Achieving Low Cleft Palate Fistula Rates: Surgical Results and Techniques

H. Wolfgang Losken, M.B.Ch.B., F.R.C.S.E., F.C.S. (S.A.), John A. van Aalst, M.D., M.A., F.A.C.S., Sumeet S. Teotia,
M.D., Shay B. Dean, M.D., Scott Hultman, M.D., M.B.A., F.A.C.S., Kim S. Uhrich, L.C.S.W.
Objectives: To prospectively evaluate and reduce fistula rate after primary
cleft palate repair in an academic setting.
Methods: After noting an institutional palate fistula rate of 35.8%, when a
majority of palatoplasties were performed using the Furlow double-opposing Zplasty, the decision was made to re-evaluate the surgical techniques used for
palate repair. As part of our re-evaluation, Furlow and von Langenbeck repairs
were limited to clefts less than 8 mm in width. Wider clefts were repaired early in
the series with Veau-Wardill-Kilner and later with Bardach two-flap palatoplasties. Half of each palate repair was performed by the residents.
Setting: Multidisciplinary follow-up was obtained at the University of North
Carolina Craniofacial Center.
Results: A palate fistula was noted in 2 (1.6%) out of 126 cleft palate repairs
(both fistulas were located at the anterior hard palate). A split uvula was
identified in 2 of 59 patients where the status of the uvula was reported (3.4%).
Conclusion: This study summarizes one of the lowest overall fistula rates
reported in the literature. In a tertiary-care academic setting, plastic surgery
residents can actively contribute to palatoplasty with a very low fistula rate.
Technical keys to achieving low fistula rate include skeletonization of the
vascular pedicle for medialization of the mucoperiosteal flaps, aggressive
posterior repositioning of the levator muscle, and meticulous two-layer
mattress-suture closure. We recommend Furlow repair for narrower clefts (less
than 8 mm wide at the posterior border of the hard palate) and the Bardach twoflap palatoplasty for wider clefts.
KEY WORDS:

cleft outcomes, cleft palate, palate, palate fistula, palatoplasty

The surgical goals for palate repair are complete palate

closure, velopharyngeal competence, and normal maxillary
growth. The latter two are long-term goals; whereas,
avoidance of a palate fistula is a short-term goal that is
established within a month following palatoplasty. Palate
fistula rates reported in the literature range from 0% to
byholm
45%. In one of the largest series of palate repairs, A
reported an 18% incidence of palate fistulas in 1108 patients
byholm, 1979). Salyer et al. (2006)
from 1954 to 1969 (A

reported a 10% fistula rate in 382 two-flap palatoplasties. The

lowest fistula rates reported are by Wilhelmi et al. (2001), Van
Demark et al. (1989), Agrawal and Panda (2006), and more
recently, Losee et al. (2008). Wilhelmi et al. (2001) reported a
3.4% fistula rate using a two-flap palatoplasty in private
practice. Van Demark et al. (1989) reported a 0% fistula rate;
however, follow-up consisted of only a 3-day examination of
37 of 54 patients with complete unilateral cleft lip and palate.
Not all patients were examined, and there was no indication
whether secondary intervening surgeries may have been
performed. Agrawal and Panda (2006) reported a 2.95%
fistula rate in 678 palatoplasties.
In an institutional review in 2001, we noted a fistula rate
of 35.8% in patients who underwent palatoplasty between
1996 and 2001 (Table 1). Evaluation of fistula rates
according to various surgical procedures demonstrated
that the highest fistula rates occurred when the Furlow
repair was performed: 48% in Veau II, 41% in Veau III, and
87.5% in Veau IV patients. These rates were higher than
those using other techniques. In the von Langenbeck
procedure, for example, there was a 29% fistula rate in
Veau II patients; when using the Bardach two-flap
procedure there was a 25% rate in Veau III patients and
a 75% fistula rate in Veau IV patients (Table 2). In
response to these findings, a full re-evaluation of preoperative and postoperative care, as well as operative tech-

