CLINICAL STUDY Fistula After 2-Flap Palatoplasty A 20-Year Review Ananth S. Murthy, MD, FACS,*†‡ Pranay M. Parikh, MD,§ Connie Cristion, RN,‡ Michael Thomassen, MD,§ Mark Venturi, MD,§ and Michael J. Boyajian, MD*†‡ Abstract: Oronasal fistula formation is a recalcitrant complication following palatoplasty, resulting in nasal emission during speech and deglutition. We review our series to identify factors associated with fistula incidence. A retrospective review of all children with nonsyndromic cleft palate who underwent 2-flap palatoplasty by the senior author from July 1983 to August 2004, was performed. Patient demographics, cleft characteristics, and operative techniques were recorded for each patient. The incidence rates of fistula, pharyngeal flap, and reoperation were used as primary outcomes. Statistical comparisons of frequencies were performed using Fisher exact test. Comparisons of means were performed using  2 analysis. A total of 332 consecutive children met inclusion criteria. Mean age at palatoplasty was 10.8 months, and mean follow-up was 74.1 months. Eight children (2.4%) were found to have fistulae postoperatively, ranging in size from 2 to 15 mm. Four palatal fistulas occurred in the soft palate, 2 at the junction of the hard and soft palate, 1 in the hard palate, and 1 at the incisive foramen. Symptomatic nasal emission requiring reoperation occurred in 5 children. Two of these 5 children required a second operation to achieve fistula closure. Forty pharyngeal flaps were required for correction of velopharyngeal incompetence (12.0%). Two-flap palatoplasty remains a highly successful technique for closure of a variety of palatal clefts, with low fistula incidence. Surgical technique and experience are factors associated with low fistula incidence. Key Words: fistula after 2-flap palatoplasty (Ann Plast Surg 2009;63: 000 – 000) U nintentional postoperative palatal fistulas can result in symp- toms such as fluid and air leakage. Fluid leakage may cause embarrassing nasal emission of food while chewing and swallowing or may cause food particles to be lodged in the fistula and result in fetor oris. Air leakage, when significant, may result in hypernasal speech due to abnormal nasal emission. Fistula rates after palato- plasty have been reported to range from 12% to 45%. 1 Obviously, the most important outcomes after palatoplasty are measured in terms of speech, feeding, maxillary growth, and hearing. Neverthe- less, more than half of postoperative fistulas require a surgical correction and more than two-thirds of secondary repairs require reoperation to achieve successful closure. 2,3 It is clear that the prevention of fistulas is also an important aspect in the treatment of the cleft palate. Having resected a maxilla, von Langenbeck noted bone- regeneration after leaving an intact palatal periosteum. This un- doubtedly led to the description of cleft-palate closure with the use of mucoperiosteal flaps. 4 Subsequently Veau, Wardill, and Kilner described the use of bilateral flaps based on the greater palatine artery to provide closure over the hard palate. 5 Bardach stressed the importance of multiple layer (nasal and oral mucosa), 2-flap pala- toplasty and its ability to provide a tension-free closure and prevent postoperative fistulas. 6,7 By design, the 2-flap palatoplasty, with a 2-layer closure in the hard palate and 3-layer closure in the soft palate, provides the best approach to achieve fistula-free outcomes. Previous studies have emphasized the efficacy of the 2-flap palatoplasty to prevent fistulas with reported rates of 3.4% to 10%. 1,8 It is the goal of this study to review the fistula rate based on the 2-flap palatoplasty at our institution and identify factors associated with fistula formation. METHODS Population and Study Design An IRB approved retrospective review of all children who underwent a 2-flap palatoplasty by the senior surgeon (M.J.B.) was performed. Six hundred consecutive patients with complete records over a 20-year period (from July 1983 to August 2004) were reviewed. To maintain a homogeneous sample, children with syn- dromic cleft palate (223) and submucous cleft palate (45) were excluded from this review. Asymptomatic patients were routinely followed through the completion of maxillary expansion. Symptom- atic patients were followed until resolution of their symptoms. A total of 332 children meeting inclusion criteria were identified and their multidisciplinary craniofacial clinic records were reviewed for patient demographics, cleft characteristics, perioperative course, incidence and location of fistula, and need for surgical correction for velopharyngeal incompetence (VPI). Outcomes and Analysis Clefts were characterized using the Veau classification. Fis- tula incidence was defined as the occurrence of a full-thickness oronasal defect at the palatoplasty repair site. Alveolar fistulae associated with concomitant cleft lip were excluded from analysis, as their repair is intentionally delayed until the time of alveolar bone grafting. Statistical comparisons of frequencies were performed using a Fisher exact test. Comparisons of means were performed using  2 analysis. Surgical Technique The technique of 2-flap palatoplasty has been well described. 7 A standard Bardach closure was performed in all patients with limited dissection of the velar musculature and intervelar veloplasty. Hamulotomy was routinely performed to medialize the velar mus- culature. Opening ring osteotomy at the greater palatine foramen and mobilization of the pedicle was performed when excess width of the Received December 6, 2008, and accepted for publication, after revision, Decem- ber 16, 2008. From the Departments of *Surgery and †Pediatrics, George Washington Univer- sity Medical Center, Washington, DC; ‡Section of Plastic Surgery, Children’s National Medical Center, Washington, DC; and §Department of Plastic Surgery, Georgetown University, Washington, DC. Presented (in part) at the 2007 Meeting of the Northeastern Society of Plastic Surgeons; October 3–7, 2007; Southampton, Bermuda. Reprints: Ananth S. Murthy, MD, FACS, Division of Plastic Surgery, Akron Children’s Hospital, One Perkins Square, