PEDIATRIC/CRANIOFACIAL

A Successful Algorithm for Limiting Postoperative

Fistulae following Palatal Procedures in the
Patient with Orofacial Clefting
Joseph E. Losee, M.D.
Darren M. Smith, M.D.
Ahmed M. Afifi, M.D.
Shao Jiang, M.D.
Matthew Ford, M.S., C.C.C.,
S.L.P.
Lisa Vecchione, D.M.D.,
M.D.S.
Gregory M. Cooper, Ph.D.
Sanjay Naran, B.S.
Mark P. Mooney, Ph.D.
Joseph M. Serletti, M.D.
Pittsburgh, Pa.
Background: Palatal procedures include (1) primary palatoplasty, (2) oronasal
fistulas repair, and (3) secondary palatoplasty for velopharyngeal insufficiency.
Any time a palatal procedure is performed, postoperative fistulas remain po-
tential consequences. Presented here is a successful algorithm for performing
palatal procedures and decreasing the rate of postoperative fistulas in a large,
single-surgeon, consecutive series.
Methods: A retrospective review of all consecutive palatal procedures per-
formed between 2002 and 2006 including (1) primary palatoplasty, (2) oronasal
fistulas repair, and (3) secondary palatoplasty for velopharyngeal insufficiency
was performed. Cleft Veau type, surgical technique, and outcomes are reviewed.
The algorithm included (1) relaxing incisions, (2) complete intravelar velo-
plasty, (3) total release of the tensor tendon, (4) dissection of the neurovascular
bundle with optional osteotomy of the foramen, and (5) incorporation of
acellular dermal matrix to achieve complete nasal lining reconstruction.
Results: Two hundred sixty-eight palatal procedures were performed: (1) 132
primary Furlow palatoplasties yielding one symptomatic post–Furlow palato-
plasty fistula (0.76 percent) (acellular dermal matrix was used in 39.4 percent
of primary palatoplasties); (2) 55 oronasal fistula repairs yielding two symp-
tomatic postoperative fistulas (3.6 percent) (acellular dermal matrix was used
in 90.9 percent of fistula repairs); and (3) 81 secondary palatoplasties for
velopharyngeal insufficiency resulting in no postoperative fistulas. Acellular
dermal matrix was used in 14.8 percent of secondary palatoplasties for velo-
pharyngeal insufficiency. No recommendations for speech surgery followed
palatoplasty.
Conclusions: Using the proposed algorithm in this single-surgeon consecutive
series of 268 cases, the authors achieved the lowest reported incidence of
postoperative fistulas in all forms of palatal procedures, including the lowest
incidence (0.76 percent) of symptomatic palatal fistulas following primary Fur-
low palatoplasty. (Plast. Reconstr. Surg. 122: 544, 2008.)

A
lthough the quality of speech remains the
most important metric of success in palato-
plasty,1 postoperative fistulas remain a con-
siderable challenge. Fistulas may be clinically sig-
nificant when they lead to nasal air escape, speech
distortion, hearing loss, or regurgitation of fluid
From the Division of Plastic Surgery, Children’s Hospital of
Pittsburgh, University of Pittsburgh.
Received for publication September 24, 2007; accepted Jan-
uary 2, 2008.
Presented at the 64th Annual Meeting of the American Cleft
Palate-Craniofacial Association, in Broomfield, Colorado,
April 24 through 28, 2007.
Copyright ©2008 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e31817d6223
and food.2 They may also induce velopharyngeal
insufficiency, complicating speech management
and outcome assessment.3 Fistulas are difficult to
repair definitively. The cleft palate literature sur-
rounding this recalcitrant complication is difficult
to interpret secondary to vague definitions and a
lack of standardized language addressing fistula
location and clinical significance. The incidence
of cleft palate fistulas is reported to range from 0
Disclosure: The senior author (J.E.L.) has received
educational and research funding in the past from
LifeCell Corp.

