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Objective: This retrospective study investigated the influence of palatal fistula (PF) formation after double opposing Z-plasty (DOZ) on speech outcomes in patients with cleft palate (CP), focusing on cleft width and palatal length as predictors of velopharyngeal insufficiency (VPI)., Methods: This study included 1117 patients with CP (579 males, 538 females) who underwent DOZ, performed by a single surgeon, between 1988 and 2017. Demographic characteristics, cleft dimensions, history of PF formation, and speech outcomes were investigated. Speech evaluations were performed at a minimum age of five to assess nasal emission, hypernasality, compensatory articulation, intelligibility, necessity for VPI surgery, and speech therapy. Logistic regression analysis was performed., Results: Speech assessments were conducted at the median age of five (interquartile range [IQR], 5-6 years). Overall, 96.5% of patients achieved 'socially acceptable speech' after DOZ. Patients with PF history showed greater cleft width and experienced higher rates of hypernasality, nasal emission, and VPI on videofluoroscopy (VFS) compared to those without PF history (mean, 11.4 mm vs. 7.1 mm; 28.4% vs. 23.6%; 34.8% vs. 14.9%, 38.5% vs. 14.0%, 40.6% vs. 28.3%, respectively; all p < 0.0001). Cleft width was significantly associated with VPI-related speech outcomes in the multivariate logistic regression analysis, affecting both perceptual and VFS-measured outcomes., Conclusions: A wider CP gap significantly increased the risk of VPI-related speech difficulties after DOZ. Cleft width is a more critical predictor of adverse speech outcomes than the presence of small-to-medium-sized PFs. Patients with a history of PF and wider cleft gaps require targeted interventions and intensified follow-up to effectively manage and improve speech outcomes., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objectives: Oronasal fistulas are common sequelae following cleft lip and palate surgery and can significantly impact a patient's quality of life. They result from various factors, including surgical techniques, tissue management, and patient-specific factors. This case report explores the modern approach to oronasal fistula closure using periodontal plastic surgery principles., Materials and Methods: The report presents two cases of patients with oronasal fistulas due to previous maxillofacial surgical intervention. These patients underwent microsurgical procedures that involved partial flap thickness preparation of the fistula areas, the use of connective tissue grafts from the palate, and meticulous suturing techniques to ensure graft integrity. The procedures were performed in stages, and postoperative care was provided., Results: Both cases demonstrated successful fistula closure and graft survival. The patients reported improvements in breathing, speech, aesthetics, and quality of life. The second case also included guided bone regeneration and implant placement., Conclusions: Oronasal fistulas resulting from maxillofacial surgery can be effectively treated using periodontal plastic surgery techniques, significantly improving patients' quality of life and aesthetic outcomes. This approach represents a valuable addition to the existing repertoire of oronasal fistula closure methods., (© 2024 The Author(s). Clinical and Experimental Dental Research published by John Wiley & Sons Ltd.)

Recurrent rhinorrhoea that occurs chronically, needs to consider the possibility of a fistula in the nasal cavity, which has the potential to form a rhinolith. We report the case of a 39-year-old man with complaints of recurrent rhinorrhoea since four years ago, accompanied by thick secretions, symptoms of post-nasal drips, and olfactory disturbances. The patient had a history of removing the left upper molar (molar I), which causes a fistula in the tooth extraction site, making it more likely for food and drink to enter the left nasal cavity. Anterior rhinoscopy examination revealed a white mass in the left inferior meatus and a purulent odour discharge. In addition, there were gingival defects of the first molar teeth, multi-sinusitis, and nasal septum deviation. Rinolith extraction was performed using functional endoscopic sinus surgery, submucosal resection, and repair of gingivo-nasal defects with rotational flaps. Follow-up for one week showed that the flap was in place and there were no complications.

Introduction: Fistula formation and velopharyngeal insufficiency (VPI) are complications of cleft palate repair that often require surgical correction. The goal of the present study was to examine a single institution's experience with cleft palate repair with respect to fistula formation and need for surgery to correct velopharyngeal dysfunction., Methods: Institutional review board approval was obtained. Patient demographics and operative details over a 10-year period were collected. Primary outcomes measured were development of fistula and need for surgery to correct VPI. Chi-square tests and independent t tests were utilized to determine significance (0.05)., Results: Following exclusion of patients without enough information for analysis, 242 patients were included in the study. Fistulas were reported in 21.5% of patients, and surgery to correct velopharyngeal dysfunction was needed in 10.7% of patients. Two-stage palate repair was associated with need for surgery to correct VPI (P = 0.014). Furlow palatoplasty was associated with decreased rate of fistula formation (P = 0.002) and decreased need for surgery to correct VPI (P = 0.014)., Conclusion: This study reiterates much of the literature regarding differing cleft palate repair techniques. A 2-stage palate repair is often touted as having less growth restriction, but the present study suggests this may yield an increased need for surgery to correct VPI. Prior studies of Furlow palatoplasty have demonstrated an association with higher rates of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be due to the use of the Children's Hospital of Philadelphia modification. This study suggests clinically superior outcomes of the Furlow palatoplasty over other techniques., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The aim of palatoplasty is to create a functional palate to achieve normal speech, while minimizing post-operative complications. This study aimed to compare the long-term outcomes of modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ) and conventional Furlow palatoplasty (conventional-DOZ) performed in a single center., Methods: A retrospective review of consecutive patients who underwent Furlow palatoplasty between May 2007 and March 2014 was executed. Non-syndromic patients subjected to palatoplasty prior to 24 months of age and followed-up until at least 9 years of age were included., Results: A total of 196 small-DOZ and 280 conventional-DOZ palatoplasty patients were included in this study. Overall, 14 patients (2.9%) developed oronasal fistula, and 40 patients (8.4%) received velopharyngeal insufficiency (VPI) surgery. In comparisons, oronasal fistula rate was significantly higher in conventional-DOZ (0.5% vs. 4.6%, p = 0.01), and the VPI prevalence was not significantly different (9.2% vs. 7.9%, p = 0.62). Patients who developed fistula had a significantly higher likelihood of developing VPI than patients without oronasal fistula (50.0% vs. 7.1%, respectively; p < 0.01), with an odds ratio of 13.0., Conclusion: Both modalities of palatoplasty yielded commendable velopharyngeal function in the long-term follow-up. The small-DOZ with reduced tension lowered the risk of oronasal fistula., Competing Interests: Conflicts of interest statement No conflicting relationship exists for all authors., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background and Purpose: Anterior palatal reconstruction using vomer flaps has been described during primary cleft lip repair. In this procedure, the mucoperiosteal tissue of the vomer is elevated to reconstruct the nasal mucosa overlying the cleft of the hard palate. Here the authors, evaluate the efficacy of a technique in which a superiorly based vomer flap is sutured to the lateral nasal mucosa. The authors assess vomer flap dehiscence rates and compare the likelihood of fistula development in this cohort to patients who underwent palatoplasty without vomer flap reconstruction., Methods: A retrospective chart review was conducted of all palatoplasties performed by the senior author at an academic institution during a 7-year period. Medical records were reviewed for demographic variables, operative characteristics, and postoperative complications up to 1 year following surgery. Logistic regression analysis was conducted to assess the effects of vomer flap reconstruction on fistula formation, adjusting for age and sex., Results: Fifty-eight (N=58) patients met the inclusion criteria. Of these, 38 patients (control group) underwent cleft palate reconstruction without previous vomer flap placement. The remaining 20 patients underwent cleft lip repair with vomer flap reconstruction before palatoplasty (vomer flap group). When bilateral cases were counted independently, 25 total vomer flap reconstructions were performed. Seventeen of these 25 vomer flap reconstructions (68%) were completely dehisced by the time of cleft palate repair. In the vomer flap group, 3 of the 20 patients (15%) developed fistulas in the anterior hard palate following the subsequent palatoplasty procedure. In the control group, only 1 of the 38 patients (2.6%) developed a fistula in the anterior hard palate. There was no significant association between cohorts and the development of anterior hard palate fistulas [odds ratio=10.88, 95% confidence interval (0.99-297.77) P =0.07], although analysis was limited by low statistical power due to the small sample size., Conclusions: In our patient population, anterior palatal reconstruction using a superiorly based vomer flap technique was associated with complete dehiscence in 68% of cases. Fistula formation in the anterior hard palate was also proportionately higher following initial vomer flap reconstruction (15% versus 2.6%). These results prompted the senior author to adjust his surgical technique to 1 in which the vomer flap overlaps the oral mucosa. While follow-up from these adjusted vomer flap reconstruction cases remains ongoing, early evidence suggests a reduced requirement for surgical revision following implementation of the modified technique., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

