases, obturators can be combined with palatal expansion devices as a temporary method of closure before definitive surgical intervention.211 Hard palate obturators can close palatal fistulae, while obturators with pharyngeal bulbs can replace soft palate tissue to help provide velopharyngeal closure.209,212,213 Edentulous patients may require partial or complete obturator dentures to allow for mastication.209,214 Though the ability to create custom prosthetics is impressive, their use should be reserved for unique situations where surgical closure is not achievable or when the patient is either not a surgical candidate or does not desire surgical intervention.
Outcomes
The ultimate goals of palatal fistula repair are to achieve intelligible speech and to allow for feeding without the passage of oral contents into the nasal cavity. Thus, outcome markers in ONF studies should focus on speech, feeding, and longevity and durability of ONF repair. However, data regarding speech outcomes are often reported in a subjective manner rather than in a standardized fashion, making it difficult to draw conclusions based on single-institution studies. One of the more thorough reviews of speech outcomes following ONF repair comes from Funayama et al, who found that patients experienced a decrease in compensatory malarticulations with earlier closure of the palatal fistulae30; another study also showed that earlier repair of fistulae improved speech overall.215 Sullivan et al corroborated this in multiple studies, with worse speech outcomes noted in internationally adopted patients with delayed repair.216,217 This may not necessarily extrapolate to the timing of the original cleft palate repair, as 1 study found no association between timing of initial palatoplasty and hypernasality.47 As expected, nasality and nasal emissions showed improvement in 1 study after the repair of alveolar clefts with bone grafting.218 Symptoms of hypernasal speech were reported to improve with a variety of reconstructive methods for hard and soft palate fistulae, including tongue flaps, conchal cartilage grafts, buccal myomucosal flaps, and RFFFs.60,161,170,185,219,220
Although one can extrapolate that a successful closure of ONF would result in improvement of feeding and decreased nasal regurgitation, these data are typically excluded in ONF study results, a limitation of the current literature on ONF. The most often reported outcome of ONF repair is the recurrence rate following repair. Recurrence rates range in the literature from 10% to 37%.2,110,120,121,124 One review noted a 25% secondary recurrence rate, with a higher recurrence rate associated with increasing Veau classification. Larger fistula size was also found to be associated with a higher rate of recurrence. Several small case series reported lower recurrence rates of 8% to 17%.142,149,151,221 Another study noted a similar rate of 7% recurrence, which increased to 40% with secondary ONF repairs.222 Losee et al made an important distinction when classifying fistula recurrence: whereas there was an 11% overall recurrence rate, only 3.6% were symptomatic.70 With significant risk of fistula recurrence following repair, patient counseling is critical along with a recognition that the best fistula treatment strategy is avoidance.
Conclusions
With the reported overall success rate of ONF repair approaching 85% and a recurrence rate of 10% to 37%, treatment of ONF remains a challenging problem.1 There is not a general consensus in the available literature on the best palatoplasty techniques for the prevention and treatment of ONF. More aggressive palatal undermining and lateral relaxing incisions can diminish closure tension and reduce risk of fistula formation but will also leave denuded maxillary bone, which can impact secondary facial growth due to scar contracture. Surgical teams should select their palatoplasty technique based on surgeon experience and comfort level and target these tension-relieving maneuvers to the appropriate patients to not only reduce the risk of ONF but to also optimize speech outcomes.
When fistulae do occur, they present unique problems to each patient. A myriad of reconstructive options and adjunctive therapies exist, and their use is guided by both the size and location of the fistula. Treatment should be tailored to the specific needs of the patient, and consideration must be given to not only the problem to be fixed but also to the patient’s stage of growth and development the patient. Fistula repair should not detract from truly important procedures for patients, such as secondary speech surgery. This review of the literature reinforces that the study of these fistulae is hampered by nomenclature; study bias; varying anatomy, size, and symptoms; along with a lack of reporting on various outcome measures. Large-scale multicenter studies are needed in which ONF are described with standardized nomenclature, and improved outcomes reporting is necessary to better define an algorithm for a truly holistic approach to palate surgery and reduce the incidence of palatal fistula.
Acknowledgments
Affiliations: 1Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
Correspondence: S. Alex Rottgers, MD; srottge1@jhmi.edu
Funding: This work is partially supported by Career Development Award Number IK2 CX001785 from the United States Department of Veterans Affairs Clinical Science R&D (CSRD) Service to Eric Tkaczyk.
Ethics: Institutional review board approval was obtained for this study.
Disclosures: The authors disclose no relevant financial or nonfinancial interests.
References
1. Dufresne C. Oronasal fistula and nasolabial fistulas. In: Bardach J, Morris HL, eds. Multidisciplinary Management of Cleft Lip and Palate. 1st ed. W.B. Saunders; 1990:787-791.
2. Cohen SR, Kalinowski J, Larossa D, et al. Cleft-palate fistulas—a multivariate statistical analysis of prevalence, etiology, and surgical management. Plast Reconstr Surg. Jun 1991;87(6):1041-1047. doi:10.1097/00006534-199106000-00005
3. Muzaffar AR, Byrd HS, Rohrich RJ, et al. Incidence of cleft palate fistula: an institutional experience with two-stage palatal repair. Plast Reconstr Surg. Nov 2001;108(6):1515-1518. doi:10.1097/00006534-200111000-00011
4. Jackson IT, Moreira-Gonzalez AA, Rogers A, Beal BJ. The buccal flap - A useful technique in cleft palate repair? Cleft Palate Craniofac J. Mar 2004;41(2):144-151. doi:10.1597/02-124
5. Bindingnavele VK, Bresnick SD, Urata MM, et al. Superior results using the islandized hemipalatal flap in palatoplasty: experience with 500 cases. Plast Reconstr Surg. Jul 2008;122(1):232-239. doi:10.1097/PRS.0b013e31817741e8
6. Bresnick S, Walker J, Clarke-Sheehan N, et al. Increased fistula risk following palatoplasty in Treacher Collins syndrome. Cleft Palate Craniofac J. May 2003;40(3):280-283. doi:10.1597/1545-1569(2003)040<0280:ifrfpi>2.0.co;2
7. Steinbacher DM, McGrath JL, Low DW. Is nasal mucoperiosteal closure necessary in cleft palate repair? Plast Reconstr Surg. Feb 2011;127(2):768-773. doi:10.1097/PRS.0b013e3181fed80a