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Volume 122, Number 2 • Limiting Postoperative Fistulae
to 76 percent,4 – 6 whereas the recurrence rate of
palatal fistulas reportedly approaches 65 percent.7
Various attempts to repair and decrease the in-
cidence of postoperative palatal fistulas have been
reported.7–26 In 2003, Kirschner et al. described the
use of acellular dermal matrix in repairing palatal
fistulas.19,20 Using this concept, we developed an in-
traoperative algorithm for all palatal procedures, in-
cluding (1) primary palatoplasty, (2) oronasal fistula
repair, and (3) secondary palatoplasty for velopha-
ryngeal insufficiency to decrease the incidence of
postoperative fistulas. In this article, we outline strat-
egies, including the use of acellular dermal matrix
for primary palatoplasty,27 to decrease formation of
postoperative fistulas. In an effort to validate these
methods, we report a large, single-surgeon, consec-
utive series of palatal procedures implementing this
algorithm.
To address the literature’s ambiguity regard-
ing postoperative fistulas and to evaluate our own
results with palatal procedures, our group intro-
duced the Pittsburgh Fistula Classification System,
an anatomically based numerical classification sys-
tem for palatal fistulas.28 The Pittsburgh Fistula
Classification System includes seven fistula types
(Fig. 1): fistulas at the uvula, or bifid uvulae (type
I); within the soft palate (type II); at the junction
of the soft and hard palates (type III); within the
hard palate (type IV); at the incisive foramen, or
junction of the primary and secondary palates
(type V (this designation is reserved for use with
Veau type IV clefts); lingual-alveolar (type VI); and
labial-alveolar (type VII). This system provides
clear nomenclature that serves as a prerequisite
for meaningful discussion, ongoing research, and
evolving new treatment strategies. Application of
Fig. 1. Pittsburgh Fistula Classification System.
the Pittsburgh Fistula Classification System in
our center has prospectively clarified ambiguity
by establishing internal and external consis-
tency in reporting and has facilitated our clin-
ical research efforts.
PATIENTS AND METHODS
A retrospective review of consecutive palatal
procedures performed from 2002 to 2006 was
completed and included 268 procedures on 236
patients. All palatal procedures were reviewed, in-
cluding (1) primary palatoplasty, (2) oronasal fis-
tula repair, and (3) secondary palatoplasty for
velopharyngeal insufficiency. Veau cleft type (Fig.
2), Pittsburgh fistula type (Fig. 1), surgical tech-
nique, and outcomes, including postoperative fis-
tulas, Pittsburgh Weighted Speech Score (Table
1), and complications, were recorded in our
group’s Cleft-Craniofacial Center database. No pa-
tients were excluded from this study, despite the
severity of cleft or complicating circumstances. All
palatal procedures were performed consecutively
by a single surgeon (J.E.L.) within our academic
teaching program. Outcomes were verified by a
single surgeon and speech pathologist. Pittsburgh
fistula type VI (lingual-alveolar) and type VII (la-
bial-alveolar) were not quantified in this study, as
alveolar clefts were not consistently treated with
gingivoperiosteoplasty during the entire study pe-
riod. Statistical analyses for changes in Pittsburgh
Weighted Speech Score with palatoplasty were
performed with Wilcoxon signed ranks tests using
SPSS v15.1 (SPSS, Inc., Chicago, Ill.).
The following algorithm was used during pal-
atal procedures to ensure a two-layer, tension-free,
watertight closure: (1) relaxing incisions, (2) a
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 Plastic and Reconstructive Surgery • August 2008

Fig. 2. Veau classification of palatal clefts. (Above, left) Veau type I cleft of the soft palate.
(Above, right) Veau type II cleft of the soft and hard palates. (Below, left) Veau type III unilateral
cleft. (Below, right) Veau type IV bilateral cleft.

Table 1. Pittsburgh Weighted Speech Score

Score Interpretation
0 Competent
1–2 Borderline competent
3–6 Borderline incompetent
ⱖ7 Incompetent

complete intravelar veloplasty, (3) “total release”

of the tensor aponeurosis at the level of the ham-
ulus, (4) circumferential dissection of the greater
palatine neurovascular bundle with optional os-
teotomy of the bony foramina when necessary,
and (5) acellular dermal matrix when needed to
either augment a tenuous repair or close a defect
in the nasal lining (Figs. 3 and 4). In these in- Fig. 3. Surgical repair of a Veau type III cleft with a defect in the
stances, an ultrathin 6 to 12/1000-inch, or thin nasal lining, noted by green backing.
0.3– 0.7 mm, 2 ⫻ 4-cm piece of acellular dermal
matrix (AlloDerm; LifeCell Corp., Branchburg,
N.J.) was sewn to the nasal lining to cover the RESULTS
defect and achieve a complete nasal lining repair,
and augmenting the nasal lining repair at the junc- Primary Palatoplasty
tion of the hard and soft palates. The acellular One hundred thirty-two primary palatoplasties
dermal matrix is placed in the palate where the were performed on 66 male (50 percent) and 66
normal tensor aponeurosis would be anatomically female patients (50 percent). The population by
found in the nonclefted palate (Figs. 5 and 6). diagnosis consisted of 30.3 percent patients with

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Volume 122, Number 2 • Limiting Postoperative Fistulae
Fig. 4. Schematic illustrating a defect in the nasal lining at the
junction of the hard and soft palates during palatoplasty.
Fig. 5. Surgical repair of a Veau type III cleft with acellular dermal
matrix in white, sewn onto the nasal lining, covering the junction
of the soft and hard palates, draped over the hard palate, and
sewn anteriorly to the alveolar gingiva.
submucous cleft palate, 8.3 percent with Veau type
I clefts of the soft palate, 17.4 percent with Veau
type II clefts of the hard and soft palates, 23.5
percent with Veau type III clefts (unilateral cleft
palate), 19.7 percent with Veau type IV clefts (bi-
lateral cleft palate), and 0.76 percent traumatic
palatal injuries. Also, 92.4 percent of the pri-
Fig. 6. Schematic illustrating acellular dermal matrix noted in
yellow, sewn to the nasal lining and covering the junction of the
soft and hard palates, draped over the hard palate, and sewn to
the alveolar gingiva.
mary palatoplasties consisted of Furlow palato-
plasties, 1.5 percent consisted of straight-line pal-
ate repairs, and 3.8 percent consisted of palatal
adhesions (defined as a first-stage straight-line pal-
atoplasty without intravelar veloplasty, before sec-
ond-stage definitive conversion Furlow palato-
plasty). The average age of patients undergoing
primary palatoplasty was 3 years (range, 0.6 to 18
years). Average follow-up was 25 months (range, 2
months to 5 years). Excluding postoperative fis-
tula, there were no major complications. There
was one episode of postoperative tongue swelling
that resolved after reintubation. Acellular dermal
matrix was used in 39.1 percent of primary repairs
as follows: no Veau type I clefts of the soft palate,
13 Veau type II clefts of the soft and hard palates
(65.2 percent), 16 Veau type III unilateral clefts
(53.1 percent), and in 16 Veau type IV bilateral
clefts (73.1 percent). Of the 132 primary palato-
plasties performed, there were a total of four post-
operative fistulas (3.0 percent) (Fig. 7). Two were
asymptomatic Pittsburgh type I fistulas (bifid uvu-
lae) and two were symptomatic fistulas, for a symp-
tomatic fistula rate of 1.5 percent. The symptom-
atic fistulas included a Pittsburgh type III fistula of
the soft palate in a palatal adhesion (first-stage,
straight-line palatal procedure without intravelar
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 Plastic and Reconstructive Surgery • August 2008

Fig. 7. Pittsburgh fistula type following primary palatoplasty: type I, bifid

uvulae; type III, junction of hard and soft palates; type IV, hard palate.