Dr. Losken is Clinical Affiliated Professor of Plastic Surgery, University

of North Carolina, Chapel Hill, North Carolina. Dr. van Aalst is
Assistant Professor, Director of Pediatric and Craniofacial Plastic
Surgery, University of North Carolina, Chapel Hill, North Carolina.
Dr. Dean is Plastic Surgeon, Dean Plastic Surgery Associates, Los
Angeles, CA. Dr. Teotia is Associate ProfessorPlastic Surgery, University of Texas Southwestern, School of Health Professions, Dallas, Texas.
Dr. Hultman is Associate ProfessorPlastic Surgery, University of North
Carolina, Chapel Hill, North Carolina. Ms. Uhrich is Social Worker,
University of North Carolina, Chapel Hill, North Carolina.
Presented at the International Cleft PalateCraniofacial Society
Meeting, Durban, South Africa, September 48, 2005, and the International Craniofacial Meeting, Coolum, Australia, September 2005.
Submitted March 2009; Accepted June 2010.
Address correspondence to: Dr. John A. van Aalst, Division of Plastic
Surgery, CB 7195, 7033 Burnett Womack Building, Chapel Hill, NC
27599. E-mail john_vanaalst@med.unc.edu.
DOI: 10.1597/08-288
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TABLE 1 Consecutive Palate Repairs Between 1996 and 2001 Performed by Two Craniofacial Surgeons (n = 109) and Occurrence of Fistulas
Following Furlow Repair*
Veau Classification

No. of Repairs

I
II
III
IV
Total

17
42
32
18
109

Fistulas, no. (%)

0
15
11
13
39

Furlow Z-plasty

(0)
(35.7)
(34.4)
(72.2)
(35.8)

Fistulas, no. (%)

14
25
22
8
69

0
12
9
7
28

(0)
(48)
(41)
(87.5)
(40.6)

* The 109 palate repairs were categorized by Veau classification and type of repair. There were 17 Veau I patients, 42 Veau II patients, 32 Veau III patients, and 18 Veau IV patients.
Following Furlow repair the highest fistula rates were noted in Veau IV clefts, followed by Veau II and III patients, respectively. No fistulas were noted in Veau I clefts following Furlow repair.
The overall fistula rate among patients who underwent a Furlow repair was 40.6%.

niques, was initiated in order to decrease our institutional

palate fistula rate. The following summary of 126
consecutive palate repairs from 2001 to 2005 with two
craniofacial surgeons (W.H.L. and J.A.v.A.) reports the
changes made in order to achieve a fistula rate of 1.6%.

at least 12 months of age; if a tracheostomy was present,

the repair was performed at the standard 9 to 12 months of
age. In submucous cleft palates, the repair was only
performed if significant velopharyngeal incompetence
(VPI) was present. The Veau classification system was
used to describe the extent of clefting and to aid in
organizing repair techniques by cleft type.
Prior to surgery, families were instructed to change the
childs mode of feeding from a Pigeon nipple to a sippy cup
without a ball valve (to prevent suction-generated stress on
the palate repair).

METHODS
The institutional review board approved this study in
2004 (IRB: 04-SURG-823). All consecutive palate repairs
between 2001 and 2005 with at least 1 year of follow-up
were evaluated. A total of 126 patients were identified and
included in the study. Syndromic patients were included.
Patients with Pierre Robin Sequence (PRS) were also
included, and they were not considered syndromic.
Retrospective review of these patients included examination of the yearly clinic notes of all craniofacial team
services that performed an intraoral examination after
palate repair, including plastic surgery, oral maxillofacial
surgery, speech pathology, otolaryngology, pediatric dentistry, and the orthodontic service. Any documentation of a
fistula was included in the group of patients with fistulas.
The nonoperating craniofacial surgeon (H.W.L. or
J.A.v.A.) examined the other craniofacial surgeons patients in all cases. A palate fistula included both symptomatic and nonsymptomatic openings into the nasal cavity,
but it did not include nasoalveolar fistulas.

Techniques for Repair

Furlow Repair
The Furlow double-opposing Z-plasty repair lengthens
the soft palate while simultaneously mobilizing the levator
muscle posteriorly: Oral mucosa and muscle from one side
and nasal mucosa and muscle from the opposite side
interdigitate (Fig. 1; Furlow, 1986). The palate is effectively
lengthened in a narrow cleft and an incomplete cleft of the
soft palate. Due to concerns that palate lengthening is not
effective in a wider cleft and that there would be tension at
the suture line (primarily at the junction of the hard and
soft palates), the Furlow repair was limited to more narrow
clefts (,8 mm). This distance was chosen based on
discussions regarding the threshold for a moderate cleft
and was arbitrary. In submucous clefts of the palate with
VPI, a Furlow double-opposing Z-plasty repair was
routinely used.