8. Rossell-Perry P. Flap necrosis after palatoplasty in patients with cleft palate. Biomed Res Int. 2015;2015:516375. doi:10.1155/2015/516375
9. Campbell DA. Fistulae in the hard palate following cleft palate surgery. Br J Plast Surg. Oct 1962;15:377-384. doi:10.1016/s0007-1226(62)80062-9
10. Li F, Wang HT, Chen YY, et al. Cleft relapse and oronasal fistula after Furlow palatoplasty in infants with cleft palate: incidence and risk factors. Int J Oral Maxillofac Surg. Mar 2017;46(3):275-280. doi:10.1016/j.ijom.2016.09.019
11. de Agostino Biella Passos V, de Carvalho Carrara CF, da Silva Dalben G, et al. Prevalence, cause, and location of palatal fistula in operated complete unilateral cleft lip and palate: retrospective study. Cleft Palate Craniofac J. Mar 2014;51(2):158-164. doi:10.1597/11-190
12. Kim JY, Kim SG, Park YW, et al. The effect of buccal fat pad graft in the palatoplasty and the risk factor of postoperative palatal fistula. J Craniofac Surg. May/Jun 2020;31(3):658-661. doi:10.1097/scs.0000000000006151
13. 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. Nov 2010;47(6):623-630. doi:10.1597/09-069
14. Parwaz MA, Sharma RK, Parashar A, et al. Width of cleft palate and postoperative palatal fistula--do they correlate? J Plast Reconstr Aesthet Surg. Dec 2009;62(12):1559-1563. doi:10.1016/j.bjps.2008.05.048
15. Emory RE, Clay RP, Bite U, et al. Fistula formation and repair after palatal closure: an institutional perspective. Plast Reconstr Surg. May 1997;99(6):1535-1538. doi:10.1097/00006534-199705000-00010
16. Kahraman A, Yuce S, Kocak OF, et al. Comparison of the fistula risk associated with rotation palatoplasty and conventional palatoplasty for cleft palate repair. J Craniofac Surg. Sep 2014;25(5):1728-1733. doi:10.1097/scs.0000000000000967
17. Wilhelmi BJ, Appelt EA, Hill L, et al. Palatal fistulas: rare with the two-flap palatoplasty repair. Plast Reconstr Surg. Feb 2001;107(2):315-318. doi:10.1097/00006534-200102000-00002
18. Ha S, Koh KS, Moon H, et al. Clinical outcomes of primary palatal surgery in children with nonsyndromic cleft palate with and without lip. Biomed Res Int. 2015;2015:185459. doi:10.1155/2015/185459
19. Shimizu M, Shigetaka Y, Mizuki H, et al. Oronasal fistulae in repaired cleft palates. J Craniomaxillofac Surg. Dec 1989;17 Suppl 1:37-38. doi:10.1016/s1010-5182(89)80039-3
20. Obad Saleh H, Nasr KM, Abdull Sattar AH, et al. Relation between palatal index and the incidence of postoperative fistula in patients with complete unilateral cleft palate (a prospective cohort study). J Plast Reconstr Aesthet Surg. Dec 2019;72(12):2064-2094. doi:10.1016/j.bjps.2019.09.042
21. Tse RW, Siebold B. Cleft palate repair: description of an approach, its evolution, and analysis of postoperative fistulas. Plast Reconstr Surg. May 2018;141(5):1201-1214. doi:10.1097/prs.0000000000004324
22. Al-Nawas B, Wriedt S, Reinhard J, et al. 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. Mar 2013;41(2):135-139. doi:10.1016/j.jcms.2012.06.005
23. Aldaghir OM, AlQuisi AF, Aljumaily HA. Risk factors for fistula development following palatoplasty. J Craniofac Surg. Nov-Dec 2019;30(8):e694-e696. doi:10.1097/scs.0000000000005635
24. Andersson EM, Sandvik L, Semb G, et al. Palatal fistulas after primary repair of clefts of the secondary palate. Scand J Plast Reconstr Surg Hand Surg. 2008;42(6):296-299. doi:10.1080/02844310802299676
25. Eliason MJ, Hadford S, Green L, et al. Incidence of fistula formation and velopharyngeal insufficiency in early versus standard cleft palate repair. J Craniofac Surg. Jun 2020;31(4):980-982. doi:10.1097/scs.0000000000006307
26. Reddy RR, Gosla Reddy S, Chilakalapudi A, et al. Effect of one-stage versus two-stage palatoplasty on hypernasality and fistula formation in children with complete unilateral cleft lip and palate: a randomized controlled trial. Plast Reconstr Surg. Jul 2018;142(1):42e-50e. doi:10.1097/prs.0000000000004486
27. Stein MJ, Zhang Z, Fell M, et al. Determining postoperative outcomes after cleft palate repair: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. Jan 2019;72(1):85-91. doi:10.1016/j.bjps.2018.08.019
28. Tache A, Mommaerts MY. On the frequency of oronasal fistulation after primary cleft palate repair. Cleft Palate Craniofac J. Nov 2019;56(10):1302-1313. doi:10.1177/1055665619856243
29. Mommaerts MY, Gundlach KK, Tache A. “Flip-over flap” in two-stage cleft palate repair. J Craniomaxillofac Surg. Jan 2019;47(1):143-148. doi:10.1016/j.jcms.2018.10.019
30. Funayama E, Yamamoto Y, Nishizawa N, et al. Important points for primary cleft palate repair for speech derived from speech outcome after three different types of palatoplasty. Int J Pediatr Otorhinolaryngol. Dec 2014;78(12):2127-2131. doi:10.1016/j.ijporl.2014.09.021
31. Amaratunga NA. Occurrence of oronasal fistulas in operated cleft palate patients. J Oral Maxillofac Surg. Oct 1988;46(10):834-837. doi:10.1016/0278-2391(88)90044-4
32. Becker M, Hansson E. Low rate of fistula formation after Sommerlad palatoplasty with or without lateral incisions: an analysis of risk factors for formation of fistulas after palatoplasty. J Plast Reconstr Aesthet Surg. May 2013;66(5):697-703. doi:10.1016/j.bjps.2013.01.031
33. Mapar D, Khanlar F, Sadeghi S, et al. The incidence of velopharyngeal insufficiency and oronasal fistula after primary palatal surgery with Sommerlad intravelar veloplasty: a retrospective study in Isfahan Cleft Care Team. Int J Pediatr Otorhinolaryngol. May 2019;120:6-10. doi:10.1016/j.ijporl.2018.12.035
34. Moar KK, Sweet C, Beale V. Fistula Rate after primary palatal repair with intravelarveloplasty: a retrospective three-year audit of six units (NorCleft) in the UK. Br J Oral Maxillofac Surg. Jul 2016;54(6):634-637. doi:10.1016/j.bjoms.2016.03.021
35. Bekerecioglu M, Isik D, Bulut O. Comparison of the rate of palatal fistulation after two-flap and four-flap palatoplasty. Scand J Plast Reconstr Surg Hand Surg. 2005;39(5):287-289. doi:10.1080/02844310510006529
36. Dong Y, Dong F, Zhang X, et al. An effect comparison between Furlow double opposing Z-plasty and two-flap palatoplasty on velopharyngeal closure. Int J Oral Maxillofac Surg. May 2012;41(5):604-611. doi:10.1016/j.ijom.2012.01.010
37. Ogata H, Nakajima T, Onishi F, et al. Cleft palate repair using a marginal musculo-mucosal flap. Cleft Palate Craniofac J. Nov 2006;43(6):651-655. doi:10.1597/05-011
38. Shi B, He X, Zheng Q, et al. Modified 2-flap technique in the correction of the wide “circumflex”-shaped incomplete cleft palate. J Oral Maxillofac Surg. Oct 2009;67(10):2302-2306. doi:10.1016/j.joms.2009.03.016
39. Stewart TL, Fisher DM, Olson JL. Modified Von Langenbeck cleft palate repair using an anterior triangular flap: decreased incidence of anterior oronasal fistulas. Cleft Palate Craniofac J. May 2009;46(3):299-304. doi:10.1597/07-185.1
40. Rintala AE, Haapanen ML. The correlation between training and skill of the surgeon and reoperation rate for persistent cleft palate speech. Br J Oral Maxillofac Surg. Oct 1995;33(5):295-271; discussion 297-298. doi:10.1016/0266-4356(95)90040-3