A 6-year-old neutered male mixed-breed dog underwent curative-intent surgical resection of a hard palatal multilobular osteochondrosarcoma and closure of the defect using bilateral buccal mucosal flaps. However, failure of the flaps resulted in a massive hard palatal defect that was subsequently repaired using a haired skin angularis oris axial pattern flap. This report describes the clinical outcome using this surgical approach and novel complications encountered. Key clinical message: The haired skin angularis oris axial pattern flap appears to be a suitable and robust option for reconstruction of large palatal defects., (Copyright and/or publishing rights held by the Canadian Veterinary Medical Association.)

Background: Traditionally, patients undergoing free flap reconstruction for oral cavity defects have been given nothing by mouth for 6-14 days post-operatively due to concern for orocutaneous fistula development., Methods: Multiple databases were screened for studies assessing the rate of orocutaneous fistula formation in early (≤5 days) versus late (>5 days) feeding groups following oral cavity free flap reconstruction. Fixed- and random-effects meta-analyses were used., Results: One randomized controlled trial, one prospective cohort, and three retrospective cohort studies were included. The early feeding group displayed no significant increase in orocutaneous fistula formation (RD = -0.02, p = 0.06) or free flap failure (RD = -0.01, p = 0.39), with a significantly shorter hospital length of stay (mean difference [days] = -2.43, p < 0.01)., Conclusions: While further prospective trials are necessary, initiation of oral intake before post-operative day 5 may be appropriate in properly selected patients following oral reconstruction., (© 2024 Wiley Periodicals LLC.)

Background: Palate, a midface bone, shapes the face and supports buttresses. Palatine process of maxilla and horizontal plate of palatine bone constitute it. Palatal bone is thicker anteriorly and laterally than posteriorly and centrally. Palatal fractures occur with maxillary fractures. Palatal-maxillary fractures occur 8-46.4% of the time.2,5 Palatal fractures can cause palatal ecchymosis in closed fractures and lacerations of upper lip, palatal mucosa, incisor tooth loss, or occlusal disruption in displaced fractures. The objective was to determine the surgical outcome of palatal fractures with locking plates as external fixator vs. alveolar plating in terms of frequency of oronasal fistula formation., Methods: A Randomized control trial was carried out in Department of Oral and Maxillofacial surgery, Pakistan Institute of Medical Sciences, Islamabad. between 14th July, 2017 to 14th July, 2018. Lottery split patients into groups A and B. Data was collected on designed questionnaire and was entered and analyzed using SPSS v22. Chi-square was applied to check the association., Results: A total of 130 patients were enrolled in the trial based on the predefined inclusion criteria. The average age of participants in the research was 41.16 years with a standard deviation of 10.44. Of the total participants, 88 (67.7%) were male and 42 (32.3%) were female, as per the inclusion criteria. The occurrence rate of oronasal fistula development in both groups, namely palatal fractures treated with locking plates as an external fixator vs alveolar plating, was 1 (1.5%) and 7 (10.8%) respectively. This difference was found to be statistically significant with a p-value of 0.029., Conclusions: Osteosynthesis using 2.0 mm locking plates as external fixator had a lower rate of oronasal fistula than alveolar plating. Future investigations at numerous configurations are needed to determine which approach is best. such that a regular strategy will reduce infection, fistula development, and necrosis afterwards.

