R e v i s i o n P a l a t e Su r g e r y

Neal Deot, MD*, Sherard Austin Tatum, MD

KEYWORDS
 Cleft Surgery  Oronasal fistula  Velopharyngeal insufficiency  Bone grafting

KEY POINTS
 Two of the most impactful complications of primary cleft repair are velopharyngeal insufficiency
(VPI) and oronasal fistula (ONF).
 The success of the revision surgery depends on several factors, including the size and location of
the defect, the patient’s age and overall health, and the surgeon’s experience and skill in performing
the procedure.
 Surgical treatment options for oronasal fistulae include primary closure, local or regional flap
closure, free tissue transfer, or the use of prosthetic obturators.
 Treatment options for velopharyngeal insufficiency in cleft patients include speech therapy, surgery
such as pharyngeal flap surgery, sphincter pharyngoplasty or injection augmentation of the poste-
rior pharyngeal wall, and use of speech prosthetics.
 Alveolar bone grafting can provide numerous benefits including promoting optimal dental eruption,
preserving permanent teeth near the cleft gap, stabilizing the dental and maxillary arch, supporting
the nose, and reducing the risk of fistula recurrence by creating durable bone between the oral and
nasal lining repairs.

INTRODUCTION delay surgery. Several main schools of thought

A cleft palate (CP) arises from the failure of the
frontonasal and maxillary prominences to fuse
during development. Patients are left with feeding
and speech issues.1 They are thought to be multi-
factorial in etiology, ranging from genetic predis-
position to environment exposures including
alcohol.2 They are typically diagnosed prenatally
through ultrasound or after birth through a physical
examination. According to the World Health Orga-
nization (WHO), the overall worldwide incidence of
cleft lip and palate is approximately 1 in 600 to 800
live births while isolated cleft palate occurs
approximately in 1 in 2000 live births.3 The inci-
dence is even higher in populations including
Asians and indigenous people of the Americas.
Cleft palate repair was first documented per Le
Monnier around 1764.4 The timing of cleft palate
repair depends on several factors, including the
cleft severity and type, patient age, comorbidities,
for repairing a cleft palate remain common in mod-
ern practice.5 There are straight line repairs with or
without soft palate muscle rearrangements such
as von Langenbeck’s bipedicled flaps and Bar-
dach’s unipedicled flaps. Other repairs attempt
to lengthen the palate by pushback, buccal flaps,
or Furlow’s double-opposing Z-plasty. Single-
stage primary repair options are typically per-
formed around 6 to 12 months of age. On the other
hand, two-stage repairs often include a first sur-
gery to repair the soft palate typically around 6 to
12 months of age and a second surgery for hard
palate repair done around 18 to 24 months (or
later) of age. Proponents of this approach cite
decreased tension and delayed subperiosteal
dissection resulting in better maxillo-facial growth,
dental occlusion, and smile aesthetics tissues.6,7
Opponents express concern over speech prob-
lems with delayed hard palate closure. Ultimately,
facialplastic.theclinics.com

attention to blood supply, layered closure of the

and family or surgeon preference. If the cleft is very oral and nasal mucosa and minimizing tension
wide or if the child has other health issues allow for reliable results.
including prematurity, the preference may be to

Department of Otolaryngology, Upstate Medical University, Syracuse, NY, USA

* Corresponding author. 750 East Adam Street, Syracuse, NY 13210.
E-mail address: deotn@upstate.edu

Facial Plast Surg Clin N Am 32 (2024) 63–68

https://doi.org/10.1016/j.fsc.2023.05.003
1064-7406/24/Published by Elsevier Inc.
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64 Deot & Tatum
The need for revision surgery following primary
cleft palate repair is estimated to be around
21.1%.8 A significantly higher rate of secondary
correction was found in patients with primary repair
of a complete cleft (44%) as compared to patients
with incomplete cleft palate (9.8%). Revision sur-
gery is complex because of inevitable scarring,
altered vascularity, and persistent tension after pri-
mary palatoplasty.9 The two most impactful compli-
cations are velopharyngeal insufficiency (VPI) and
oronasal fistula (ONF) which we will focus on in
this article. Herein we will review these complica-
tions and methods of repair.
ANATOMY
To understand cleft repair and secondary compli-
cations, we must have a detailed understanding of
palatal anatomy. The soft palate is comprised of
the tensor veli palatini and levator veli palatini mus-
cles that normally insert into the palatine aponeu-
rosis at the midline of the palate. However, in the
presence of a palatal cleft, these muscles are ante-
riorly angled lateral to the cleft margin and attach
to the posterior edge of the hard palate, which ren-
ders them less effective. Additionally, the lateral
segments of the soft palate are shortened. The
main objective of cleft palate repair is to close
the cleft and thus reposition the palatine muscles
and lengthen the soft palate to help to restore a
tight seal between the velum and posterior pharyn-
geal wall.
Palatal dysfunction is thus driven by cleft severity.
The Veau classification system can be used to quan-
tify cleft severity by categorizing clefts into four
groups based on the degree of involvement, ranging
from isolated soft palate clefts to bilateral complete
clefts. While some studies indicate no association
between the Veau classification and surgical out-
comes, others suggest a higher incidence of VPI
and ONF in groups III and IV clefts.10
ORONASAL FISTULA
ONF is one of the most common complications
following cleft palate repair. Older age and Robin
sequence have been associated with higher rates
of oronasal fistula repair.11 Bykowski and col-
leagues found the ONF rate to be around 4.9%
with a higher incidence in higher Veau classes.12
These typically present at the hard and soft palate
junction, generally the site of highest tension
following repair. The nasal layer is particularly prone
to dehiscence due to limited mobility prior to
closure and friable tissue secondary to food expo-
sure. Other predisposing factors include a wide
cleft, poor oral hygiene, inadequate muscular layer,
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upper respiratory tract infection, hemorrhage, poor
surgical technique, and unsatisfactory postopera-
tive care. Depending on size, an ONF can be
asymptomatic or cause significant nasal regurgita-
tion, changes in speech, and feeding difficulty. In
some cases, the small fistula may not be visible or
palpable in the mouth or nose. These potential
or pinhole fistulae may remain asymptomatic or
become symptomatic during later orthopedic
palatal expansion. Some studies have found pri-
mary repair method can impact fistula rates, with
higher rates noted in the Furlow double-opposing
Z-plasty technique (12.1%) versus Busan modifica-
tion (3.0%) or two-flap technique (2.0%).13 Push-
back techniques, such as the Veau-Wardill-Kilner
palatoplasty or VY pushback, have been associ-
ated with a higher risk of fistula formation due to
the increased tension and the fact that only a single
nasal layer is used, resulting in incomplete oral
closure anteriorly.14
Several other techniques have been proposed
to reduce the risk of ONF including preoperative
nasoalveolar molding, vomerine flaps, hamuloto-
mies, tensor transposition, palatine foraminal
osteotomies, application of fibrin tissue sealant,
and placement of an antibiotic oral pack or splint
without definitive results.15 Some surgeons advo-
cate for a third layer between the oral and nasal
mucosa using interposition grafts such as gelatin
foam (Gelfoam), acellular dermal matrix (ADM),
amniotic membrane allograft, cartilage, bone,
and fascia. Rothermel found no significant differ-
ence in fistula rate with and without the use of
ADM.16
Management of ONF can vary based on symp-
tom severity. When asymptomatic, these can often
be observed. For symptomatic patients, interven-
tions range from non-surgical devices such as ob-
turators to revision surgery. A variety of surgical
techniques can be employed, ranging from mar-
ginal revision, local flaps, regional flaps, to free tis-
sue transfers. The choice of technique will depend
on the size and location of the fistula, the status of
the adjacent tissue, and the overall health of the
patient.
Local Flap Techniques
Primary closure is often difficult in revision cases
due to the scarring of the involved margins. In
cases of small, isolated fistulae of the soft palate,
cleft margin excision and primary approximation
can be performed. Another option is the use of os-
motic tissue expanders to permit primary closure
which has shown success in even large anterior
palatal fistulae.16 ADM can serve as an adjunct
when local soft tissue options prove inadequate

for a watertight closure by sewing the incised fis-
tula margin to the exposed graft. More commonly,
ADM is used as a reinforcing middle layer that is
not exposed intraorally with a recurrent fistulae
rate of 3.6%.17
Often a local flap is required. Closure can be
paired with an intravelar veloplasty (IVVP) or a con-
version Furlow palatoplasty if there is concurrent
VPI. For the nasal layer, palate-based hinge flaps,
buccal fat pad (BFP) flaps, and nasal septum or
inferior turbinate flaps may be used. BFP is rela-
tively easy to harvest, highly vascular, and in close
proximity to the palate. It can be used for either fis-
tula closure or covering secondary defects to limit
contracture or as a middle reinforcing layer with
the additional benefit of potentially lengthening
the palate.18 Fox and colleagues found a 93% suc-
cess rate with nasoseptal flaps for anterior palatal
fistulae.19 Lee found success using a pushback
palatoplasty for the oral side of posterior fistulae
while the nasal side was reconstructed with a
triangular shaped mucoperiosteal flap from the
anterior hard palate and bilateral rectangular
shape oral mucoperiosteal turn over hinge flap.20
For medium fistulae, unipedicled or bipedicled
flaps based off the greater palatine artery can be
elevated and advanced, translated, or rotated.
For larger defects, tongue flaps, buccal myomu-
cosal flaps, and facial artery myomucosal
(FAMM) flaps have been used. Alsalman described
a 0% fistula recurrence rate using a single layer
tongue flap in cases of large fistulae, scarred pal-
ate with no adequate tissue, and previous failure
of other options.21 Buccal myomucosal and
FAMM flap are often routed behind the molars
for defects ending posterior to the incisive fora-
men; for defects extending anterior to the incisive
foramen, these are routed through the alveolar
cleft.16 For even larger fistulae with VPI, a pedicled
buccal fat pad and palatal lengthening with a
buccinator myomucosal flap combined with
sphincter pharyngoplasty or pharyngeal flap can
be considered.9 The main disadvantages of such
procedures are donor site morbidity, technical dif-
ficulty, and considerable postoperative care,
particularly regarding the airway.
Regional Flap Techniques
Regional flap techniques involve using tissue from
a nearby area to close the ONF. The tissue is often
taken from the forehead, the scalp, or the neck.22
Regional flap techniques have the advantage of
using tissue that is more substantial than local
flaps, allowing for larger fistulae to be repaired. Ex-
amples include the temporalis muscle flap (TMF)
which can be used to fill a residual cleft palate
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Revision Palate Surgery 65
defect, although the length can be an issue. These
are suited for large soft palate defects; however,
they can be difficult to pass to the defect site.23
Free Flap Techniques
Free flap techniques involve taking tissue from a
remote area of the body and transplanting it to
the area of interest with blood supply obtained
from the neck or face vasculature. They are often
utilized for larger traumatic or oncologic defects.
Free flap techniques have the advantage of
providing a large amount of tissue for both layers
if needed, allowing for tension-free closures of de-
fects of all sizes. Additionally, bone is available for
alveolar defects making dental implants possible.
Rothermel suggested the most utility when the
defect spans greater than 4 cm.17 Previous studies
have employed numerous free flaps for palatal
repair including the fibula flap, iliac flap, dorsalis
pedis flap, scapular flap, anterolateral thigh flap
with success.23 The vascular pedicle is often
routed through a cleft in the maxillary arch or via
pyriform aperture.
VELOPHARYNGEAL INSUFFICIENCY
This edition contains a separate article about the
management of VPI, but some mention is useful
here due to the interplay between VPI and ONF.
VPI is the incomplete closure of the soft palate
against the pharyngeal wall during speech and
swallowing. Velopharyngeal competence is largely
driven by the superior pharyngeal constrictor mus-
cles and the levator veli palatini muscle, which act
as (pseudo)sphincters, as well as the bunching of
the uvula.24 Postoperative incidence of VPI after
primary cleft palate repair ranges from 5% to
36%.25 Common presenting symptoms include
hypernasal speech, nasal regurgitation of food or
liquid, and difficulty with consonant sounds. It is
important to separate nasal air escape through a
fistula from air escape behind the palate due to
VPI. Both can occur simultaneously. Both can be
addressed in the same carefully planned surgery.
Temporary plugging of the fistula with bubble gum
or an obturator during evaluation can help distin-
guish. There is an increased incidence of secondary
surgery for VPI in patients with increased cleft
severity based on the Veau hierarchy.26
VPI typically arises due to insufficient palate
lengthening, tissue contracture, or an inadequate
reorientation of the muscles of the soft palate. To
diagnose VPI, the evaluation process typically be-
gins with a speech assessment. The Pittsburgh
Weighted Speech Scores (PWSS) provide a sub-
jective grading of speech competency, with
scores above 6 considered socially stigmatizing
66 Deot & Tatum
and often leading to further evaluation for VPI.25
Objective evaluation of velopharyngeal closure
competency is best achieved via nasal endoscopy
or multiview videofluoroscopy (MVF). There are
three primary patterns of velopharyngeal closure:
coronal, where the levator musculature elevates
and retracts the velum posteriorly; circular, where
all structures come together in a "purse-string"
movement; and sagittal, where the lateral pharyn-
geal walls move toward the midline. There is a
continuum of closures among these patterns.
Pre-operative assessment is crucial in determining
the best surgical intervention for VPI.
The aim of treatment for VPI is to enhance
speech function by restoring the proper closure
of the velopharyngeal valve. If the velopharyngeal
mechanism is close to competence, a speech-
language pathologist may correct placement and
improve the function of this valve to correct the
VPI. In certain instances, orthodontic intervention
might be required to rectify teeth and jaw misalign-
ment. If non-surgical measures prove to be inef-
fective, surgical intervention may be necessary,
with the specific procedure depending on the un-
derlying cause of the VPI, pattern of closure, and
the child’s overall health, especially the airway. A
multidisciplinary approach involving a team of
healthcare professionals is generally recommen-
ded to ensure the best possible outcome for the
individual with VPI.
TREATMENT
Local Flaps
Patients who have previously undergone straight
line repair with or without muscle rearrangement
(eg, IVVP) may be considered for conversion to Fur-
low palatoplasty.27 Closure of fistula at or behind
the hard-soft junction can be included in the Furlow
flaps. Furlow palatoplasty is suitable for patients
with a velopharyngeal gap of less than w9 mm. In
cases where the velopharyngeal gap is greater
than 9 mm with a sagittal closure pattern, a
superior-based pharyngeal flap may be used. The
splitting of the soft palate to inset the flap can be
designed to include fistulae in this area. This
approach has been demonstrated to be 82% to
89% effective in treating VPI and significant
improvement in speech assessment scores.26
Bilateral buccal myomucosal flaps can also be uti-
lized to close large palate fistulae at the hard-soft
junction and lengthen the palate for VPI. In this tech-
nique, the velum is separated from the hard palate,
the intact levator sling retracts the velum posteriorly,
and the residual defect is repaired using a buccal
myomucosal flap for nasal lining repair, while the
contralateral buccal myomucosal flap is employed
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for oral lining repair.25 Other treatment options
including injection pharyngoplasty, posterior
pharyngeal flaps, and sphincter pharyngoplasty
are beyond the scope of this article.
Alveolar Bone Grafting
In cleft lip and palate, the cleft crosses the alveolar
ridge creating a bony defect and allowing the
collapse of the lesser or shorter segment of the
maxillary arch. There is frequently a fistula located
where the lip repair and the palate repair meet.
Consequently, the lateral incisor is missing or
poorly shaped. This bony and dental defect cre-
ates problems with hygiene, biting, and smile es-
thetics. For some patients, orthodontic
preparation is helpful to align the alveolar arch
and sometimes necessary to address crowding
and make space for the graft.
Alveolar bone grafting (ABG) involves taking
bone from another part of the body, typically the
hip, tibia, or mandible and using it to fill in the
gap in the alveolus where the cleft is located.
Bone graft reconstruction allows for multiple ad-
vantages including optimal dental eruption,
salvage of permanent dentition erupting on the
margins of the cleft gap, creation of a stable one-
piece dental and maxillary arch (particularly in
bilateral clefts), proper skeletal support for the
nose (including grafting along the hypoplastic piri-
form), and durable bone between the oral and
nasal lining repairs decreasing the risk of fistula
recurrence.28 If the lateral incisor is missing, and
there is enough room, a dental implant can be
placed at skeletal maturity. If there is not enough
room, the canine can be moved mesially into the
consolidated graft and “lateralized,” meaning
substituted for the missing lateral incisor. Autolo-
gous graft of cancellous bone is considered the
gold standard, however more recent studies
have begun to explore the utility of three-
dimensional biomaterials including PCL matrix,
b-TCP matrix, and hydroxyapatite matrix.29 While
unapproved in children, some are using bone
morphogenic protein products in this applica-
tion.30 There appears to be no benefit to using a
platelet-rich plasma concentrate combined with
autologous bone for alveolar cleft grafting in terms
of bone volume, bone density, or complications.31
Often there are deciduous or supernumerary
teeth in the cleft that need to be extracted before
ABG. Additionally, some prefer to fix the alveolar
fistula before grafting. Other prefer to do fistula
repair as part of the ABG. The use of ABG can
help facilitate ONF closure. The presence or
absence of an ONF prior to grafting is not thought
to be associated with differences in revision rates

of ABG.32 A metanalysis showed a success rate of
ABG of 76.52%, and the rate of definite natural
eruption of canine within the graft was 80.89%.33
The success of bone grafting depends on several
factors, including the size and location of the cleft,
the age of the patient, and the overall health of the
patient. Most patients experience significant im-
provements in their oral function and appearance
following bone grafting.
ABG procedures can be characterized as pri-
mary, secondary, or tertiary grafting. Primary graft-
ing means that the procedure is performed before
palatal closure usually with rib. Some concerns of
early-stage ABG include growth disturbances of
the middle third of the facial skeleton with the inhi-
bition of maxillary growth and donor site
morbidity.34 Most commonly, secondary bone
grafting is performed during the mixed dentition
stage, early for lateral incisor eruption, later for
cuspid eruption. When the adult dentition has
completely erupted, late or tertiary bone grafting
is possible.35 This is found to have less chance
of full alveolar height of the graft and orthodontic
closure of the cleft in the dental arch than in pa-
tients grafted before canine eruption.34,36
SUMMARY
In conclusion, ONF and VPI are common complica-
tions that can occur after cleft palate surgery and
are often interdependent. Repair of the alveolar
cleft is an important part of overall cleft habilitation.
While these issues can be challenging to manage,
there are a variety of treatment options available,
including speech therapy, prosthetic devices, and
surgery. Early identification and intervention are
critical for the best possible outcome. It is important
for patients and their families to work closely with a
team of experienced healthcare professionals to
develop a comprehensive treatment plan that ad-
dresses all aspects of cleft palate care. With proper
management and support, patients can success-
fully overcome these challenges and achieve
optimal speech and swallowing function.
CLINICS CARE POINTS
 Two of the most impactful complications of
primary cleft repair are velopharyngeal insuf-
ficiency (VPI) and oronasal fistula (ONF).
 The success of the revision surgery depends
on several factors, including the size and loca-
tion of the defect, the patient’s age and over-
all health, and the surgeon’s experience and
skill in performing the procedure.
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Revision Palate Surgery 67
 Surgical treatment options for oronasal
fistulae include primary closure, local or
regional flap closure, free tissue transfer, or
the use of prosthetic obturators.
 Treatment options for velopharyngeal insuf-
ficiency in cleft patients include speech ther-
apy, surgery such as pharyngeal flap surgery,
sphincter pharyngoplasty or injection
augmentation of the posterior pharyngeal
wall, and use of speech prosthetics.
 Alveolar bone grafting can provide numerous
benefits including promoting optimal dental
eruption, preserving permanent teeth near
the cleft gap, stabilizing the dental and
maxillary arch, supporting the nose, and
reducing the risk of fistula recurrence by
creating durable bone between the oral and
nasal lining repairs.
DISCLOSURE
No funding or conflicts of interest to disclose.
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