41. Salimi N, Aleksejūnienė J, Yen EH, et al. Fistula in Cleft Lip and Palate Patients-A Systematic Scoping Review. Ann Plast Surg. Jan 2017;78(1):91-102. doi:10.1097/sap.0000000000000819
42. Mann EA, Sidman JD. Results of cleft-palate repair with the double-reverse z-plasty performed by residents. Otolaryngol Head Neck Surg. Jul 1994;111(1):76-80. doi:10.1177/019459989411100115
43. Maine RG, Hoffman WY, Palacios-Martinez JH, et al. Comparison of fistula rates after palatoplasty for international and local surgeons on surgical missions in Ecuador with rates at a craniofacial center in the United States. Plast Reconstr Surg. Feb 2012;129(2):319e-326e. doi:10.1097/PRS.0b013e31823aea7e
44. Daniels KM, Yang Yu E, Maine RG, et al. Palatal fistula risk after primary palatoplasty: a retrospective comparison of a humanitarian organization and tertiary hospitals. Cleft Palate Craniofac J. Jul 2018;55(6):807-813. doi:10.1597/16-007
45. Katusabe JL, Hodges A, Galiwango GW, et al. Challenges to achieving low palatal fistula rates following primary cleft palate repair: experience of an institution in Uganda. BMC Res Notes. Jun 7 2018;11(1):358. doi:10.1186/s13104-018-3459-6
46. Connolly KA, Kurnik NM, Truong TA, et al. Long-term outcomes for adult patients with cleft lip and palate. J Craniofac Surg. Oct 2019;30(7):2048-2051. doi:10.1097/scs.0000000000005932
47. Hosseinabad HH, Derakhshandeh F, Mostaajeran F, et al. Incidence of velopharyngeal insufficiency and oronasal fistulae after cleft palate repair: a retrospective study of children referred to Isfahan Cleft Care Team between 2005 and 2009. Int J Pediatr Otorhinolaryngol. Oct 2015;79(10):1722-1726. doi:10.1016/j.ijporl.2015.07.035
48. Swanson JW, Smartt JM, Saltzman BS, et al. Adopted children with cleft lip and/or palate: a unique and growing population. Plast Reconstr Surg. Aug 2014;134(2):283E-293E. doi:10.1097/prs.0000000000000391
49. Hansson E, Svensson H, Becker M. Adopted children with cleft lip or palate, or both, require special needs cleft surgery. J Plast Surg Hand Surg. 2012;46(2):75-79. doi:10.3109/2000656x.2012.668774
50. Werker CL, de Wilde H, van der Molen ABM, et al. Internationally adopted children with cleft lip and/or palate: a retrospective cohort study. J Plast Reconstr Aesthet Surg. Dec 2017;70(12):1732-1737. doi:10.1016/j.bjps.2017.04.011
51. Ahmed MK, Maganzini AL, Marantz PR, et al. Risk of persistent palatal fistula in patients with cleft palate. JAMA Facial Plast Surg. Mar-Apr 2015;17(2):126-130. doi:10.1001/jamafacial.2014.1436
52. Stransky C, Basta M, Solot C, et al. Do patients with Pierre Robin sequence have worse outcomes after cleft palate surgery? Ann Plast Surg. Sep 2013;71(3):292-6. doi:10.1097/SAP.0b013e3182898712
53. Kocaaslan FND, Sendur S, Koçak I, et al. The comparison of Pierre Robin sequence and non-syndromic cleft palate. J Craniofac Surg. Jan/Feb 2020;31(1):226-229. doi:10.1097/scs.0000000000005961
54. Basta MN, Silvestre J, Stransky C, et al. A 35-year experience with syndromic cleft palate repair operative outcomes and long-term speech function. Ann Plast Surg. Dec 2014;73:S130-S135. doi:10.1097/sap.0000000000000286
55. Wan T, Chen Y, Wang G. Do patients with isolated Pierre Robin Sequence have worse outcomes after cleft palate repair: a systematic review. J Plast Reconstr Aesthet Surg. Aug 2015;68(8):1095-1099. doi:10.1016/j.bjps.2015.04.015
56. Inman DS, Thomas P, Hodgkinson PD, et al. Oro-nasal fistula development and velopharyngeal insufficiency following primary cleft palate surgery - an audit of 148 children born between 1985 and 1997. Br J Plast Surg. Dec 2005;58(8):1051-1054. doi:10.1016/j.bjps.2005.05.019
57. 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. Mar 2008;45(2):172-178. doi:10.1597/06-205.1
58. Huang MHS, Lee ST, Rajendran K. Anatomic basis of cleft palate and velopharyngeal surgery: Implications from a fresh cadaveric study. Plast Reconstr Surg. Mar 1998;101(3):613-627. doi:10.1097/00006534-199803000-00007
59. Abdel-Aziz M, Kamel A, Fawaz M, et al. Closure of fistula of the hard palate with two layers of mucoperiosteum. Int J Pediatr Otorhinolaryngol. Jan 2018;104:43-46. doi:10.1016/j.ijporl.2017.10.037
60. Jeffery SL, Boorman JG, Dive DC. Use of cartilage grafts for closure of cleft palate fistulae. Br J Plast Surg. Oct 2000;53(7):551-554. doi:10.1054/bjps.2000.3411
61. Nanda V, Sharma RK, Mehrotra S, et al. The “chewing gum test” for cleft palate speech. Plast Reconstr Surg. 2005;6:1822-1823.
62. Bless DM, Ewanowski SJ, Dibbell DG. A technique for temporary obturation of fistulae. Cleft Palate J. Oct 1980;17(4):297-300.
63. Reisberg DJ, Gold HO, Dorf DS. A technique for obturating palatal fistulas. Cleft Palate J. Oct 1985;22(4):286-289.
64. Richards H, van Bommel A, Clark V, et al. Are cleft palate fistulae a cause of dental decay? Cleft Palate Craniofac J. May 2015;52(3):341-345. doi:10.1597/13-282
65. Smith DM, Vecchione L, Jiang S, et al. The Pittsburgh fistula classification system: a standardized scheme for the description of palatal fistulas. Cleft Palate-Craniofac J. Nov 2007;44(6):590-594. doi:10.1597/06-204.1
66. Bykowski MR, Naran S, Winger DG, et al. The rate of oronasal fistula following primary cleft palate surgery: a meta-analysis. Cleft Palate-Craniofac J. Jul 2015;52(4):E81-E87. doi:10.1597/14-127
67. Diah E, Lo L-J, Yun C, et al. Cleft oronasal fistula: a review of treatment results and a surgical management algorithm proposal. Chang Gung Med J. 2007;30(6):529-537.
68. Murthy J. Descriptive study of management of palatal fistula in one hundred and ninety-four cleft individuals. Indian J Plast Surg. Jan-Apr 2011;44(1):41-45. doi:10.4103/0970-0358.81447
69. Schultz RC. Management and timing of cleft palate fistula repair. Plast Reconstr Surg. Dec 1986;78(6):739-745. doi:10.1097/00006534-198678060-00004
70. Losee JE, Smith DM, Afifi AM, et al. A successful algorithm for limiting postoperative fistulae following palatal procedures in the patient with orofacial clefting. Plast Reconstr Surg. Aug 2008;122(2):544-554. doi:10.1097/PRS.0b013e31817d6223
71. Rohrich RJ, Rowsell AR, Johns DF, et al. Timing of hard palatal closure: a critical long-term analysis. Plast Reconstr Surg. Aug 1996;98(2):236-246. doi:10.1097/00006534-199608000-00005
72. Eberlinc A, Kozelj V. Incidence of residual oronasal fistulas: a 20-year experience. Cleft Palate-Craniofac J. Nov 2012;49(6):643-648. doi:10.1597/10-146
73. Mahoney M-H, Swan MC, Fisher DM. Prospective analysis of presurgical risk factors for outcomes in primary palatoplasty. Plast Reconstr Surg. Jul 2013;132(1):165-171. doi:10.1097/PRS.0b013e3182910acb
74. Anani RA-A, Aly AM. Closure of palatal fistula with local double-breasted mucoperiosteal flaps. J Plast Reconstr Aesthet Surg. Sep 2012;65(9):E237-E240. doi:10.1016/j.bjps.2012.02.011
75. Abyholm FE, Borchgrevink HH, Eskeland G. Palatal fistulae following cleft palate surgery. Scand J Plast Reconstr Surg. 1979;13(2):295-300. doi:10.3109/02844317909013073
76. Aslam M, Ishaq I, Malik S, Fayyaz GQ. Frequency of oronasal fistulae in complete cleft palate repair. J Coll Physicians Surg Pak. Jan 2015;25(1):46-49.