Preoperative Care
Palate repairs were performed between 9 to 12 months of
age. In children with PRS, palate repair was delayed until

TABLE 2 Consecutive Palate Repairs Between 1996 and 2001 Performed by Two Craniofacial Surgeons (n = 109) and Occurrence of Fistulas
Following VWK, Bardach, and von Langenbeck Repairs*
Veau

Von Langenbeck

I
II
III
IV
Total

1
7
11
1
10

Fistulas, no. (%)

0
2
0
0
2

(0)
(29)
(0)
(0)
(20)

Straight Line/VWK

1
8
0
1
10

Fistulas, no. (%)

0
1
0
1
2

(0)
(12.5)
(0)
(100)
(20)

Bardach 2-flap

0
1
88
8
17

Fistulas, no. (%)

0
0
22
6
8

(0)
(0)
(25)
(75)
(47.1)

* Other types of repairs, including the von Langenbeck, Veau-Wardill-Kilner (VWK), and Bardach two-flap palatoplasty, though performed less often, resulted in lower fistula rates for each
of the designated Veau classifications.

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FIGURE 1 Initial markings for Furlow double-opposing Z-plasty. A: Markings for optional lateral releasing incisions. B: Underlying opposing Z-plasty. C:
The flaps are then transposed with the levator palati muscle released from posterior edge of the hard palate and sutured posteriorly to reconstruct the velar sling.
D: The oral mucosal closure has transposed the original flaps.

Von Langenbeck Repair

The von Langenbeck repair is a two-flap palatoplasty
where the oral mucosa of the anterior hard palate is left
intact, creating two bipedicle mucoperiosteal flaps (Fig. 2;
La Rossa, 2000). This procedure was used in complete and
incomplete clefts of the secondary palate but was not used
in the presence of an alveolar cleft. The choice to use the
von Langenbeck technique was at the primary surgeons
discretion; inclusion of this technique in the surgical

armamentarium allowed residents to become familiar with

an additional surgical procedure.
Veau-Wardill-Kilner
In the Veau-Wardill-Kilner (VWK) repair, the two-flap
palatoplasty was completely mobilized and the palate pushed
back to achieve closure of the hard palate and maintain the
length of the soft palate (Wardill, 1937). This repair is also
referred to as the VY Pushback procedure (Fig. 3).

Losken et al., ACHIEVING LOW CLEFT PALATE FISTULA RATES

315

FIGURE 2 Von Langenbeck palate repair. Note the excision of mucosa on

medial surface of uvula, with the incision line along medial edge of the cleft;
the lateral releasing incision is marked along the medial aspect of the
alveolar ridge, with extension of the incision posterior to the buccal sulcus.

Bardach Variation of Two-Flap Palatoplasty

The Bardach variation of the two-flap palatoplasty was
used to repair both complete unilateral and bilateral clefts
(Bardach et al., 1984; Bardach, 1999). The mucoperiosteal
palate flaps were incised to the immediate posterior edge of
the alveolar ridge, incorporating the entire oral mucosa of
the anterior palate (Fig. 4), which allows the closure to
extend into the alveolar cleft. In a bilateral cleft, the
mucoperiosteal flaps were transposed medially to the
lingual surface of the alveolus, and a vomer flap was
routinely used (Fig. 5).
Technical Recommendations to Prevent Palate Fistulas
All markings should be made with Bonnies Blue. The
medial surface of the uvula is marked for excision; soft
palate markings are made along the junction of the pale
oral mucosa and the more-pink nasal mucosa (Figs. 2
through 4), then proceed along the medial edge of the hard
palate. In a unilateral cleft, the markings on the hard palate
are placed at the junction of the vomer and the hard palate.
Markings for lateral releasing incisions are made posterior
to the alveolus several millimeters onto the cheek mucosa,
then anteriorly along the medial edge of the alveolus
(Figs. 2 through 4). A mixture of 0.25% Marcaine with
1:200,000 epinephrine is used as the local anesthetic because
it allows 6 to 8 hours of postoperative analgesia, which may
improve initial feeding.
The medial surface of the uvula is excised with tenotomy
scissors (Figs. 2 through 4). Incision is then made with a
beaver blade along the junction of the oral and nasal

FIGURE 3 Veau-Wardill-Kilner repair. A: Initial markings show the

preserved anterior, central hard palate mucosa. B: The palate is repaired
with a pushback of soft palate, leaving bilateral raw areas of the anterior
hard palate to heal secondarily.

mucosa then continued onto the hard palate. The lateral

releasing incisions are made on the buccal mucosa
extending along the medial alveolus, directing the cutting
edge medially to avoid damaging the tooth follicles. A
periosteal elevator is used to lift the anterior palate mucosal
flaps (Fig. 4B). If the cleft of the hard palate is unilateral,
the noncleft side is incised at the junction of the vomer and
the hard palate. The hard palate flaps are dissected in a
subperiosteal plane, avoiding damage to the bone. Abnormal attachments of the levator palati muscle to the
posterior border of the hard palate are divided with
tenotomy scissors (Fig. 4D). The tensor aponeurosis is

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Cleft PalateCraniofacial Journal, May 2011, Vol. 48 No. 3

FIGURE 4 Bardach two-flap palatoplasty. A: Note the excision of mucosa on medial surface of uvula, incisions along the medial edge of the hard palate with
extension anteriorly to include the full extent of hard palate mucosa. B: Marcaine is injected only at proposed incision sites. Dissection of the hard palate mucosa
is from lateral to medial. C: The levator palati muscle is dissected free from posterior border of the hard palate; nasal mucosa is dissected radically along the
underside of the hard palate. D: The nasal layer of the hard palate is sutured with mattress sutures inserted on the oral side with P-2 needle. When the nasal
mucosal closure is tight at the junction of the hard and soft palate, the mucosa is released laterally. E: The soft palate muscles are freed from the nasal mucosa,

Losken et al., ACHIEVING LOW CLEFT PALATE FISTULA RATES

317

The levator palati muscle is freed from the nasal mucosa

of the soft palate, avoiding fenestration of the mucosa. If
the muscle is firmly attached to the oral layer of the soft
palate and interferes with adequate posterior mobilization
of the muscle, it is dissected free of the oral mucosa; the
muscle is moved posteriorly 20 mm (Fig. 4F). Nasal
mucosa of the hard palate is freed with a Woodson
elevator laterally for a tension-free closure (Fig. 4D).
Closure of the nasal layer is performed using 5-0 Vicryl
(P-2 needle) vertical mattress sutures; this everts the
mucosal edges and avoids nasal mucosa on the oral side
of the closure (Fig. 4D). In wider clefts, a longitudinal
releasing incision in the nasal mucosa posterior to the
greater palatine vessel may be required to allow tension-free
closure at the junction of the hard and soft palate
(Fig. 4D). Soft palate nasal mucosa is repaired with vertical
mattress sutures using a 5-0 Vicryl on a TF needle. Initial
excision of mucosa on the medial surface of the uvula
ensures easy identification of the edges for more accurate
approximation, reducing the incidence of a split uvula
(Fig. 4E). The muscle is approximated using interrupted 50 Vicryl sutures; the oral mucosa is closed with 4-0 or 5-0
Vicryl vertical mattress sutures (Fig. 4F).
The anterior-most oral mucosal suture is inserted
through both the oral mucosa and the repaired nasal layer,
fixing the oral layer to the nasal layer (Fig. 4F). The lateral
releasing incisions are closed only if they do not cause
tension of the midline closure.
Postoperative Care

FIGURE 5 Repair of bilateral complete clefts. A: The vomer is incised at

midline and extended laterally along the premaxillary segment allowing
increased mobility of the vomer flaps. B: The nasal mucosa on the hard
palate is repaired with vertical mattress sutures on the oral side. If the repair
at the junction of the hard and soft palates is tight, bilateral releasing
incisions in the nasal mucosa are made.

released and freed from the superior constrictor muscle.

The greater palatine vessels are skeletonized (Fig. 4C) to
allow tension-free medialization of the mucoperiosteal
flaps. The hamulus is not fractured, and the palate does
not require an osteotomy at the greater palatine foramen.

Following palate repair, the infant is admitted to the

hospital overnight and hydrated with D5 Ringer lactate at
a maintenance rate. Pedialyte is offered to the child in a
sippy cup (without ball valve) and followed by formula or
milk and level II baby food. Diet restrictions remain in
place for 2 weeks. Arm splints are used to eliminate elbow
flexion, preventing the child from inserting fingers and
objects into his or her mouth and are worn for 2 weeks. All
children are given Keflex elixir for 5 days postoperatively.
At 2 weeks, the child is examined in the clinic. If the healing
process is favorable, the arm splints are discontinued, and
the diet is liberalized. The child is then seen at 1 month by
the operating surgeon and again at 4 months by
craniofacial team members including plastic surgery,
otolaryngology, and speech pathology.
RESULTS
Among the 126 patients, 20 had associated syndromes.
According to the Veau classification, there were 17 Veau I

r
and as needed, from the oral layer, and sutured to each other in a posterior position, consistent with normal anatomy. Vertical mattress sutures are inserted into
the uvula. F: The soft palate is repaired with alternating mattress and simple sutures over the muscle; the remainder is reapproximated with mattress sutures.
Note that the final anterior suture of the hard palate includes the nasal mucosa.

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Cleft PalateCraniofacial Journal, May 2011, Vol. 48 No. 3

TABLE 3

Consecutive Palate Repairs Performed Between 2001 and 2005 (n = 126) and Occurrence of Fistulas Following Furlow Repair*

Veau Classification

No. of Repairs

Fistulas, no. (%)

Furlow Z-plasty

I
II
III
IV
Total

17
51
38
20
126

0
0
2.6
5
1.6

11
25
0
0
36

Fistulas, no. (%)

0
0
0
0
0

(0)
(0)
(0)
(0)
(0)

* There were 17 Veau I clefts, 51 Veau II clefts, 38 Veau III clefts, and 20 Veau IV clefts. Using the Furlow repair, principally in Veau I and II patients, there were no fistulas.

clefts (clefts limited to the soft palate; seven of these

patients had submucous cleft palates), 51 Veau II (clefts of
hard and soft palates), 38 Veau III (unilateral complete
clefts), and 20 Veau IV clefts (bilateral complete clefts)
(Table 3). Cleft width exceeded 11 mm in 15 patients: two
were 12 mm, three were 14 mm, six were 15 mm, two were
17 mm, one was 18 mm, and one was 20 mm.
Two of 126 (1.6%) patients developed anterior palate
fistulas following palatoplasty. In one additional Veau III
patient, where a VWK procedure was performed, a fistula
posterior to the incisive foramen caused by the palate
pushback was noted (Fig. 6). In this patient, there was
complete healing of the palate flaps to the most anterior
aspect of the flaps, and this was not included as a palate
fistula. Of the two fistulas, one was in a patient with a Veau
III cleft who had a VWK repair and the second in a patient
with a Veau IV cleft who had a Bardach two-flap
palatoplasty.
The VWK pushback procedure was used in 16 patients at
the beginning of the study. One (6.25%) of these patients
developed a palate fistula at the anterior hard palate, and
the technique was no longer used. One (2.1%) patient with a
Bardach repair developed an anterior hard palate fistula
(Table 4). In the last 94 patients, no fistulas were noted.
The status of the uvula was recorded in 59 of 126
patients. Of these, 2 of 59 developed split uvulas (3.4%).

FIGURE 6 A palate fistula of anterior hard palate, posterior to the incisor

foramen. Note the complete healing of the palate flaps. Consequently, this
was not considered a complication of the palate repair.

None of the patients developed hematoma or infection.

None of the patients had to be taken back to the operating
room for postoperative bleeding.
Surgical Procedures
Furlow double-opposing Z-plasty was performed in 36
patients, four of whom required lateral releasing incisions
(Fig. 1A). There were 15 von Langenbeck repairs and 68
two-flap palatoplasties. Of the two-flap palatoplasties, 16
were of the VWK type and 48 were Bardach two-flap
palatoplasties, where no pushback was performed.
Resident Participation in Cleft Palate Repair
All palate repairs were performed with resident participation. The educational goal of each surgery was to teach
residents how to perform the operation and, under careful
supervision, to have the resident perform half the surgery.
The attending surgeon made the markings and dissected
one side and the resident then dissected the second side.
During closure, the attending surgeon and resident
alternated placement of sutures.
DISCUSSION
Multiple factors have been identified as contributing to
the development of palate fistulas, including type of cleft
(with width of cleft often directly related to the type of
cleft), cleft width (the wider the cleft, the more likely a
fistula), type of repair, number of cases performed by the
operating surgeon (the fewer cases performed, the higher
the fistula rate), and timing of repair.
Muzaffar et al. (2001) reported an 8.7% incidence of
palate fistulas in 103 patients. One fistula was at the
junction of the hard and soft palates and eight were located
within the hard palate. All fistulas occurred in Veau III
and IV clefts, suggesting that more extensive clefts are
associated with higher fistula rates. Musgrave and Bremner
(1960) reported on 780 cleft palate repairs performed from
1950 to 1959; these authors noted a 5% fistula rate in
unilateral clefts and a 12.5% fistula rate in bilateral clefts.
Similarly, Lindsay (1971) reported a 16% fistula rate in
unilateral clefts and 23% fistula rate in bilateral clefts in 60
patients. A higher fistula rate is to be expected after repair
of bilateral cleft palates as compared with unilateral cleft

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TABLE 4

319

Veau Classification and Occurrence of Fistulas Following VWK, Bardach, and von Langenbeck Repairs*

Veau

Von Langenbeck

Fistulas, no. (%)

Straight Line/VWK

I
II
III
IV
Total

3
12
0
0
15

0 (0)
0 (0)
0 (0)
0 (0)
0

3
3
10
4
20

Fistulas, no. (%)

0
0
1
0
1

(0)
(0)
(10)
(0)
(5.0)

Bardach 2-flap

0
11
28
16
48

Fistulas, no. (%)

0
0
0
1
1

(0)
(0)
(0)
(6.25)
(2.1)

* One fistula was present following a Veau-Wardill-Kilner (VWK) repair in a Veau IV patient, and the second was noted following a Bardach two-flap palatoplasty in a Veau III patient. No
fistulas were noted following von Langenbeck repair.

palates and incomplete clefts of the soft palate. In this

series, we report one palate fistula in 38 unilateral complete
clefts (2.6%) and one in 20 bilateral complete clefts (5%).
More direct evidence of cleft width playing a role in the
incidence of palate fistula is provided in a recent study that
suggests a statistically significant increase in fistula rate
when cleft width is $15 mm and that a ratio of the cleft
width to the sum of the width of the palatal shelves of $.48
is associated with fistula formation (Parwaz et al., 2008).
Location of palate fistulas is predictably either at the
junction of the hard and soft palates or at the anterior hard
palate (Musgrave and Bremner, 1960). Amaratunga (1988)
noted that 42% of the fistulas were at the junction of the hard
and soft palates. This location is problematic because it is
generally the widest portion of a cleft, and it is associated
with the greatest tension for both the nasal and oral mucosal
layer closures. Keys to avoiding fistulas in this region are a
two-layer, tension-free closure. This may require lateral
release of the nasal layer on the underside of the hard palate
for nasal layer closure and skeletonization of the vascular
pedicle to minimize tension on the oral layer closure.
Fistulas in the anterior hard palate are best avoided by
careful suturing techniques. In our repairs, the anteriormost suture on the hard palate mucosa incorporates both
the oral and nasal layer. Bardach described suturing the
oral and the nasal mucosa together along the full length of
the hard palate (Bardach, 1999), but this may be
unnecessarily time consuming.
The type of procedure performed for palate repair may
also lead to differences in fistula rates. Cohen et al. (1991)
reported a 23% fistula rate in 129 patients. In stratifying
rates of fistula by technique, these authors noted a 43%
fistula rate following VWK procedures, 10% following
Furlow repairs, and 22% following von Langenbeck
procedures (Cohen et al., 1991). Amaratunga (1988)
reported a 21% fistula rate in 346 cleft patients. He found
that von Langenbeck repair resulted in more palate fistulas
than the VWK method of repair, contradicting the findings
in Cohen and colleagues paper. Our institutional review of
palate repairs from 1996 to 2001 suggested a high fistula
rate associated with Furlow repairs: 48% in Veau II
patients, 41% in Veau III patients, and 87.5% in Veau IV
patients (Table 1). Subsequently, we limited Furlow repairs
to narrower clefts (,8 mm), with no fistulas identified in 36
Furlow repairs. In clefts of intermediate width (5 to 7 mm),
either a Furlow double-opposing Z-plasty or a von

Langenbeck repair was used. In wider clefts ($8 mm) a

two-flap palatoplasty was used. We believe that the key to
this repair algorithm lies in a tension-free midline closure of
the palate.
Experience of the operating surgeon has been found to be
a factor in the development of palatal fistulas (Cohen et al.,
1991). This particular study examined the fistula rates of
four surgeons: One had a 63% fistula rate; whereas, the
remaining three had fistula rates of 18%, 15%, and 14%,
respectively. The surgeon with the highest fistula rate
performed only 15% of the cleft palate repairs, suggesting
that the more occasional cleft surgeon will have a higher
incidence of fistulas. In this series, patients operated on by
a senior (W.H.L.) and junior (J.A.v.A.) craniofacial
surgeon were included; fistula rates were similar when
comparing the two surgeons.
Reports of the relationship between timing of palate
repair and fistula rates show mixed results. Some studies
have suggested that earlier repair may decrease fistula rates.
Rohrich et al. (1996) reported on a longitudinal cohort of
patients in whom a two-stage palate repair was performed;
those whose hard palate closure was performed at
10 months of age had a 5% fistula rate compared with a
fistula rate of 35 % when palate repair was delayed until
48 months. Van Demark et al. (1989), who followed a
cohort of patients whose soft palates were repaired at
18 months and hard palates at 5 years of age, noted no hard
palate fistulas, thereby suggesting that delayed repair of the
palate may lead to decreased fistula rates. With improved
speech results noted in earlier repairs of the palate and an
uncertain effect on fistula rates based on timing of repair,
most cleft practitioners would argue in favor of earlier
repair of the palate (Rohrich et al., 1996; La Rossa, 2000).
The palate repairs reported in this series were performed
at a teaching hospital with residents performing half of
each of the cleft palate operations. To date, there have been
no studies examining resident level of participation in
outcomes after palate repair. Given the fact that residents
perform as much as half of a particular operation, it would
be expected that fistula rates would be higher when palate
procedures are performed in an academic setting. Our
fistula rate of 1.6% suggests that the same standard of
excellence as in private practice (Wilhelmi et al., 2001) can
be achieved in an academic setting with residents performing half the palatoplasty. Our goal at the outset of the study
was to perform 100 palate repairs without a fistula; in this

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Cleft PalateCraniofacial Journal, May 2011, Vol. 48 No. 3

we failed, but no palate fistulas were noted in the last 94

patients.
The relative weighted contribution to fistula formation
by level of surgical expertise and the technique used for
palate repair is an intertwined argument. Both clearly
contribute to fistula formation (inexperience and choice of
inappropriate technique). Some experienced surgeons,
using a single technique, manage to anticipate and avoid
the pitfalls of that particular technique and report a low
fistula rate. Others use the same technique and note
excessive fistula formation. Choice of a particular technique alone does not guarantee avoidance of fistulas, but
must go hand in hand with adherence to particular
principles of repair, which include tension-free closure of
the nasal and oral layers, particularly at the junction of the
hard and soft palates. Whether using a Furlow or Bardach
two-flap palatoplasty technique, if closure of either the
nasal or oral layers is performed with tension, the
possibility of fistula increases.
Our own institutional review suggested that Furlow
repairs were associated with a high fistula rate. However,
some authors have reported a low fistula rate using only the
Furlow repair (Losee et al., 2008). The key pitfall to this
technique is tension at the junction of the hard and soft
palates (and hence an increased likelihood of fistula
formation), which is avoided by incorporating a layer of
Alloderm in the nasal layer repair, thereby eliminating
tension. Other surgeons have exclusively used a two-flap
palatoplasty technique with low reported fistula rates
(Wilhelmi et al., 2001; Salyer et al., 2006). We accept that
surgeons with extensive cleft experience may be able to use
any of several surgical techniques with good outcomes. We
recommend, however, that less experienced surgeons
should consider doing the Bardach two-flap palatoplasty
for wider clefts (including complete unilateral and bilateral
clefts), and reserving the Furlow repair for narrower clefts
(,8 mm wide at the posterior border of the hard palate).
CONCLUSIONS
Our experience delineates one of the lowest overall fistula
rates (1.6%) following palate repair reported in the
literature. This has been accomplished at a tertiary-care
academic setting with plastic surgery residents doing up to
half the cleft palate repair. This suggests that residents can
actively contribute to palatoplasty with a very low fistula
rate. We recognize that avoiding fistulas is a combination
of choosing an appropriate technique, and as important,
adhering to careful maneuvers at particular junctions
during the palate repair. These key junctures are tensionfree closure of both the nasal and oral mucosal layers (by
completely freeing the nasal layer from the underside of the
hard palate and skeletonization of the neurovascular
pedicle), aggressive midline recruitment of muscle with an
intravelar veloplasty technique, and meticulous two-layer

mattress-suture closure extending into the area of the

alveolar cleft. We recommend Furlow repair for narrower
clefts (,8 mm wide at the posterior border of the hard
palate) and the Bardach two-flap palatoplasty for wider
clefts. This plan is strongly recommended for less experienced surgeons and is safe for experienced cleft surgeons.
Acknowledgment. The authors would like to thank Justin Woodlief, a
first year medical student at the University of North Carolina, Chapel
Hill, for his work on the illustrations.

REFERENCES
byholm FE, Borchgrevink HK, Eskeland G. Palatal fistulae following
A
cleft palate surgery. Scand J Plast Reconstr Surg. 1979;13:295300.
Agrawal K, Panda KN. Use of vomer flap in palatoplasty: revisited. Cleft
Palate Craniofac J. 2006;43:3037.
Amaratunga NA. Occurrence of oronasal fistulas in operated cleft palate
patients. J Oral Maxillofac. Surg. 1988;46:834838.
Bardach J. Two-flap palatoplasty: Bardach technique. In: Bardach J, ed.
Atlas of Craniofacial and Cleft Surgery. Vol. 2. Philadelphia:
Lippincott-Raven Publishers; 1999:692736.
Bardach J, Morris H, Olin W. Late results of primary veloplasty: the
Marburg Project. Plast Reconstr Surg. 1984;73:207215.
Cohen SR, Kalinowski J, La Rossa D, Randall P. Cleft palate fistula: a
multivariate statistical analysis of prevalence, etiology and surgical
management. Plast Reconstr Surg. 1991;87:10411047.
Furlow LT. Cleft repair by double-opposing Z-plasty. Plast Reconstr
Surg. 1986;78:724736.
Kuehn DP, Folkins JW, Cutting CB. Relationship between muscle
activity and velar position. Cleft Palate J. 1982;19:2535.
La Rossa D. The state of the art of cleft palate surgery. Cleft Palate
Craniofac J. 2000;37:225228.
Lindsay WK. Von Langenbeck palatoplasty. In Grabb WC, Rosenstein
FW, Bzoch KR, eds. Cleft Lip and Palate. Boston: Little, Brown;
1971:392403.
Losee JE, Smith DM, Afifi AM, Jiang S, Ford M, Vecchione L, Cooper
GM, Naran S, Mooney MP, Serletti JM. A successful algorithm for
limiting postoperative fistulae following palatal procedures in the
patient with orofacial clefting. Plast Reconstr Surg. 2008;122:544554.
Musgrave RH, Bremner JC. Complications of cleft palate surgery. Plast
Reconstr Surg. 1960;26:180189.
Muzaffar A, Byrd HS, Rohrich RJ, Johns DF, LeBlanc D, Beran SJ,
Anderson C, Papaionnou A. Incidence of cleft palate fistula: an
institutional experience with two-stage palate repair. Plast Reconstr
Surg. 2001;108:15151518.
Parwaz MA, Sharma RK, Parashar A, Nanda V, Biswas G, Makkar S.
Width of cleft palate and postoperative palatal fistulado they
correlate? J Plast Reconstr Aesthet Surg. 2009;62:155963.
Rohrich RJ, Rowsel AR, Johns DF, Drury MA, Grieg G, Watson DK,
Godfrey AM, Poole MD. Timing of hard palate closure: a critical longterm analysis. Plast Reconstr Surg. 1996;98:236246.
Salyer KE, Sng KWE, Sperry EE. Two-flap palatoplasty: 20-year
experience and evolution of surgical technique. Plast Reconstr Surg.
2006;118:193204.
Wardill WEM. Technique of operation for cleft palate. Br J Surg.
1937;25:117119.
Wilhelmi BJ, Appelt EA, Hill L, Blackwell SJ. Palatal fistulas: rare with
two-flap palatoplasty repair. Plast Reconstr Surg. 2001;107:315318.
Van Demark DR, Gnoinski W, Hotz MM, Perko M, Nussbaumer H.
Speech results of the Zurich approach in the treatment of unilateral
cleft lip and palate. Plast Reconstr Surg. 1989;83:605621.