Objective: Presurgical nasoalveolar molding (PNAM) is widely used in cleft care protocol. This study investigated the correlation between PNAM and oronasal fistula after primary palatoplasty., Methods: A case-controlled study of 80 unilateral and bilateral complete cleft palate patients who underwent cleft palate repair were enrolled. Patients were divided into 2 groups: (1) no PNAM use and (2) PNAM use. The incidence of oronasal fistula and postoperative complications were compared between groups., Results: Forty patients in each group demonstrated the same baseline characteristics. The PNAM group showed a significantly lower postoperative oronasal fistula rate (15% versus 50%, P =0.003). Palatal cleft width wider than 12.5 mm increases the odds ratio of fistula formation by 1.19-fold ( P =0.037), and the PNAM protected against postoperative palatal fistula formation (odds ratio 0.20, P =0.003)., Conclusion: Presurgical nasoalveolar molding can reduce postoperative oronasal fistula in wide-gap Veau type III and IV cleft palate., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Oronasal fistula at the anterior hard palate is one of the common sequelae after cleft surgery, and the leakage negatively affects the patient's quality of life. Although several surgical techniques have been proposed for reconstruction, it remains challenging because of the scarred regional tissue with a high rate of fistula recurrence. In this study, we present the anterior oronasal fistula repair using a two-flap technique with an interpositional dermofat graft (DFG)., Methods: A retrospective review of anterior oronasal fistula repair performed by the senior author between April 2018 and August 2022 at the Craniofacial Center was conducted. Patients who underwent a fistula repair using the technique were further identified and investigated., Results: Thirty-four operations were performed using the technique, and 31 fistulas were completely closed, with a success rate of 91.2%. The fistula symptom improved but persisted postoperatively in 3 patients, of whom 2 patients underwent a second fistula repair using the same procedure, resulting in successful closure. Fistula recurrence was significantly correlated with fistula size (p = 0.04). The DFG was simultaneously utilized for nasal dorsum and/or vermillion reconstruction in 28 cases., Conclusion: The two-flap technique enabled tension-free approximation, and the interpositional DFG facilitated watertight closure of the fistula, resulting in a high success rate of anterior oronasal fistula repair. The fistula closure could be combined with other revisional procedures for cleft-related deformities, where the DFG was simultaneously utilized., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Cleft palate is the most common congenital orofacial defect in dogs. Although this topic has been extensively studied in experimental dogs, current literature on clinical patients is limited to case reports and small case series studies with many individual opinions based on experience. This narrative review summarizes the literature of the last 10 years with application to clinical practice, focusing on the preparation of the patient until surgery, options for surgical management, and perioperative complications. Surgical treatment must be performed to obtain separation between the nasal/nasopharyngeal and oral/oropharyngeal passages. This will allow the dog to have independent function and reduce clinical signs associated with food, water, and other foreign material entering the respiratory tract. Surgical treatment has good to excellent outcomes when the procedure is carefully planned and appropriately executed despite the high rates of postoperative oronasal fistula reported.

Background: Surgical treatment is recommended for patients with symptomatic submucous cleft palate once velopharyngeal insufficiency has been proven. This study describes the procedure and clinical outcomes of minimally invasive intravelar veloplasty., Methods: From August 2013 to March 2017, seven patients (median age, 36 months; range, 16-60 months, 5 females and 2 males) with submucous cleft palate underwent intravelar veloplasty. Neither a nasal mucosal incision nor a lateral relaxing incision was applied. Follow-up was performed at least twice: once at three weeks postoperatively and again between two and three years postoperatively (average, 31 months; range, 26-35 months). Speech was assessed by speech-language pathologists when the patients were at least 3 years old., Results: There were no cases of oronasal fistula or noticeable disturbance of facial development. All seven patients showed no or mild hypernasality and air emission and competent or at least borderline competent velopharyngeal function., Conclusion: Intravelar veloplasty could serve as another option for managing submucous cleft palate with velopharyngeal insufficiency, resulting in satisfactory improvement in velopharyngeal function. Because neither a lateral nor a nasal incision was used, the burden of facial growth and risk of oronasal fistula can be minimized., Competing Interests: Declaration of competing interest No potential conflicts of interest relevant to this article are reported., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: To explore the incidence of postoperative complications and investigate the impact of preselected factors on functional and quality of life outcomes following the Sommerlad-Furlow modified palatoplasty technique., Study Design: Retrospective cohort., Methods: A total of 429 patients with cleft palate, who received Sommerlad-Furlow modified technique between 2011-2017 were enrolled. The postoperative complications including oronasal fistula (ONF), velopharyngeal insufficiency (VPI), and inadequate quality of life (QOL) were collected. Data of preselected factors including gender, age at palatoplasty, cleft type, cleft width, palatal width, pharyngeal cavity depth, and operation duration were also collected., Results: Among 429 patients, 40.1% were males whereas 59.9% were females. The mean age at palatoplasty was 1.23 ± 0.69 (0.42-4) years, and the average cleft width was 10.15 ± 2.95 (4-27) mm. The cleft types had recorded rates of about 6.8%, 69.5%, 17.7%, and 6.1% of Veau I, II, III, and IV, respectively. The overall incidence rates of ONF, VPI, and inadequate QOL were 2.3%, 19.4%, and 31.3%, respectively. In both the univariate and multivariate analyses, the cleft type was significantly implicated in ONF formation (p = 0.023 and 0.032, respectively) whereas the velopharyngeal function was impacted by the palatoplasty age (p ˂ 0.001). The receiver operating characteristic curve indicated that age of palatoplasty ≥1.3 years (area under the curve = 0.611, p = 0.002) was the cutoff value for predicting the incidence of VPI., Conclusions: The Sommerlad-Furlow modified technique appears to have appropriate postoperative outcomes, even in the wide cleft palate. The older age at palatoplasty has a major impact on the overall postoperative outcomes., Level of Evidence: 4 Laryngoscope, 133:822-829, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Oronasal fistula following cleft palate repair is a considerable complication with a recurrence rate of 33% to 37% and remains a challenging problem for surgeons. Furthermore, many patients have undergone several operations and experienced scar problems and other forms of morbidity. Therefore, we report a multilayered technique for oronasal fistula closure using an endoscopic nasal inferior turbinate composite graft with a palatal advance flap. This will increase the success rate after closure of small-sized oronasal fistula surgery without complications or recurrence (IRB: 2020-1671-0001).

Summary: Large or multiply recurrent oronasal fistulas following cleft palate repair present a challenging problem. Nasal septal mucoperichondrial flaps have been widely used for repair of skull base defects; however, their use in the repair of oronasal cleft palate fistulas has not previously been described. In this pilot study, the authors describe anterior palatal fistula repair using a nasal septal flap and review their experience with this technique over 4 years. Fourteen patients with anterior palatal fistulas not amenable to repair using local palatal flaps were included for analysis. The mean size of the fistula was 12 mm in maximum dimension. Flap healing with complete or near-complete closure of fistula was achieved in 13 patients (93%). Five of these patients had a small, slit-like residual fistula that was asymptomatic. Nasal septal flaps are a new technique for repair of large or recurrent palatal fistulas. The procedure is well-tolerated with minimal side effects, high success rate, and low incidence of recurrence., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Objective: Orocutaneous fistula (OCF) after reconstruction for oral cavity resection can lead to prolonged hospitalization and adjuvant treatment delay. Few studies have examined factors leading to OCF after oral cavity resection. Primary objective: evaluate overall incidence and factors associated with OCF after oral cavity reconstruction., Data Sources: Scopus 1960-database was searched for terms: "orocutaneous fistula," "oro cutaneous fistula," "oral cutaneous fistula," "orocervical fistula," "oral cavity salivary fistula.", Review Methods: English language studies with >5 patients undergoing reconstruction after oral cavity cancer resection were included. About 1057 records initially screened; 214 full texts assessed; 78 full-texts included. PRISMA guidelines were followed, and MINORS criteria used to assess risk of bias. Data were pooled using random-effects model. Primary outcome was OCF incidence. Meta-analysis to determine the effect of preoperative radiation on OCF conducted on 12 eligible studies. Pre-collection hypothesis was that prior radiation therapy is associated with increased OCF incidence. Post-collection analyses: free versus pedicled flaps; mandible-sparing versus segmental mandibulectomy., Results: Seventy-eight studies were included in meta-analysis of overall OCF incidence. Pooled effect size showed overall incidence of OCF to be 7.71% (95% CI, 6.28%-9.13%) among 5400 patients. Meta-analysis of preoperative radiation therapy on OCF showed a pooled odds ratio of 1.68 (95% CI, 0.93-3.06). OCF incidence was similar between patients undergoing free versus pedicled reconstruction, or segmental mandibulectomy versus mandible-sparing resection., Conclusion: Orocutaneous fistula after oral cavity resection has significant incidence and clinical impact. Risk of OCF persists despite advances in reconstructive options; there is a trend toward higher risk after prior radiation.