77. Khosla RK, Mabry K, Castiglione CL. Clinical outcomes of the Furlow Z-plasty for primary cleft palate repair. Cleft Palate Craniofac J. Sep 2008;45(5):501-510. doi:10.1597/07-063.1
78. Lithovius RH, Ylikontiola LP, Sándor GK. Incidence of palatal fistula formation after primary palatoplasty in northern Finland. Oral Surg Oral Med Oral Pathol Oral Radiol. Dec 2014;118(6):632-636. doi:10.1016/j.oooo.2014.07.002
79. Schönmeyr B, Wendby L, Campbell A. Surgical complications in 1408 primary cleft palate repairs operated at a single center in Guwahati, Assam, India. Cleft Palate Craniofac J. May 2016;53(3):278-282. doi:10.1597/14-206
80. Yang AS, Richard BM, Wills AK, et al. Closer to the truth on national fistula prevalence after unilateral complete cleft lip and palate repair? The Cleft Care UK Study. Cleft Palate Craniofac J. Jan 2020;57(1):5-13. doi:10.1177/1055665619858871
81. Hardwicke JT, Landini G, Richard BM. Fistula incidence after primary cleft palate repair: a systematic review of the literature. Plast Reconstr Surg. Oct 2014;134(4):618e-27e. doi:10.1097/prs.0000000000000548
82. Jodeh DS, Nguyen ATH, Rottgers SA. Outcomes of primary palatoplasty: an analysis using the Pediatric Health Information System Database. Plast Reconstr Surg. Feb 2019;143(2):533-539. doi:10.1097/prs.0000000000005210
83. Jodeh DS, Nguyen ATH, Cray JJ, et al. The use of prophylactic antibiotics before primary palatoplasty is not associated with lower fistula rates: an outcome study using the Pediatric Health Information System Database. Plast Reconstr Surg. Aug 2019;144(2):424-431. doi:10.1097/prs.0000000000005843
84. Rottgers SA, Camison L, Mai R, et al. Antibiotic use in primary palatoplasty: a survey of practice patterns, assessment of efficacy, and proposed guidelines for use. Plast Reconstr Surg. Feb 2016;137(2):574-582. doi:10.1097/01.prs.0000475784.29575.d6
85. Tuna EB, Topçuoglu N, Ilhan B, et al. Staphylococcus aureus transmission through oronasal fistula in children with cleft lip and palate. Cleft Palate Craniofac J. Sep 2008;45(5):477-480. doi:10.1597/06-247.1
86. Sullivan SR, Marrinan EM, LaBrie RA, et al. Palatoplasty outcomes in nonsyndromic patients with cleft palate: a 29-year assessment of one surgeon’s experience. J Craniofac Surg. Mar 2009;20:612-616. doi:10.1097/SCS.0b013e318192801b
87. Brignardello-Petersen R. Antibiotic oral pack was effective in reducing the rate of oronasal fistula in patients undergoing cleft palatoplasty. J Am Dent Assoc. Aug 2018;149(8):e120. doi:10.1016/j.adaj.2018.02.017
88. Dec W, Shetye PR, Grayson BH, et al. Incidence of oronasal fistula formation after nasoalveolar molding and primary cleft repair. J Craniofac Surg. Jan 2013;24(1):57-61. doi:10.1097/SCS.0b013e31826d09b5
89. Jodeh DS, Buller M, Rottgers SA. The impact of presurgical infant orthopedics on oronasal fistula rates following cleft repair: a meta-analysis. Cleft Palate Craniofac J. May 2019;56(5):576-585. doi:10.1177/1055665618806104
90. Losken HW, van Aalst JA, Teotia SS, et al. Achieving low cleft palate fistula rates: surgical results and techniques. Cleft Palate Craniofac J. May 2011;48(3):312-320. doi:10.1597/08-288
91. Pezas T, Khan K, Richard B. What we do: greater palatine medializing foraminal osteotomy for repair of the wide cleft palate. Cleft Palate Craniofac J. Sep 2019;56(8):1080-1082. doi:10.1177/1055665619829386
92. Tang PMY. On “Cleft relapse and oronasal fistula after Furlow palatoplasty in infants with cleft palate: incidence and risk factors” by Li et al. Int J Oral Maxillofac Surg. Oct 2017;46(10):1353-1354. doi:10.1016/j.ijom.2017.03.011
93. Bütow KW, Jacobs FJ. Intravelar veloplasty: surgical modification according to anatomical defect. Int J Oral Maxillofac Surg. Oct 1991;20(5):296-300. doi:10.1016/s0901-5027(05)80159-6
94. Helling ER, Dev VR, Garza J, et al. Low fistula rate in palatal clefts closed with the Furlow technique using decellularized dermis. Plast Reconstr Surg. Jun 2006;117(7):2361-2365. doi:10.1097/01.prs.0000218788.44591.f0
95. Li J, Gerety PA, Johnston J, et al. Gelfoam interposition minimizes risk of fistula and postoperative bleeding in modified-Furlow palatoplasty. J Craniofac Surg. Nov 2017;28(8):1993-1996. doi:10.1097/scs.0000000000003616
96. Simpson A, Samargandi OA, Wong A, et al. Repair of primary cleft palate and oronasal fistula with acellular dermal matrix: a systematic review and surgeon survey. Cleft Palate Craniofac J. Feb 2019;56(2):187-195. doi:10.1177/1055665618774028
97. Winters R, Carter JM, Givens V, et al. Persistent oro-nasal fistula after primary cleft palate repair: minimizing the rate via a standardized protocol. Int J Pediatr Otorhinolaryngol. Jan 2014;78(1):132-134. doi:10.1016/j.ijporl.2013.11.007
98. Agir H, Eren GG, Yasar EK. Acellular dermal matrix use in cleft palate and palatal fistula repair: a potential benefit? J Craniofac Surg. Jul 2015;26(5):1517-1522. doi:10.1097/scs.0000000000001814
99. Hudson JW, Pickett DO. A 5-year retrospective review of primary palatoplasty cases utilizing an acellular collagen interpositional graft. J Oral Maxillofac Surg. Jul 2015;73(7):1393.e1-e3. doi:10.1016/j.joms.2015.03.035
100. El-Anwar MW, Nofal AAF, Khalifa M, et al. Use of autologous platelet-rich plasma in complete cleft palate repair. Laryngoscope. Jul 2016;126(7):1524-1528. doi:10.1002/lary.25868
101. Levi B, Kasten SJ, Buchman SR. Utilization of the buccal fat pad flap for congenital cleft palate repair [editorial]. Plast Reconstr Surg. Mar 2009;123(3):1018-1021. doi:10.1097/PRS.0b013e318199f80f
102. Horswell BB, Chou J. Does the Children’s Hospital of Philadelphia modification improve the fistula rate in Furlow double-opposing Z-plasty? J Oral Maxillofac Surg. Nov 2020;78(11):2043-2053. doi:10.1016/j.joms.2019.08.018
103. Qiu CS, Fracol ME, Bae H, et al. Prophylactic use of buccal fat flaps to improve oral mucosal healing following Furlow palatoplasty. Plast Reconstr Surg. Apr 2019;143(4):1179-1183. doi:10.1097/prs.0000000000005430
104. Mann RJ, Fisher DM. Bilateral buccal flaps with double opposing Z-plasty for wider palatal clefts. Plast Reconstr Surg. Oct 1997;100(5):1139-1143. doi:10.1097/00006534-199710000-00009
105. Mann RJ, Martin MD, Eichhorn MG, et al. The double opposing Z-plasty plus or minus buccal flap approach for repair of cleft palate: a review of 505 consecutive cases. Plast Reconstr Surg. Mar 2017;139(3):735E-744E. doi:10.1097/prs.0000000000003127
106. Mann RJ, Neaman KC, Armstrong SD, et al. The double-opposing buccal flap procedure for palatal lengthening. Plast Reconstr Surg. Jun 2011;127(6):2413-2418. doi:10.1097/PRS.0b013e3182131d3e