veloplasty) and a Pittsburgh type IV fistula of the
hard palate (1 ⫻ 2 mm) occurring after partial
injury to a neurovascular bundle during Furlow
palatoplasty. Thus, only one symptomatic fistula
occurred after 132 primary Furlow palatoplasties,
making the rate of symptomatic fistula formation
after primary Furlow palatoplasty 0.76 percent
(Table 2).
Because of the relatively short follow-up and
young age of the cohort undergoing primary pala-
toplasty, Pittsburgh Weighted Speech Scores could
not be assessed for all patients. Seventeen nonsyn-
dromic patients have undergone standardized per-
ceptual speech evaluation following primary palato-
plasty and received Pittsburgh Weighted Speech
Scores with a median value of 1 (range, 0 to 9)
(Table 1). Of those, two palates were repaired with
acellular dermal matrix, and their postoperative
Pittsburgh Weighted Speech Scores were 0 and 9.
No recommendations for secondary speech sur-
gery have been made for any patients undergoing
primary palatoplasty.
Oronasal Fistula Repair
Fifty-five secondary oronasal fistulas repairs
were performed on 30 male patients (54.5 per-
cent) and 25 female patients (45.5 percent). The
population by diagnosis consisted of 1.8 percent
craniofacial clefts, 3.6 percent submucous cleft
palate, 3.6 percent Veau type I clefts of the soft
palate, 18.2 percent Veau type II clefts of the hard
and soft palates, 29.1 percent Veau III clefts (uni-
lateral cleft palate), and 43.6 percent Veau type IV
clefts (bilateral cleft palate). The average age of
patients undergoing oronasal fistula repair was 9.6
years (range, 1.2 to 19.2 years). Average follow-up
was 25 months (range, 2 months to 5 years). Ex-
cluding recurrent postoperative fistula, there were
no major complications. Acellular dermal matrix
was used in 90.9 percent of oronasal fistula repairs.
Six recurrent postoperative fistulas (10.9 percent)
were identified (Fig. 8). All recurrent fistulas oc-
curred in patients with initial large (ⱖ1 cm) Pitts-
burgh type V fistulas at the junction of the primary
and secondary palates in Veau type IV bilateral
clefts. Of these six recurrent fistulas, two were
symptomatic, resulting in a 3.6 percent rate of
symptomatic recurrent fistulas (Table 2). An anal-
ysis of speech in the 18 secondary palatal opera-
tions incorporating acellular dermal matrix (non-
syndromic patients for whom preoperative and

Table 2. Fistula Incidence in Primary Furlow Palatoplasty and Fistula Repair

Pittsburgh Fistula Type

1 2 3 4 5 Total Occurrence Rate (%)

Primary Furlow palatoplasty (n ⫽ 132)
Postoperatively symptomatic 0 0 0 1 0 1 0.76
Postoperatively asymptomatic 2 0 0 0 0 2 1.5
Fistula repair (n ⫽ 55)
Postoperatively symptomatic 0 0 0 0 2 2 3.6
Postoperatively asymptomatic 0 0 0 0 4 4 7.3

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Volume 122, Number 2 • Limiting Postoperative Fistulae
Fig. 8. Recurrent Pittsburgh fistula type following fistula repair. Type V fis-
tulas are those at the junction of the primary and secondary palates or at the
incisive foramen (Veau type IV clefts).
postoperative speech data were available) was not
statistically significant according to the Wilcoxon
signed ranks test (Z ⫽ ⫺1.32; p ⫽ 0.186), and an
improvement in Pittsburgh Weighted Speech
Score was noted. The median values for preopera-
tive and postoperative Pittsburgh Weighted Speech
Scores were 3 (range, 0 to 27) and 2 (range, 0 to 5),
respectively. No recommendations for secondary
speech surgery were made for any patients under-
going secondary palatal procedures in which acel-
lular dermal matrix was used.
Secondary Palatoplasty for Velopharyngeal
Insufficiency
Eighty-one secondary palatoplasties for velo-
pharyngeal insufficiency were performed on 47
male patients (58.0 percent) and 34 female pa-
tients (42.0 percent). The population by diagnosis
consisted of 3.7 percent submucous cleft palate,
5.0 percent Veau type I clefts of the soft palate,
37.0 percent Veau type II clefts of the hard and soft
palates, 32.0 percent Veau type III clefts (unilat-
eral cleft palate), and 22.2 percent Veau type IV
clefts (bilateral cleft palate). Of 81 secondary pal-
atoplasties, 76 were conversion Furlow palatoplas-
ties (93.8 percent), defined as secondary Z-plasty
palatoplasty for previous straight-line palatoplas-
ties with incomplete intravelar veloplasty and sub-
sequent velopharyngeal insufficiency. The re-
maining five secondary palatoplasties included
three double-opposing Z-plasty palatoplasties (3.7
percent) following pharyngeal flap takedown and
two straight-line palatoplasties in combination
with pharyngoplasty. The average age of patients
undergoing secondary palatoplasty for velopha-
ryngeal insufficiency was 8.1 years (range, 1.2 to
20.8 years). Average follow-up was 25 months
(range, 2 months to 5 years). There were no post-
operative complications in this cohort. Acellular
dermal matrix was used in 14.8 percent of sec-
ondary palatoplasties for velopharyngeal insuffi-
ciency. No fistulas occurred after secondary pala-
toplasties (Table 3).
Patients undergoing secondary palatoplasty for
velopharyngeal insufficiency were mature enough to
cooperate for Pittsburgh Weighted Speech Score
assignment. The Pittsburgh Weighted Speech Score
is a validated tool for assessing velopharyngeal com-
petence and is composed of five categories of per-
ceptual speech symptoms: nasal emission, facial gri-
mace, nasality, phonation, and articulation (Table
1).29 Although the individual components are qual-
itatively evaluated, the weighted, numerical compos-
ite has prognostic value allowing for quantitative
comparison between preoperative and postopera-
tive states. A statistically significant improvement was
Table 3. Secondary Procedures Incorporating
Acellular Dermal Matrix
Percentage
Procedure with ADM
Fistula repair (n ⫽ 55) 90.9
Conversion Furlow palatoplasty (n ⫽ 74) 13.5
Furlow palatoplasty with pharyngeal
flap takedown (n ⫽ 5) 40.0
Palatal adhesion (n ⫽ 1) 0.0
Straight-line repair (n ⫽ 1) 0.0
All secondary procedures (n ⫽ 136) 45.6
ADM, acellular dermal matrix.
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 Plastic and Reconstructive Surgery • August 2008

noted in Pittsburgh Weighted Speech Scores for the

35 nonsyndromic conversion Furlow palatoplasties
for which preoperative and postoperative speech
data were available: the median preoperative Pitts-
burgh Weighted Speech Score was 10 (range, 0 to
27) and the median postoperative Pittsburgh
Weighted Speech Score was 1 (range, 0 to 5) (Z ⫽
⫺4.98, p ⬍ 0.001, Wilcoxon signed ranks test). Fur-
ther speech surgery (posterior pharyngeal flap or
sphincter pharyngoplasty) was not recommended
for any patients undergoing secondary Furlow pal-
atoplasty for velopharyngeal insufficiency.

DISCUSSION
Primary Palatoplasty and Secondary Palatoplasty
for Velopharyngeal Insufficiency
Fig. 9. Intraoperative photograph of palatoplasty demonstrat-
In an effort to decrease postoperative fistulas,
ing bilateral relaxing incisions marked with white arrows and a
the authors have applied the previously described
ruler identifying the levator muscle reconstruction in the middle
algorithm equally to both primary palatoplasty
50 percent of the velum, a full 2 cm from the junction of the hard
and secondary palatoplasty for velopharyngeal in-
and soft palates.
sufficiency.

Bilateral Relaxing Incisions

Bilateral relaxing incisions of the soft and/or
hard palate were performed when necessary to
facilitate tension-free closure in the midline. Re-
laxing incisions are made in the crease formed
from the junction of the lateral buccal wall and the
soft palate, and can potentially extend from the
retromolar region of the mandible to the anterior
hard palate, allowing for adequate mobilization of
the soft palate Furlow flaps and the hard palate
mucoperiosteal flaps (Fig. 9). The space of Ernst
is gently dissected medial to the superior constric-
tor, facilitating soft-tissue mobilization.

Complete Intravelar Veloplasty

A complete intravelar veloplasty, or an inde-
pendent reconstruction of the levator muscle, is
performed routinely in both primary and second-
ary palatoplasty. To perform a complete intravelar
veloplasty, the levator muscle is initially released
from the posterior edge of the hard palate in the Fig. 10. Three abnormal attachments of the cleft levator palatini
midline. Next, it is cut free from the abnormal muscle: 1, posterior edge of the hard palate; 2, aponeurosis of the
tensor aponeurosis, seen as a flat, white, fibrous tensor veli palatini; and 3, superior constrictor.
sheet, found along the midaspect of the posterior
edge of the hard palate; and, finally, it is swept free
from the abnormal connections to the superior intravelar veloplasties are, in fact, “incomplete,” in
constrictor laterally (Fig. 10). The “complete in- that they partially release the abnormally posi-
travelar veloplasty” allows for complete mobilization tioned levator muscle from the posterior edge of
of the levator muscle from its abnormal anteropos- the hard palate in the midline only. The incom-
terior (sagittal) clefted orientation to an anatomi- plete intravelar veloplasty does not adequately free
cally correct mediolateral horizontal (coronal) ori- the levator muscle from the tensor aponeurosis or
entation. It is the authors’ contention that many superior constrictor and therefore limits its ana-

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Volume 122, Number 2 • Limiting Postoperative Fistulae
tomical reconstruction. As the incomplete intrav-
elar veloplasty addresses only the medialmost as-
pect of the levator muscle, much of the muscle
remains in the nonanatomical clefted sagittal ori-
entation. This results in less favorable muscle func-
tion, and a weakened “motor” for the velum. It is
the authors’ belief that, ultimately, speech is neg-
atively impacted, and this is borne out in the data
from secondary palatoplasty for velopharyngeal
insufficiency (conversion Furlow palatoplasty).30
Total Release of Tensor Aponeurosis
A “total release” of the tensor aponeurosis,31 or
the medial transection of the aponeurosis as it
courses medially around the hamulus32 (Fig. 11),
is performed routinely in both primary and sec-
ondary palatoplasty. The total release of the tensor
aponeurosis allows for complete mobilization and
medialization of the levator muscle and Z-plasty
flaps. Addressing the tensor aponeurosis along the
posterior edge of the hard palate only, without
completely transecting it at the medial aspect of
the hamulus, does not allow for complete mobi-
lization of the levator muscle, which is tethered by
its tendinous attachments. This total release of
the tensor aponeurosis (both at the posterior
edge of the hard palate and as it courses medially
around the hamulus) facilitates a radical retroposi-
tion of the levator muscle and allows for its anatom-
ical reconstruction in the middle 50 percent of the
velum, approximately 2 cm posterior to the junction
of the hard and soft palates (Fig. 9).33 The total
release of the tensor aponeurosis may be the single
most powerful maneuver in mobilizing the velar
Fig. 11. Intraoperative dissection of the aponeurosis of the tensor veli palatini as it courses medially around
the hamulus. The aponeurosis is divided to allow for a complete release of the levator muscle. (Left) 1, tensor
aponeurosis medial to the hamulus; 2, medial cut edge of the velar relaxing incision; 3, distalmost dentition;
4, space of Ernst just medial to the superior constrictor. (Right) Magnified view of the same photograph.
flaps, facilitating medialization of the flaps and a
tension-free closure.
Neurovascular Bundle Dissection
Dissection in the region of the greater palatine
neurovascular bundle, under loupe magnifica-
tion, is a routine part of primary and secondary
palatoplasty. With increasing complexity of the
procedure (i.e., width of palatal defect), more
complete and circumferential dissection of the
neurovascular pedicle is required. “Skeletoniza-
tion” of the neurovascular pedicle, releasing the
connective tissue in that region, allows mobiliza-
tion of the soft tissues tethering the flaps in place.
A subperiosteal dissection of the bony foramina
and osteotomy of the medial aspect of the foram-
ina allows for medial translocation of the neuro-
vascular bundle and palatal flaps. In the very rare
instances in which other methods fail to facilitate
tension-free closure, the periosteal sleeve of the
neurovascular bundle can be incised and released
onto the undersurface of the hard palate flap. This
last-ditch, risky maneuver can add additional mo-
bility and facilitate closure.
Acellular Dermal Matrix
Acellular dermal matrix can be used discrimi-
nately in primary or secondary palatoplasty; how-
ever, its use in oronasal fistula repair is essentially
routine. Acellular dermal matrix is used when a
two-layer, tension-free, water-tight repair is not
possible. In those cases, acellular dermal matrix
either augments a tenuous soft-tissue repair or
closes a defect in the nasal lining (Figs. 3 and 4).
551
 Plastic and Reconstructive Surgery • August 2008
Based on Kirschner’s experience19,20 and that of
others,27,34 –36 a thin (6 to 12/1000-inch or 0.3 to 0.7
mm), 2 ⫻ 4-cm piece of acellular dermal matrix
(AlloDerm) is sewn to the nasal lining in the re-
gion where the normal tensor aponeurosis in a
nonclefted palate would be found, achieving a
complete nasal lining repair (Figs. 5 and 6). Our
main indication for using acellular dermal matrix
in primary palatoplasty is difficulty obtaining ad-
equate two-layer closure. In Furlow palatoplasty, it
is not uncommon to experience a nasal lining
defect of approximately 1 cm2 at the junction of
the hard and soft palates where the left-sided,
anteriorly based, nasal mucosal flap cannot be
extended to reach the mucosal defect of the right-
sided posterior edge of the hard palate (Figs. 3 and
4). A 2 ⫻ 4-cm sheet of thin acellular dermal
matrix is sewn onto the nasal lining, covering the
defect as a graft to complete the nasal closure. It
is then draped over the hard palate and sewn to
the alveolar gingiva (Figs. 5 and 6). The acellular
dermal matrix is placed where the tensor aponeu-
rosis would normally be found in a nonclefted
palate, and not sewn or attached to the levator muscle
repair proper.
Although in our experience incorporating
acellular dermal matrix into palatoplasty has likely
decreased the incidence of postoperative fistulas,
this retrospective report was not designed to in-
clude an acellular dermal matrix–free control
group. Because of our free use of acellular dermal
matrix, we must compare our fistula incidence to
an analogous series. In 1999, The Children’s Hos-
pital of Philadelphia reported a series of primary
palatoplasties using a similar surgical technique—
the modified Furlow double-opposing Z-plasty.37
Moreover, the senior surgeon (J.E.L.) performing
the repairs reported in this article trained at The
Children’s Hospital of Philadelphia and uses that
institution’s palatoplasty technique. When com-
paring The Children’s Hospital of Philadelphia’s
primary post-Furlow fistula rate (6.8 percent) with
that in this series (2.5 percent), a cautious assump-
tion may point to the positive influence of acel-
lular dermal matrix on the incidence of postop-
erative fistula.
Potential disadvantages to using acellular der-
mal matrix in palatoplasty—including velar scar-
ring with speech impairment and the transmission
of infectious diseases—are likely of theoretical
concern only. Kirschner et al. demonstrated his-
tologically that acellular dermal matrix supported
the regeneration of native tissue with scarless heal-
ing of fistulas.19,20 In addition, acellular dermal ma-
trix is not sewn to the levator reconstruction but
552
placed into a relatively static portion of the velum,
the site of the normal tensor aponeurosis. Finally, in
primary and secondary palatal procedures incorpo-
rating acellular dermal matrix, we have seen positive
speech outcomes; no negative effect on speech has
been demonstrated to date. Although acellular der-
mal matrix is of cadaveric origin, it is pretreated with
multiple antipathogen measures; extensive applica-
tions in reconstructive surgery have not yielded a
report of disease transmission.38
Oronasal Fistula Repair
The palatal fistula’s clinical significance is
magnified by its propensity for recurrence. Myriad
surgical approaches to fistula repair span the re-
constructive ladder. Cauterization was described
by Obermeyer in 1967.39 Berkman designed a vinyl
appliance to guide local healing.11 Local flap op-
tions for fistula repair are numerous; the origins
of these procedures are encyclopedically reviewed
by Millard, from von Langenbeck’s 1864 turnover
hinge flap to Gabka’s 1964 V-Y advancement
flaps.22 Guerrero-Santos and Altamirano popular-
ized the tongue flap in the 1960s and 1970s.18,40
Ohsumi et al. used free conchal cartilage grafts.24
Multiple pedicle flaps (i.e., tongue flaps, facial
artery myomucosal flaps)9,14,18,40,41 and even free
tissue transfer10,13,17,21,23,24 have been described to
address this problem. Despite the wealth of cre-
ativity invested in managing the postpalatoplasty
fistula, the recurrence rate of this recalcitrant le-
sion reportedly approaches 65 percent.7
Excessive scarring is a drawback common to
many of the above-mentioned fistula repair tech-
niques. Scarring translates into disturbed palatal
dynamics and speech abnormality. Kirschner et
al. introduced acellular dermal matrix to fistula
closure,19,20 which does not seem to disturb palatal
mobility. This group demonstrated consistent repair
of oronasal fistulas created in a swine model by sand-
wiching a sheet of thin acellular dermal matrix be-
tween the oral and nasal mucosa by means of von
Langenbeck–type relaxing incisions. Histologic eval-
uation revealed the acellular dermal matrix’s re-
population by host cells and healing by tissue regen-
eration and remodeling without scarring. Next,
Kirschner et al. conducted a clinical trial in which
eight fistulas (six primary, one secondary, and one
tertiary) were treated with acellular dermal matrix;
all resolved completely.19,20
The data support the routine use of acellular
dermal matrix when addressing all oronasal fistu-
las except for Pittsburgh type I (bifid uvulae) and
type II (soft palate) fistulas; these type I and type
Volume 122, Number 2 • Limiting Postoperative Fistulae
II fistulas account for the fistula repairs that did
not receive acellular dermal matrix. The oronasal
fistula repair is approached with an initial wide
subperiosteal dissection of the oral and nasal mu-
cosa surrounding the fistula. Once this dissection
is performed, the oral and nasal linings are sep-
arated sharply in such a way as to recruit enough
tissue for a healthy oral closure. A nasal lining
repair is attempted and, despite the ability to ob-
tain a two-layer, watertight, tension-free repair,
acellular dermal matrix is used. This protocol has
decreased our recurrent symptomatic fistula rate
to 3.6 percent. In this series, the only recurrent
fistula occurred in the setting of large type IV
fistulas at the junction of the primary and second-
ary palates in Veau type IV bilateral clefts—the
most challenging of all oronasal fistulas.
Double-Opposing Z-Plasty Palatoplasty
Despite its potential to offer superior speech
results,1 many surgeons hesitate to perform the
Furlow palatoplasty because of its perceived diffi-
culty and propensity for fistulation. Although the
procedure is challenging and its imperfect appli-
cation can potentially lead to closure under ten-
sion with subsequent fistulation, meticulous tech-
nique and the following strategies can render the
Furlow palatoplasty a universal repair stoutly re-
sistant to fistulation. The lateral limb incisions of
the double-opposing Z-plasty do not directly over-
lap one another: if one incision dehisces, a layer
of tissue remains intact. Pittsburgh type II (soft
palate) and type III (junction of hard and soft
palates) fistulas are impeded by using the double-
opposing Z-plasty technique.
CONCLUSIONS
This single-surgeon consecutive series of 268
palatal procedures uses a successful algorithm for
limiting postoperative palatal fistula following (1)
primary palatoplasty, (2) oronasal fistula repair,
and (3) secondary palatoplasty for velopharyngeal
insufficiency. This study reports one of the lowest
incidence rates of postoperative palatal fistulas
(3.0 percent), and specifically symptomatic fistu-
las following primary Furlow palatoplasty (0.76
percent), seen in the literature. From this expe-
rience, we submit the following algorithm to limit
postoperative fistulas, including the use of (1) re-
laxing incisions, (2) complete intravelar velo-
plasty, (3) total release of the tensor tendon at the
level of the hamulus, (4) complete dissection of
the neurovascular bundle with optional osteotomy
of the bony foramen, and (5) incorporation of
acellular dermal matrix to achieve complete nasal
lining reconstruction and adequate two-layer clo-
sure in difficult cleft repairs.
Joseph E. Losee, M.D.
Division of Pediatric Plastic Surgery
Children’s Hospital of Pittsburgh
3705 Fifth Avenue
G437 De Soto Wing
Pittsburgh, Pa. 15213
joseph.losee@chp.edu
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