Background: The buccal fat flap is an encapsulated mass originating from a specific fat tissue that is easily accessed and richly vascularized. The aim of this study was to report the effect of using the buccal fat flap on the oronasal fistula rate in primary palatoplasty., Methods: A case-controlled study of 94 patients who underwent primary cleft palate repair. Patients were divided into two groups: (1) two-flap palatoplasty with buccal fat flap for coverage of lateral hard palate defect and (2) conventional two-flap palatoplasty. The incidence of oronasal fistula and postoperative complications were compared between groups. Multivariate analysis was performed to determine the risk factors of oronasal fistula development., Result: Forty-seven patients in each group demonstrated the same baseline characteristics. The buccal fat group showed a significant lower postoperative oronasal fistula rate (2.13 percent versus 21.28 percent, p = 0.008) and smaller fistula size (2 mm versus 4 mm, p = 0.049). A cleft width wider than 11.5 mm increased the odds ratio of fistula formation by 8.44-fold (p = 0.047), and the use of buccal fat protected against postoperative palatal fistula formation (OR, 0.08, p = 0.019)., Conclusion: The use of buccal fat flaps for lateral hard palatal defect coverage in primary palatoplasty can reduce the rate of postoperative palatal fistula, especially in cases of wide palatal cleft., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Oronasal fistulas are sequelae to periodontal disease in dogs. Previous case series have described the use of auricular cartilage as a type of membrane to help with surgical repair of oronasal fistulas. This case series explores the use of a commercially available flexible bone membrane in the surgical repair of ten acquired oronasal fistulas in dogs. The use of the flexible bone membrane did not necessarily improve the surgical outcomes in these cases; however, larger controlled trials are necessary to further evaluate its use.

Fistula recurrence is high after secondary follow-up operation to close the fistula after primary palatal surgery. Therefore, preventing fistula recurrence is important. Here, we describe the technique of closing palatal fistula after palatal surgery with a buccal fat graft in 2 cases. We elevate the mucosal flap around the palatal fistula, suture the nasal mucosa, transplant the buccal fat between the nasal and oral mucosa for the palatal fistula after palatal surgery, and suture the oral mucosa. Palatal fistula did not recur after surgery. This method is simple and useful for suturable fistula and does not require a local flap.

Different cleft palate repair techniques have been described to achieve optimum results and minimise complications. Postoperative fistulae are one of the most challenging complications after palate repair. In this clinical study, we reviewed the records of patients who underwent palatoplasty using acellular dermal matrix (ADM) as an addition to facilitate difficult cleft palate and palatal fistula closure. It was a retrospective, comparative, single-centre study, in which records of patients who underwent cleft palate surgeries between 2015 and 2018 were reviewed. Patients who underwent cleft palate or palatal fistula repair with and without ADM were included. Fischer's exact test was used to compare the two groups (primary cleft palate repair with and without ADM) in relation to the rate of fistula occurrence postoperatively. Charts of a total of 31 patients were reviewed. ADM was used in 13 patients; 8(61.5%) were primary repairs and 5(38.5%) were fistula repairs. Eighteen patients were repaired without ADM, of whom 16(88.9%) were primary cleft palate repairs and 2(11.1%) were fistula repairs. The statistical analysis showed no significant difference in fistula formation rate or recurrence in both the groups. ADM is a simple, safe, and helpful tool for augmenting cleft palate repair, mainly in relatively wide and high-tension cleft palate repairs. In our study, a trend showing decreased complications with ADM was observed. Therefore, we recommend a multi-centre study with a larger sample to assess the significance of ADM in cleft palate and palatal fistulae repair.

The aim of primary palatoplasty is to achieve optimum speech with minimal morbidity. Symptomatic fistulae are well-recognised complications of palatoplasty and may require additional surgical intervention, increasing the burden of care. Our aims were to better understand fistula experience in our unit and compare fistula rates between an established consultant and a newly appointed training interface group (TIG) trained consultant. Post-operative fistulae were prospectively and independently recorded by Cleft Clinical Nurse Specialists as part of routine 6-week post-operative reviews. Cleft type and intra-operative hard-soft palate junction (HSPJ) width were prospectively recorded by operating surgeons. Data were collated and analysed using Microsoft Excel. Between 1 January 2014 and 31 December 2018, 250 primary palatoplasties were performed. The overall fistula rate was 8% (0% SMCP, ICP 7%, UCLP 8%, BCLP 22%). Fistulae clustered in clefts with a mid-range HSPJ width of 12-16 mm. Numerically, fistula rates remained similar over time despite increased unit activity (doubling of primary surgeries in 2017 and 2018). There was no significant difference in fistulae rates between surgeons (P > 0.05). Overall fistulae rate compared favourably with published data. TIG fellowships were designed in the context of cleft surgery to address issues relating to steep operative learning curves. These data demonstrate that results from a newly appointed TIG-trained surgeon are comparable to that of an established TIG-trained surgeon. Data also suggest surgeons should be aware of the risk of fistulae in the mid-range palatal defect and in HSPJ widths of 12-16 mm., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose of Review: The aim of this article is to present the current opinion on the prevention and management of oronasal fistulas in cleft palate patients., Recent Findings: Though cleft palate repair has seen numerous modifications and improvements, oronasal fistulas remain one of the most common complications of palatoplasty. There are various techniques available for preventing and managing this complication., Summary: Oronasal fistulas can be minimized by employing proper principles for palatoplasty. Once a fistula occurs, the repair technique should be appropriate for the fistula type. Oronasal fistula classifications, various repair techniques, tissue adjuncts, and biomaterials used in both the primary palate repair and oronasal fistula repair are discussed in this review., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: While the formation of a palatal fistula after septoplasty has been reported previously, it is a rare occurrence, especially in a patient with a normal palate. In most of the previous reports, the palatal fistulas were located on the hard palate and associated with various underlying conditions. Here, we present a case of soft palate fistula which developed in a patient with a normal palate after septoplasty. The 20-year old woman complained of liquid regurgitation after her septoplasty procedure. A pin-point size fistula opening was observed on the soft palate. A shallow depression was identified at the junction between the hard and soft palate by a computed tomography scan done before surgery. The fistula was subsequently repaired through a palatal flap. After surgery, the defect was completely closed, and the patient had no more symptoms. In addition, we review the previously reported cases of palatal fistula after septoplasty., Competing Interests: The author reports no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Objectives/hypothesis: To assess the incidence of palatal fistula after primary repair of the cleft palate among two cohorts of Otolaryngologist-Head and Neck Surgeons and to identify patient and surgeon characteristics that may predict fistula development., Study Design: Retrospective case series with chart review., Methods: Children who underwent primary repair of cleft palate at one of two multidisciplinary cleft centers over a 10 year period were identified. Charts were reviewed for the presence of palatal fistula; chi square test and multivariate logistic regression analysis were performed to determine variables associated with fistula formation., Results: From 2007 to 2017, 477 patients underwent primary repair of cleft palate by one of 6 Otolaryngologist-Head and Neck Surgeons. Twenty-four children had incomplete charts, allowing 453 patients to be included in the final analysis. The pooled mean incidence of palatal fistula was 6.6% (P = .525) and varied significantly by cleft type. Logistic regression analysis controlling for multiple variables, showed that Veau IV classification had the highest risk of fistula (OR = 10.582; P = .004). Repair by a specific surgeon was not a significant risk factor for fistula development (P > .07 for each surgeon)., Conclusions: Among six Otolaryngologist-Head and Neck Surgeons with fellowship training in cleft palate repair postoperative fistula rates were consistent and compared favorably to standards in the Cleft and Craniofacial surgery literature established by other surgical specialties. Consistent with larger database studies involving multiple surgical specialties, Veau IV classification was the strongest predictor of palatal fistula development, even after adjusting for multiple variables, including differing levels of experience., Level of Evidence: 4 Laryngoscope, 131:1281-1285, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Background: Oronasal fistula (ONF) is a common complication following cleft palate surgery. This study aims to determine the prevalence of ONF and the factors that influence development of ONF following primary palatoplasty., Materials and Methods: There were 234 patients undergoing primary palatoplasty during 2012 to 2016 included in this cross-sectional study. Patient demographics, surgeon's experience, age at the time of primary palatoplasty, cleft type by Veau classification, cleft width, and operative technique were recorded. The prevalence of fistulae was the primary outcome. Association of age at the time of repair, cleft type, cleft associated with syndromes, cleft width, and surgeon's experience with fistula rate were secondary outcomes., Results: There were 234 consecutive patients (128 boys [54.7%] and 106 girls [45.3%]). The mean age at primary palatoplasty was 13 months. Oronasal fistulae occurred in 61 (26.07%) patients. There was a statistically significant association between postoperative oronasal fistulae and the following independent variables: Veau classification (adjusted odds ratio 2.1; 95% confidence interval [CI] = 1.45-3.1, P < 0.01), cleft associated with syndromes (adjusted odds ratio 4.76; 95% CI = 1.48-15.2, P < 0.01) and cleft width more than 11.5 mm (adjusted odds ratio 1.96; 95% CI = 1.00-3.85, P = 0.04)., Conclusion: The overall number of fistulae was moderate in patients who had undergone primary palatoplasty in our center. Cleft severity as defined by the Veau classification, cleft width, and cleft associated with syndromes were predictive factors for development of postoperative fistulae., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Summary: Large oronasal palatal fistulas can be challenging to reconstruct. The authors present a modified buccal myomucosal flap repair technique and review intermediate-term outcomes. In this technique, large anterior palatal fistulas are closed in two layers. First, apposing nasal turnover flaps of vomer mucosa medially and nasal wall mucosa laterally are approximated. Second, a posteriorly based buccal flap incorporating full-thickness buccinator muscle and overlying mucosa is transposed with interposition of the flap in the retromolar trigone and lateral palate to preserve dental occlusion. Consecutive patient cases performed in low-resource settings were reviewed and outcomes reported. Among eight subjects aged 3 to 22 years, with average defect size of 2.5 cm2 (range, 0.8 to 3.5 cm2), the flap was viable in all cases and required revision or pedicle division in only two patients (25 percent); all patients showed symptom improvement. The modified buccal myomucosal flap shows promising intermediate-term results as a single-stage reconstruction suitable to a wide patient age range, low airway/anesthetic risk, reliable functional outcomes, and low comorbidity., Competing Interests: Disclosure:The authors have no financial or nonfinancial conflicts of interest to disclose., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Objective: To assess risk factors for oronasal fistula, including 2-stage palate repair., Design: Retrospective analysis., Setting: Tertiary children's hospital., Patients: Patients with non-submucosal cleft palate whose entire cleft repair was completed at the study hospital between 2005 and 2013 with postsurgical follow-up., Interventions: Hierarchical binary logistic regression assessed predictive value of variables for fistula. Variables tested for inclusion were 2 stage repair, Veau classification, sex, age at surgery 1, age at surgery 2, surgeon volume, surgeon, insurance status, socioeconomic status, and syndrome. Variables were added to the model in order of significance and retained if significant at a .05 level., Main Outcome Measure: Postoperative fistula., Results: Of 584 palate repairs, 505 (87%) had follow-up, with an overall fistula rate of 10.1% (n = 51). Among single-stage repairs (n = 211), the fistula rate was 6.7%; it was 12.6% in 2-stage repairs (n = 294, P = .03). In the final model utilizing both single-stage and 2-stage patient data, significant predictors of fistula were 2-stage repair (odds ratio [OR]: 2.5, P = .012), surgeon volume, and surgeon. When examining only single-stage patients, higher surgeon volume was protective against fistula. In the model examining 2-stage patients, surgeon and age at hard palate repair were significant; older age at hard palate closure was protective for fistula, with an OR of 0.82 ( P = .046) for each additional 6 months in age at repair., Conclusions: Two-stage surgery, surgeon, and surgeon volume were significant predictors of fistula occurrence in all children, and older age at hard palate repair was protective in those with 2-stage repair.

Purpose: Oronasal fistulas (ONFs) have been the most common complication of primary cleft palatoplasty. The present study evaluated the incidence of ONFs after primary standard Furlow and modified Furlow palatoplasty and a buccal fat pad flap (BFPF) as a viable tissue layer to facilitate wound healing., Patients and Methods: A retrospective cohort study was conducted. The data from all the patients who had met the criteria for primary palatoplasty from 2003 to 2016 and had undergone surgery by a single surgeon were retrospectively reviewed from an established cleft databank. An initial group of patients (2003 to 2007; standard Furlow palatoplasty) and a subsequent group (2008 to 2016; modified Furlow palatoplasty), all of whom had received the BFPF, were evaluated. The primary outcome variable was the development of palatal fistula. An additional outcome predictor included single versus staged palatoplasty. A χ 2 analysis using a 1-tailed Fisher exact test was used, with statistical significance established at P ≤ .05 to determine the difference in ONF development using different operative techniques., Results: A total of 49 patients had undergone standard Furlow palatoplasty, with an ONF rate of 22.4%. Of the 49 patients, 28 had had isolated cleft palate (ICP; 6 ONFs), 12 had had unilateral cleft lip/palate (UCLP; 2 ONFs), 9 had had bilateral cleft lip/palate (BCLP; 3 ONFs). A total of 65 patients had undergone modified Furlow palatoplasty with a BFPF, with a total ONF rate of 3%. Of the 65 patients, 40 had had ICP (1 ONF), 18 had had UCLP, and 7 had had BCLP (1 ONF). This difference in the ONF rate was statistically significant (P = .0015). The staged repairs resulted in an ONF rate (22.6%) that was significantly greater (P = .029) than the rate with nonstaged repairs (7.1%). The occurrence of ONFs tended to be greater in the patients with BCLP, syndromic patients, after staged repairs, and patients with wide cleft defects., Conclusions: A reduced ONF rate appeared to be associated with the modified Furlow palatoplasty and single-stage palatoplasty. Among the cleft types, BCLP showed a tendency to an increased postoperative ONF rate., (Copyright © 2020 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Palate fistula is the most frequent complication following palatoplasty. The objectives of this study were: to describe the most widely used repair techniques; to study results and recurrence rate; to analyze potentially predictive recurrence variables; and to assess whether a specific technique is superior according to fistula size and location., Materials and Methods: Retrospective study of patients undergoing palate fistula repair in 7 healthcare facilities from 2008 to 2018. All facilities had at least 20 new cases of cleft lift and palate annually (range: 20-80), with a fistula incidence of 14% (range: 1.5-20%). Minimum follow-up was 1 year. 8 variables were collected for statistical analysis purposes., Results: 234 fistula patients underwent surgery. Most fistulas occurred in complete bilateral cleft lift and palate (Veau type IV). The most frequent location was the hard palate (Pittsburgh types IV and V (63.2%)), and fistulas were mostly large (42.1%) and medium (39.5%). The most frequent repair technique was re-palatoplasty (34.2%). Recurrence rate was 22%. The multivariate analysis demonstrated more recurrences in re-palatoplasty repaired type III fistulas in patients over 3 years old., Conclusion: A tendency towards using flap repair in large hard palate fistulas, re-palatoplasty in medium hard palate and soft and hard palate junction fistulas, and local flaps or re-palatoplasty in small fistulas at any location was observed. However, it could not be statistically demonstrated whether a specific repair technique was superior in different clinical situations.

Purpose: The aim of this study was to evaluate the effect of buccal fat pad (BFP) in the palatoplasty and to investigate the risk factors associated with postoperative palatal fistula formation., Materials and Methods: Sixty-five cleft palate patients were enrolled for this study. Clinical data regarding sex, age, type of cleft, surgical technique, the ratio of cleft width, and BFP graft were collected. The ratio of cleft width was measured and calculated using preoperative clinical photographs. In 36 patients, the BFP was harvested and grafted on the cleft palate to prevent palatal fistula formation. The patients were followed up, the incidence of fistula formation was investigated, and the risk factors related with the fistula were evaluated., Results: Four patients had postoperative palatal fistula and were not BFP grafted during operation. The BFP graft and ratio of cleft width are significant factors in palatal fistula formation (P = .035, .003). There was a significant difference in the ratio of cleft width between the normal and fistula groups (P = .006). In the logistic regression analysis, there was significant association between high ratio of cleft width and palatal fistula formation in the no BFP group (odds ratio; 11.15, P = .036)., Conclusions: The ratio of cleft width and BFP graft was a significant factor in palatal fistula formation. The BFP graft is a reliable procedure to prevent palatal fistula formation and increase the success of palatoplasty.

Closure of large oronasal fistula (ONF) in cleft patients is a challenge for patients and surgeons. The extent of functional impairment has psychologic, social, and developmental consequences. The ONF affects the feeding and speech of patients. Keys to repairing fistulas in this region are a 2-layer, tension-free closure, and an attentive suturing technique. In this article, the details and effectiveness of 2-flap palatoplasty are presented.

The incidence of postoperative fistula following primary cleft palate repair ranges from 0% to 58%. The reported recurrence rate is between 33% and 37%, and the prognosis of a successful closure declines with each reoperation. Closure of palatal fistulas can be achieved by different techniques depending on its size and the experience of the surgeon. Local, regional and distant flaps are commonly used. Alternatively, or in addition to the previous ones, synthetic materials are becoming very popular nowadays. However, a scarcity of articles explains in detail a simple and effective method in children. We present a case report and the procedure proposed by our pediatric surgery team consisting of a three-layered repair, with a collagen membrane placed over the reconstructed nasal mucosa, and a rotational palatal mucosa flap reinforced with a fibrine sealant. This method is simple, easy to reproduce, effective and has a low rate of complications., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Orocutaneous fistula (OCF) is one of the frequently encountered postoperative complications following surgery for oral cancer, leading to prolonged hospital stay and delay in the initiation of adjuvant therapy., Methods: We included all patients with oral cancer operated between January 2016 to December 2017 and at risk to develop an OCF. We assessed the incidence of OCF, its management, and factors predisposing to its development., Results: Of 587 eligible patients, 9% developed OCF. On univariate and multivariate analysis, patients undergoing bilateral neck dissection or with surgical site infection (SSI) (P < .001) were at maximum risk. On univariate analysis, the incidence was higher following resections for tongue-floor of mouth sub site (P = .002), irrespective of the type of flap used for reconstruction. Majority (57%) required surgical intervention for management., Conclusion: The presence of SSI and performing bilateral neck dissection posed the maximum risk for developing OCF in patients undergoing surgery for oral cancer., (© 2019 Wiley Periodicals, Inc.)

The purpose of this study was to evaluate a single center's experience with adult patients who had cleft lip, cleft palate, or both. The authors aimed to identify common long-term needs in this patient population and evaluated the relationship of team-based care in meeting those needs. To do so, the authors retrospectively reviewed chart records from a single private practice and tertiary referral cleft center for all patients who were ≥15 years of age and who had a history of clefts of the lip or palate, or both, from January 1, 2013, to June 30, 2014. The authors compared the concerns of the patients who received cleft-team-based care by a single, multidisciplinary cleft team; multiple multidisciplinary cleft teams; or no formal cleft team. The authors analyzed data for 142 patients. The most common patient concerns were lip aesthetics (64%), nose aesthetics (61%), septal deviations (47%), nasal obstruction (44%), malocclusion (32%), oronasal fistulas (29%), and speech (21%). Oronasal fistulas were more commonly reported in the group of patients who had care by multiple teams (42.9%; P < .001). Malocclusion was more commonly reported in the group of patients who had care by multiple teams (50%; P = .001). The authors found that adult patients who have undergone rehabilitation for cleft lip and palate appear to have a common set of long-term needs. Multidisciplinary cleft-team-based care appears to be the most effective way to address these needs.

Objectives: This study was designed to determine the incidence of velopharyngeal insufficiency (VPI), oronasal fistula development and facial grimace in patients seen by Isfahan Cleft Care Team (ICCT) after primary Sommerlad intravelar veloplasty (SIVV). Furthermore the association of gender, cleft type and age at primary surgery with the incidence of hypernasality and fistula is determined., Methods: A group of 40 patients with history of cleft palate with or without cleft lip were identified from the records of ICCT between 2011 and 2014. The main outcome measures were the incidence of hypernasality and fistula after primary palate repair with SIVV. Speech recordings were analyzed by consensus by two speech therapists according to the Cleft Audit Protocol for Speech- Augmented (CAPS-A), (Kappa = 82.4). Deciding whether or not to have a fistula was based on the oral examination videos., Results: Severe and moderate hypernasality was observed in 42.5% of patients. Normal resonance and mild/borderline hypernasality was observed in 37.5% and 20% of patients, respectively. The frequency of fistulas was 7.5%. There was a significant association between hypernasality with cleft type and the age at primary surgery (p < 0.05)., Conclusion: Significant progress has been made in the outcomes of the primary palate surgeries with the SIVV technique compared to the previous study in the ICCT., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Previous attempts at reporting oronasal fistula development and secondary speech surgery following cleft palate surgery have been limited to single-center case series. This limitation can be overcome by querying large databases created by health care governing bodies or health care alliances. The authors examined the effect of cleft type and demographic variables on the clinical outcomes., Methods: Data from the Pediatric Health Information System database were queried for patients, aged 6 to 18 months, who had undergone primary palatoplasty between 2004 and 2009. Subsequent repair of an oronasal fistula and/or secondary speech surgery between 2004 and 2015 was identified by procedure codes. Logistic regression models were used to assess the associations between cleft type with oronasal fistula and with secondary speech surgery., Results: Seven thousand three hundred twenty-five patients were identified, and 6.4 percent (n = 468) had a subsequent repair of an oronasal fistula and 18.5 percent (n = 1355) had a secondary speech operation. Adjusted for age, sex, and race, patients with cleft lip and palate have increased odds of oronasal fistula (OR, 5.60; 95 percent CI, 4.44 to 7.07) and secondary speech surgery (OR, 2.32; 95 percent CI, 2.05 to 2.63)., Conclusions: Using a large, multi-institution billing database, the authors were able to estimate the prevalence of oronasal fistula and surgically treated velopharyngeal insufficiency following primary palatoplasty in the United States. In addition, the authors demonstrated that patients with isolated cleft palate develop fewer oronasal fistulas and require less secondary speech surgery than patients with cleft lip and palate., Clinical Question/level of Evidence: Risk, III.

Objective: The objective of this study was to compare the surgical outcome between 2 patient groups with complete unilateral cleft lip and palate who underwent different types of palatoplasty., Methods: This is a cohort study between 2 groups of patients with complete unilateral cleft lip and palate who were operated using different surgical techniques from 2008 to 2011. About 28 patients were operated using a primary lip nose repair with vomer flap for hard palate single-layer closure and delayed soft palate repair (modified Oslo protocol) and 32 patients were operated using our protocol in Lima. Data collection was accomplished by evaluation of symptomatic oronasal fistulas, presence of velopharyngeal insufficiency and evaluation of dental arch relationships (scored using the 5-year-olds' index)., Results: Our comparative study observed statistically significant differences between the 2 groups regarding the presence of oronasal fistulas and velopharyngeal insufficiency in favor of our palatoplasty technique. A statistically significant difference was not found in functional vestibular oronasal fistula development between the studied techniques for unilateral cleft palate repair. This comparative study did not observe significant differences in dental arch relationships between the studied techniques., Conclusion: In this study, better surgical outcome than modified Oslo protocol regarding oronasal fistulas and velopharyngeal insufficiency on patients with complete unilateral cleft lip and palate was observed. The results arising from this study do not provide evidence that one technique is enough to obtain better functional closure of the alveolar cleft and dental arch relationship at 5 years.

Background: Humanitarian surgical organizations provide palatoplasties for patients without access to surgical care. Few organizations have evaluated the outcomes of these trips. This study evaluates the palatal fistula rate in patients from two cohorts in rural China and one in the United States., Methods: This study compared the odds of fistula formation among three cohorts whose palates were repaired between 2005 and 2009. One cohort included 97 Chinese patients operated on by teams from the United States and Canada under the auspices of Resurge International. They were compared to cohorts at Huaxi Stomatology Hospital and the University of California San Francisco (UCSF). Age, fistula presence, and Veau class were compared among cohorts using Chi-square tests. Logistic regression was used to analyze predictors of fistula formation., Results: The fistula risk was 35.4% in patients treated by humanitarian teams, 12.8% at Huaxi University Hospital and 2.5% at UCSF ( P < 0.001). Age and Veau class were associated with fistula formation (Age P = 0.0015; Veau P < 0.001). ReSurge and Huaxi patients had 20.2 and 5.6 times the odds of developing a fistula, respectively, compared to UCSF patients ( P < 0.01, both). A multivariable model controlling for surgical group, age, and gender showed an association between Veau class and the odds of fistula formation., Conclusions: Chinese children undergoing palatoplasty by international teams had higher odds of palatal fistula than children treated by Chinese surgeons in established institutions and children treated in the United States. More research is required to identify factors affecting complication rates in low-resource environments.

Objective: Oronasal fistula is an important complication of cleft palate repair that is frequently used to evaluate surgical quality, yet reliability of fistula classification has never been examined. The objective of this study was to determine the reliability of oronasal fistula classification both within individual surgeons and between multiple surgeons., Design: Using intraoral photographs of children with repaired cleft palate, surgeons rated the location of palatal fistulae using the Pittsburgh Fistula Classification System. Intrarater and interrater reliability scores were calculated for each region of the palate., Participants: Eight cleft surgeons rated photographs obtained from 29 children., Results: Within individual surgeons reliability for each region of the Pittsburgh classification ranged from moderate to almost perfect (κ = .60-.96). By contrast, reliability between surgeons was lower, ranging from fair to substantial (κ = .23-.70). Between-surgeon reliability was lowest for the junction of the soft and hard palates (κ = .23). Within-surgeon and between-surgeon reliability were almost perfect for the more general classification of fistula in the secondary palate (κ = .95 and κ = .83, respectively)., Conclusions: This is the first reliability study of fistula classification. We show that the Pittsburgh Fistula Classification System is reliable when used by an individual surgeon, but less reliable when used among multiple surgeons. Comparisons of fistula occurrence among surgeons may be subject to less bias if they use the more general classification of "presence or absence of fistula of the secondary palate" rather than the Pittsburgh Fistula Classification System.

Background: Fistulas following cleft palate repair impair speech, health, and hygiene and occur in up to 35 percent of cases. The authors detail the evolution of a surgical approach to palatoplasty; assess the rates, causes, and predictive factors of fistulas; and examine the temporal association of modifications to fistula rates., Methods: Consecutive patients (n = 146) undergoing palatoplasty during the first 6 years of practice were included. The technique of repair was based on cleft type, and a common surgical approach was used for all repairs., Results: The fistula rate was 2.4 percent (n = 125) after primary repair and 0 percent (n = 21) after secondary repair. All complications occurred in patients with type III or IV clefts. Cleft width and cleft-to-total palatal width ratio were associated with fistulas, whereas syndromes, age, and adoption were not. Most complications could also be attributed to technical factors. During the first 2 years, modifications were made around specific anatomical features, including periarticular bony hillocks, maxillopalatine suture, velopalatine pits, and tensor insertion. The fistula rate declined by one-half in subsequent years., Conclusions: The authors describe a surgical approach to cleft palate repair, its evolution, and surgically relevant anatomy. Fistulas were associated with increasing cleft severity but could also be attributed to technical factors. A reduction in frequency and severity of fistulas was consistent with a learning curve and may in part be associated with modifications to the surgical approach., Clinical Question/level of Evidence: Therapeutic, IV.

Orocutaneous fistula sometimes occurs in locallyadvanced unresectable or recurrent oral squamous cell carcinoma. The developed orocutaneous fistula results in constant leakage of saliva, ingested foods and liquids and decline in patients' quality of life(QOL). A 47-year-old Japanese man had received treatment for tongue carcinoma. At the routine follow-up, a cystic lesion in the right submandibular region was detected. Biopsyof the specimen of the cystic lesion revealed squamous cell carcinoma. After chemotherapy, an orocutaneous fistula between the right oropharyngeal and the right submandibular region developed and graduallyincreased. Although closure and dressing of the orocutaneous fistula with various materials was attempted, it was ultimatelyunsuccessful. Finally, application of a rubber film and silicone adhesive agent to the skin was successful for closure and dressing of the fistula. Orocutaneous fistula is one of major contributors to decline in patients' QOL. The sharing of information regarding effective methods or materials for closure and dressing of orocutaneous fistula is necessaryto maintain patients' QOL.

Reconstruction of pharyngocutaneous fistula (PCF) or orocutaneous fistula is always a challenging task. It has many causes and is especially related to radiation therapy after resection of head and neck cancers. There are many reports of surgical procedures for fistula repair. For example, 2-stage methods, methods of combining multiple flaps, and methods of using chimeric flaps have been reported. However, there is no established simple method as a treatment of choice. The authors describe 5 patients of head and neck fistulas and recommend a useful 1-stage reconstruction method using a double skin paddle free flap.The authors modified the free flaps simply with a double skin paddle sharing 1 pedicle. The skin paddle of the flap was split into 2 parts, one skin island for inner mucosal coverage, and the other for outer skin resurfacing. The bridge between the 2 skin paddles was deepithelialized and then folded. To prevent leakage, a water-tight closure was ensured.The double skin paddle free flap method was used in 5 patients. Two patients had orocutaneous fistula, and the other 3 patients had PCF due to irradiation. Flap losses did not occur, but wound dehiscence was noted in the 3 PCF patients. Repeat wound revision procedures were performed in these patients, and the end result was good.Conventional methods are complex and require multiple flaps or repeat surgery. However, the double skin paddle free flap method allows for simple and effective 1-stage reconstruction using 1 flap, 1 pedicle, and 1 microanastomosis even for patients who received preoperative radiotherapy.

This study was performed to investigate the incidence of and risk factors for postoperative cleft relapse and oronasal fistula after Furlow palatoplasty in infants. Sixty-two infants with cleft palate, aged 6-12 months (mean 8.25 months), who underwent cleft repair by Furlow double opposing Z-plasty between March 2012 and August 2014, were enrolled in the study. Risk factors for postoperative cleft relapse and oronasal fistula after Furlow palatoplasty were identified by logistic regression analysis. The incidence rates of cleft relapse at 1 week and oronasal fistula at 3 months after surgery were 24.2% (15/62) and 9.7% (6/62), respectively. Among all of the variables screened, only the width of the cleft was significantly associated with the incidence of postoperative cleft relapse (P=0.001) and oronasal fistula (P=0.011); the incidence rates were positively correlated with the width of the cleft when it exceeded 6.8mm and 7.5mm, respectively. Based on these findings, in order to reduce the incidence of postoperative cleft relapse and oronasal fistula, Furlow repair is not recommended for patients with wide clefts. An appropriate angle between the Z-flap incision and the central axis, use of a bilateral relaxation incision, and postoperative nursing care can help reduce the incidence of postoperative cleft relapse., (Copyright © 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)