107. Hill C, Riaz M, Leonard AG. A technique for repair of the “unrepairable” cleft palate. Br J Plast Surg. Dec 1999;52(8):658-660. doi:10.1054/bjps.1999.3199
108. Jigjinni V, Kangesu T, Sommerlad BC. Do babies require arm splints after cleft palate repair? Br J Plast Surg. Dec 1993;46(8):681-685. doi:10.1016/0007-1226(93)90200-u
109. Murrell GL, Requena R, Karakla DW. Oronasal fistula repair with three layers. Plast Reconstr Surg. Jan 2001;107(1):143-147. doi:10.1097/00006534-200101000-00021
110. Denny AD, Amm CA. Surgical technique for the correction of postpalatoplasty fistulae of the hard palate. Plast Reconstr Surg. Feb 2005;115(2):383-387. doi:10.1097/01.prs.0000148650.32055.01
111. Eufinger H, Machtens E. Microsurgical tissue transfer for rehabilitation of the patient with cleft lip and palate. Cleft Palate-Craniofac J. Sep 2002;39(5):560-567. doi:10.1597/1545-1569(2002)039<0560:mttfro>2.0.co;2
112. Laine J, Vahatalo K, Peltola J, et al. Rehabilitation of patients with congenital unrepaired cleft palate defects using free iliac crest bone grafts and dental implants. Int J Oral Maxillofac Implants. Jul-Aug 2002;17(4):573-580.
113. Freda N, Rauso R, Curinga G, et al. Easy closure of anterior palatal fistula with local flaps. J Craniofac Surg. Jan 2010;21(1):229-232. doi:10.1097/SCS.0b013e3181c5a179
114. Raoul G, Ferri J. [Oronasal fistula in sequels of labialalveolarvelopalatine clefts]. Rev Stomatol Chir Maxillofac. Sep 2007;108(4):321-8. doi:10.1016/j.stomax.2007.06.008
115. Bénateau H, Traoré H, Gilliot B, et al. [Repair of palatal fistulae in cleft patients]. Rev Stomatol Chir Maxillofac. Jun 2011;112(3):139-144. Fermeture des fistules palatines séquellaires de fentes. doi:10.1016/j.stomax.2011.02.007
116. Elsherbiny A, Grant JH, 3rd. Total palatal mobilization and multilamellar suturing technique improves outcome for palatal fistula repair. Ann Plast Surg. Dec 2017;79(6):566-570. doi:10.1097/sap.0000000000001216
117. Jackson IT. Closure of secondary palatal fistulae with intra-oral tissue and bone grafting. Br J Plast Surg. 1972-Apr 1972;25(2):93-105. doi:10.1016/s0007-1226(72)80028-6
118. Kim HY, Hwang J, Lee WJ, et al. Palatal mucoperiosteal island flaps for palate reconstruction. Arch Craniofac Surg. 2014-Aug 2014;15(2):70-74. doi:10.7181/acfs.2014.15.2.70
119. Verdi FJ, Lanzi GL, Cohen SR, et al. Use of the Branemark implant in the cleft palate patient. Cleft Palate-Craniofac J. Jul 1991;28(3):301-304. doi:10.1597/1545-1569_1991_028_0301_cotspf_2.3.co_2
120. Fukuda M, Iino M, Takahashi T. Closure of large oronasal fistulas at the time of secondary bone grafting in patients with cleft lip and palate. Scand J Plast Reconstr Surg Hand Surg. Dec 2003;37(6):339-343. doi:10.1080/02844310310004424
121. Abdel-Aziz M. V-Y two-layer repair for oronasal fistula of hard palate. Int J Pediatr Otorhinolaryngol. Sep 2010;74(9):1054-1057. doi:10.1016/j.ijporl.2010.06.003
122. Lee JY, Alizadeh K. Spacer facial artery musculomucosal flap: simultaneous closure of oronasal fistulas and palatal lengthening. Plast Reconstr Surg. Jan 2016;137(1):240-243. doi:10.1097/prs.0000000000001904
123. Rintala A. A double, overlapping hinge flap to close palatal fistula. Scand J Plast Reconstr Surg. 1971;5(2):91-95. doi:10.3109/02844317109042945
124. Erdenetsogt J, Ayanga GN, Tserendulam D, et al. The closure of postpalatoplasty fistula with local turn-down flap. Ann Maxillofac Surg. 2015 2015;5(2):271-273. doi:10.4103/2231-0746.175776
125. Ardehali MM, Farshad A. Repair of palatal defect with nasal septal flap. Int J Oral Maxillofac Surg. Jan 2007;36(1):77-78. doi:10.1016/j.ijom.2006.06.020
126. Rahpeyma A, Khajehahmadi S. Nasoplatine island advancement flap for closure of anterior palatal fistula in patient with isolated cleft palate. J Craniofac Surg. Jul 2019;30(5):e462-e463. doi:10.1097/scs.0000000000005549
127. Black JS, Gampper TJ. Transverse mucoperiosteal flap inset by rotation for cleft palate repair technique and outcomes. Ann Plast Surg. Jun 2014;72(6):S90-S93. doi:10.1097/sap.0000000000000153
128. Alkan A, Bas B, Ozer M, et al. Closure of a large palatal fistula with maxillary segmental distraction osteogenesis in a cleft palate patient. Cleft Palate-Craniofac J. Jan 2007;44(1):112-115. doi:10.1597/05-195
129. Taub PJ, Bradley JP, Kawamoto HK. Closure of an oronasal fistula in an irradiated palate by tissue and bone distraction osteogenesis. J Craniofac Surg. Sep 2001;12(5):495-499. doi:10.1097/00001665-200109000-00018
130. Jenq TF, Hilliard SM, Kuang AA. Novel use of osmotic tissue expanders to treat difficult anterior palatal fistulas. Cleft Palate-Craniofac J. Mar 2011;48(2):217-221. doi:10.1597/09-215
131. Shash H, Al-Halabi B, Jozaghi Y, et al. A review of tissue expansion-assisted techniques of cleft palate repair. J Craniofac Surg. May 2016;27(3):760-766. doi:10.1097/scs.0000000000002468
132. De Mey A, Malevez C, Lejour M. Treatment of palatal fistula by expansion. Br J Plast Surg. May 1990;43(3):362-364. doi:10.1016/0007-1226(90)90090-m
133. Van Damme PA, Freihofer HP. Palatal mucoperiosteal expansion as an adjunct to palatal fistula repair: case report and review of the literature. Cleft Palate Craniofac J. May 1996;33(3):255-257. doi:10.1597/1545-1569_1996_033_0255_pmeaaa_2.3.co_2
134. Losee JE, Smith DM. Acellular dermal matrix in palatoplasty. Aesthet Surg J. Sep 2011;31(7):108S-115S. doi:10.1177/1090820x11418216
135. Cole P, Horn TW, Thaller S. The use of decellularized dermal grafting (AlloDerm) in persistent oro-nasal fistulas after tertiary cleft palate repair. J Craniofac Surg. Jul 2006;17(4):636-41. doi:10.1097/00001665-200607000-00005
136. Sader R, Seitz O, Kuttenberger J. Resorbable collagen membrane in surgical repair of fistula following palatoplasty in nonsyndromic cleft palate. Int J Oral Maxillofac Surg. May 2010;39(5):497-499. doi:10.1016/j.ijom.2010.02.012
137. Ahmed A, Gibson C, Ayliffe P. Use of polydioxanone sheet to repair palatal fistulas in patients with cleft palate. Br J Oral Maxillofac Surg. Oct 2013;51(7):e197-e198. doi:10.1016/j.bjoms.2012.05.016
138. Alonso V, Abuin AS, Duran C, et al. Three-layered repair with a collagen membrane and a mucosal rotational flap reinforced with fibrine for palatal fistula closure in children. Int J Pediatr Otorhinolaryngol. Dec 2019;127:109679. doi:10.1016/j.ijporl.2019.109679
139. Alonso Arroyo V, Sánchez Abuín A, Gómez Beltrán OD, et al. [Multilayer repair of palatal fistula with an interpositional collagen matrix]. Cir Pediatr. Oct 1 2019;32(4):207-211.
140. Atherton DD, Boorman JG. Use of a purified collagen membrane to aid closure of palatal fistulae. J Plast Reconstr Aesthet Surg. Jul 2016;69(7):1003-1007. doi:10.1016/j.bjps.2016.02.009
141. Kirschner RE, Cabiling DS, Slemp AE, et al. Repair of oronasal fistulae with acellular dermal matrices. Plast Reconstr Surg. Nov 2006;118(6):1431-1440. doi:10.1097/01.prs.0000239612.35581.c3
142. El-Kassaby MA, Khalifah MAA-J, Metwally SA, et al. Acellular dermal matrix allograft: An effective adjunct to oronasal fistula repair in patients with cleft palate. Ann Maxillofac Surg. 2014;4(2):158-161. doi:10.4103/2231-0746.147108
143. Steele MH, Seagle MB. Palatal fistula repair using acellular dermal matrix - The University of Florida experience. Ann Plast Surg. Jan 2006;56(1):50-53. doi:10.1097/01.sap.0000185469.80256.9e
144. Ashtiani AK, Fatemi MJ, Pooli AH, et al. Closure of palatal fistula with buccal fat pad flap. Int J Oral Maxillofac Surg. Mar 2011;40(3):250-254. doi:10.1016/j.ijom.2010.09.027
145. Baumann A, Ewers R. Application of the buccal fat pad in oral reconstruction. J Oral Maxillofac Surg. Apr 2000;58(4):389-392; discussion 392-393. doi:10.1016/s0278-2391(00)90919-4
146. de Castro CH, de Souza LN, Fernandes Santos Melo M. Use of the buccal fat pad as free graft for closure of oronasal fistula in a cleft palate patient. J Craniofac Surg. Jan 2015;26(1):e14-e16. doi:10.1097/scs.0000000000001225
147. Denadai R, Seo HJ, Lo LJ. Persistent symptomatic anterior oronasal fistulae in patients with Veau type III and IV clefts: a therapeutic protocol and outcomes. J Plast Reconstr Aesthet Surg. Jan 2020;73(1):126-133. doi:10.1016/j.bjps.2019.05.033
148. González-Sánchez JG, Jiménez-Barragán K. [Closure of recurrent cleft palate fistulas with plasma rich in growth factors]. Acta Otorrinolaringol Esp. Nov-Dec 2011;62(6):448-453. doi:10.1016/j.otorri.2011.06.006
149. Assuncao AG. The design of tongue flaps for the closure of palatal fistulas. Plast Reconstr Surg. Apr 1993;91(5):806-810.
150. Babu CHS, Rai BA, Nair MA, et al. Single layer closure of palatal fistula using anteriorly based dorsal tongue flap. J Maxillofac Oral Surg. Jun 2009;8(2):199-200. doi:10.1007/s12663-009-0049-0
151. Guzel MZ, Altintas F. Repair of large, anterior palatal fistulas using thin tongue flaps: long-term follow-up of 10 patients. Ann Plast Surg. Aug 2000;45(2):109-114.
152. Habib ASE, Brennan PA. The deepithelialized dorsal tongue flap for reconstruction of anterior palatal fistulae: literature review and presentation of our experience in Egypt. Cleft Palate-Craniofac J. Sep 2016;53(5):589-596. doi:10.1597/15-017
153. Denadai R, Zanco GL, Raposo-Amaral CA, et al. Outcomes of surgical management of palatal fistulae in patients with repaired cleft palate. J Craniofac Surg. Jan/Feb 2020;31(1):e45-e50. doi:10.1097/scs.0000000000005852
154. Gupta N, Shetty S, Degala S. Tongue flap: a “workhorse flap” in repair of recurrent palatal fistulae. Oral Maxillofac Surg. Mar 2020;24(1):93-101. doi:10.1007/s10006-019-00823-9
155. Nawfal F, Hicham B, Achraf B, et al. Repair of large palatal fistula using tongue flap. Afr J Paediatr Surg. Jan-Mar 2014;11(1):82-3. doi:10.4103/0189-6725.129247
156. Prakash A, Singh S, Solanki S, et al. Tongue flap as salvage procedure for recurrent and large palatal fistula after cleft palate repair. Afr J Paediatr Surg. Apr-Jun 2018;15(2):88-92. doi:10.4103/ajps.AJPS_131_16
157. Strujak G, Nascimento TC, Biron C, et al. Pedicle tongue flap for palatal fistula closure. J Craniofac Surg. Nov 2016;27(8):2146-2148. doi:10.1097/scs.0000000000003042
158. Coghlan K, O’Regan B, Carter J. Tongue flap repair of oro-nasal fistulae in cleft palate patients. A review of 20 patients. J Craniomaxillofac Surg. Aug 1989;17(6):255-259. doi:10.1016/s1010-5182(89)80093-9
159. Pigott RW, Rieger FW, Moodie AF. Tongue flap repair of cleft palate fistulae. Br J Plast Surg. 1984 1984;37(3):285-293. doi:10.1016/0007-1226(84)90068-7
160. Posnick JC, Getz SB. Surgical closure of end-stage palatal fistulas using anteriorly-based dorsal tongue flaps. J Oral Maxillofac Surg. Nov 1987;45(11):907-912. doi:10.1016/0278-2391(87)90438-1
161. Vasishta SMS, Krishnan G, Rai YS, et al. The versatility of the tongue flap in the closure of palatal fistula. Craniomaxillofac Trauma Reconstr. Sep 2012;5(3):145-159. doi:10.1055/s-0032-1313352
162. Al-Qattan MM. A modified technique of using the tongue tip for closure of large anterior palatal fistula. Ann Plast Surg. Oct 2001;47(4):458-460. doi:10.1097/00000637-200110000-00019
163. Kummer AW, Neale HW. Changes in articulation and resonance after tongue flap closure of palatal fistulas: case reports. Cleft Palate J. Jan 1989;26(1):51-55.
164. Argamaso RV. The tongue flap: placement and fixation for closure of postpalatoplasty fistulae. Cleft Palate J. Oct 1990;27(4):402-410. doi:10.1597/1545-1569(1990)027<0402:ttfpaf>2.3.co;2
165. Barone CM, Argamaso RV. Refinements of the tongue flap for closure of difficult palatal fistulas. J Craniofac Surg. Apr 1993;4(2):109-111. doi:10.1097/00001665-199304000-00011
166. Bagatin M, Goldman N, Nishioka GJ. Combined tongue and pharyngeal flaps for reconstruction of large recurrent palatal fistulas. Arch Facial Plast Surg. Apr-Jun 2000;2(2):146-147. doi:10.1001/archfaci.2.2.146
167. Rahpeyma A, Khajehahmadi S. Buccinator-based myomucosal flaps in intraoral reconstruction: a review and new classification. Nat J Maxillofac Surg. 2013-Jan 2013;4(1):25-32. doi:10.4103/0975-5950.117875
168. Kobayashi S, Fukawa T, Hirakawa T, et al. The folded buccal musculomucosal flap for large palatal fistulae in cleft palate. Plast Reconstr Surg-Global Open. Feb 2014;2(2):4.e112. doi:10.1097/gox.0000000000000058
169. Nakakita N, Maeda K, Ando S, et al. Use of a buccal musculomucosal flap to close palatal fistulae after cleft palate repair. Br J Plast Surg. Jul 1990;43(4):452-456. doi:10.1016/0007-1226(90)90012-o
170. Varghese D, Datta S, Varghese A. Use of buccal myomucosal flap for palatal lengthening in cleft palate patient: experience of 20 cases. Contemp Clin Dent. 2015-Mar 2015;6(Suppl 1):S36-S40. doi:10.4103/0976-237x.152935
171. Abdel-Aziz M. The use of buccal flap in the closure of posterior post-palatoplasty fistula. Int J Pediatr Otorhinolaryngol. Nov 2008;72(11):1657-1661. doi:10.1016/j.ijporl.2008.07.020
172. Bozola AR, Gasques JA, Carriquiry CE, et al.. The buccinator musculomucosal flap: anatomic study and clinical application. Plast Reconstr Surg. Aug 1989;84(2):250-257. doi:10.1097/00006534-198908000-00010
173. Fang L, Yang M, Wang C, et al. A clinical study of various buccinator musculomucosal flaps for palatal fistulae closure after cleft palate surgery. J Craniofac Surg. 2014;25(2):e197-e202. doi:10.1097/scs.0000000000000411
174. Robertson AG, McKeown DJ, Bello-Rojas G, et al. Use of buccal myomucosal flap in secondary cleft palate repair. Plast Reconstr Surg. Sep 2008;122(3):910-917. doi:10.1097/PRS.0b013e318182368e
175. Ariffuddin I, Arman Zaharil MS, Wan Azman WS, et al. The use of facial artery musculomucosal (FAMM) readvancement flap in closure of recurrent oronasal fistula. Med J Malaysia. 2018-04 2018;73(2):112-113.
176. Ashtiani AK, Emami SA, Rasti M. Closure of complicated palatal fistula with facial artery musculomucosal flap. Plast Reconstr Surg. Aug 2005;116(2):381-386; discussion 387-388. doi:10.1097/01.prs.0000142475.63276.87
177. Lahiri A, Richard B. Superiorly based facial artery musculomucosal flap for large anterior palatal fistulae in clefts. Cleft Palate-Craniofac J. Sep 2007;44(5):523-527. doi:10.1597/06-164.1
178. Khanna S, Dagum AB. Waltzing a facial artery musculomucosal flap to salvage a recurrent palatal fistula. Cleft Palate Craniofac J. Nov 2012;49(6):750-752. doi:10.1597/11-040
179. Penna V, Bannasch H, Stark B. The turbinate flap for oronasal fistula closure. Ann Plast Surg. Dec 2007;59(6):679-681. doi:10.1097/SAP.0b013e318033e88d
180. Rahpeyma A, Khajehahmadi S. Premaxillary palatal flap (PPF) as an aid to create nasal floor in anterior palatal fistula closure of cleft patients. Int J Surg. Jun 2016;30:35-37. doi:10.1016/j.ijsu.2016.04.003
181. Wallace AF. Esser’s skin flap for closing large palatal fistulae. Br J Plast Surg. Oct 1966;19(4):322-326. doi:10.1016/s0007-1226(66)80073-5
182. Rossell-Perry P, Arrascue HM. The nasal artery musculomucosal cutaneous flap in difficult palatal fistula closure. Craniomaxillofac Trauma Reconstr. Sep 2012;5(3):175-183. doi:10.1055/s-0032-1322533
183. Schwabegger AH, Hubli E, Rieger M, et al. Role of free-tissue transfer in the treatment of recalcitrant palatal fistulae among patients with cleft palates. Plast Reconstr Surg. Apr 1 2004;113(4):1131-1139. doi:10.1097/01.prs.0000110370.67325.ed
184. Zemann W, Kruse AL, Lüebbers HT, et al. Microvascular tissue transfer in cleft palate patients: advocacy of the prelaminated radial free forearm flap. J Craniofac Surg. Nov 2011;22(6):2006-2010. doi:10.1097/SCS.0b013e31823197d8
185. Chen HC, Ganos DL, Coessens BC, et al. Free forearm flap for closure of difficult oronasal fistulas in cleft palate patients. Plast Reconstr Surg. Nov 1992;90(5):757-762. doi:10.1097/00006534-199211000-00004
186. Macleod AM, Morrison WA, McCann JJ, et al. The free radial forearm flap with and without bone for closure of large palatal fistulae. Br J Plast Surg. Jul 1987;40(4):391-395. doi:10.1016/0007-1226(87)90043-9
187. Felemovicius J, Ortiz-Monasterio F. Management of the impaired adult cleft patient: the last chance. Cleft Palate Craniofac J. Sep 2004;41(5):550-558. doi:10.1597/03-039.1
188. Krimmel M, Hoffmann J, Reinert S. Cleft palate fistula closure with a mucosal prelaminated lateral upper arm flap. Plast Reconstr Surg. Dec 2005;116(7):1870-1872. doi:10.1097/01.prs.0000191173.14154.ef
189. Correa Chem R, Franciosi LF. Dorsalis pedis free flap to close extensive palate fistulae. Microsurgery. 1983;4(1):35-39. doi:10.1002/micr.1920040111
190. Caterson EJ, Singh M, Stephens W, et al. Use of osteocutaneous second-toe free flap for anterior oronasal fistulas. Plast Reconstr Surg. Oct 2015;136(4):834-837. doi:10.1097/prs.0000000000001618
191. Ninkovic M, Hubli EH, Schwabegger A, et al. Free flap closure of recurrent palatal fistula in the cleft lip and palate patient. J Craniofac Surg. Nov 1997;8(6):491-495. doi:10.1097/00001665-199711000-00013
192. Ahuja RB, Chatterjee P, Shrivastava P. A novel route for placing free flap pedicle from a palatal defect. Indian J Plast Surg. May-Aug 2014;47(2):249-251. doi:10.4103/0970-0358.138965
193. Roy Chowdhury SK, Menon PS, Vasant MR, et al. Secondary and delayed bone grafting in alveolar and anterior palatal clefts. Med J Armed Forces India. 2006-Jul 2006;62(3):231-235. doi:10.1016/s0377-1237(06)80007-9
194. Seifeldin SA. Is alveolar cleft reconstruction still controversial? (Review of literature). Saudi Dental Journal. Jan 2016;28(1):3-11. doi:10.1016/j.sdentj.2015.01.006
195. Bilkay U, Tokat C, Ozek C, et al. Cancellous bone grafting in alveolar cleft repair: new experience. J Craniofac Surg. Sep 2002;13(5):658-663. doi:10.1097/00001665-200209000-00012
196. Paulin G, Astrand P, Rosenquist JB, et al. Intermediate bone grafting of alveolar clefts. J Craniomaxillofac Surg. Jan 1988;16(1):2-7. doi:10.1016/s1010-5182(88)80005-2
197. Abyholm FE, Bergland O, Semb G. Secondary bone grafting of alveolar clefts. A surgical/orthodontic treatment enabling a non-prosthodontic rehabilitation in cleft lip and palate patients. Scand J Plast Reconstr Surg Hand Surg. 1981;15(2):127-140. doi:10.3109/02844318109103425
198. Hall HD, Posnick JC. Early results of secondary bone grafts in 106 alveolar clefts. J Oral Maxillofac Surg. 1983;41(5):289-294. doi:10.1016/0278-2391(83)90295-1
199. Paulus C, Souchère B, Breton P, et al. [Osteotomy of the median tubercule as a consequence of bilateral complete labio-maxillo-palatal cleft]. Rev Stomatol Chir Maxillofac. 1994;95(5):363-368.
200. Koberg WR. Present view on bone grafting in cleft palate. (A review of the literature). J Maxillofac Surg. 1973-Dec 1973;1(4):185-193. doi:10.1016/s0301-0503(73)80039-6
201. Bergland O, Semb G, Abyholm FE. Elimination of the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment. Cleft Palate J. Jul 1986;23(3):175-205.
202. Turvey TA, Vig K, Moriarty J, et al. Delayed bone grafting in the cleft maxilla and palate: a retrospective multidisciplinary analysis. Am J Orthod. 1984;86(3):244-256. doi:10.1016/0002-9416(84)90376-2
203. Martin-Smith JD, O’Sullivan JB, Duggan L, et al. Repair of anterior cleft palate fistulae with cancellous bone graft: a simple technique that facilitates dental reconstruction. Plast Reconstr Surg. Mar 2013;131(3):380e-387e. doi:10.1097/PRS.0b013e31827c7027
204. Ishii M, Ishii Y, Moriyama T, et al. Simultaneous cortex bone plate graft with particulate marrow and cancellous bone for reliable closure of palatal fistulae associated with cleft deformities. Cleft Palate Craniofac J. May 2002;39(3):364-369. doi:10.1597/1545-1569_2002_039_0364_scbpgw_2.0.co_2
205. Schultz RC. Cleft palate fistula repair. Improved results by the addition of bone. J Craniomaxillofac Surg. Dec 1989;17 Suppl 1:34-36. doi:10.1016/s1010-5182(89)80038-1
206. Posnick JC, Adachie A, Choi E. Segmental maxillary osteotomies in conjunction with bimaxillary orthognathic surgery: indications - safety - outcome. J Oral Maxillofac Surg. Jul 2016;74(7):1422-1440. doi:10.1016/j.joms.2016.01.051
207. Bowers DG, Gruber H. Use of acrylic obturators to protect suture lines in the hard palate. Plast Reconstr Surg. Jan 1973;51(1):98-101. doi:10.1097/00006534-197301000-00028
208. Tan A, Heijdenrijk K, Moues CM. Custom-made palatal shield use in cleft palate and fistula repair: a potential benefit for fast postoperative recovery. Cleft Palate Craniofac J. Feb 2018;55(2):307-311. doi:10.1177/1055665617727001
209. Goiato MC, dos Santos DM, Moreno A, et al. Prosthetic treatments for patients with oronasal communication. J Craniofac Surg. Jul 2011;22(4):1445-1447. doi:10.1097/SCS.0b013e31821d17bd
210. Pinborough-Zimmerman J, Canady C, Yamashiro DK, et al. Articulation and nasality changes resulting from sustained palatal fistula obturation. Cleft Palate Craniofac J. Jan 1998;35(1):81-87. doi:10.1597/1545-1569_1998_035_0081_aancrf_2.3.co_2
211. Hobson RS, Clasper R. A combined obturator and expansion appliance for use in patients with patent oral-nasal fistula. Br J Orthod. Nov 1995;22(4):357-359. doi:10.1179/bjo.22.4.357
212. Sala Marti S, Merino Tessore MD, Escuin Henar T. Prosthetic assessment in cleft lip and palate patients: a case report with oronasal communication. Med Oral Patol Oral Cir Bucal. Nov 2006;11(6):E493-E496.
213. Borzabadi-Farahani A, Groper JN, Tanner AM, et al. The nance obturator, a new fixed obturator for patients with cleft palate and fistula. J Prosthodont. Jul 2012;21(5):400-403. doi:10.1111/j.1532-849X.2012.00853.x
214. Law MYT, Chung RWC, Lam OLT. Prosthetic rehabilitation of an edentulous patient with an oronasal fistula. J Prosthet Dent. Apr 2015;113(4):347-349. doi:10.1016/j.prosdent.2014.09.023
215. Smyth AG, Wu J. Cleft palate outcomes and prognostic impact of palatal fistula on subsequent velopharyngeal function-a retrospective cohort study. Cleft Palate Craniofac J. Sep 2019;56(8):1008-1012. doi:10.1177/1055665619829388
216. Sullivan SR, Jung YS, Mulliken JB. Outcomes of cleft palatal repair for internationally adopted children. Plast Reconstr Surg. Jun 2014;133(6):1445-1452. doi:10.1097/prs.0000000000000224
217. Sullivan SR, Marrinan EM, LaBrie RA, et al. Palatoplasty outcomes in nonsyndromic patients with cleft palate: a 29-year assessment of one surgeon’s experience. J Craniofac Surg. Mar 2009;20 Suppl 1:612-616. doi:10.1097/SCS.0b013e318192801b
218. Bureau S, Penko M, McFadden L. Speech outcome after closure of oronasal fistulas with bone grafts. J Oral Maxillofac Surg. Dec 2001;59(12):1408-1413; discussion 1413-1414. doi:10.1053/joms.2001.28270
219. Mohanna PN, Kangesu L, Sommerlad BC. The use of conchal-cartilage grafts in the closure of recurrent palatal fistulae. Br J Plast Surg. 2001;3:274.
220. Ohsumi N, Onizuka T, Ito Y. Use of a free conchal cartilage graft for closure of a palatal fistula: an experimental study and clinical application. Plast Reconstr Surg. Mar 1993;91(3):433-440. doi:10.1097/00006534-199303000-00007
221. Richardson S, Hoyt JS, Khosla RK, et al. Use of regenerative tissue matrix as an oral layer for the closure of recalcitrant anterior palatal fistulae: a pilot study. J Korean Assoc Oral Maxillofac Surg. Apr 2016;42(2):77-83. doi:10.5125/jkaoms.2016.42.2.77
222. Abdali H, Hadilou M, Feizi A, et al. Recurrence rate of repaired hard palate oronasal fistula with conchal cartilage graft. J Res Med Sci. Oct 2014;19(10):956-960.
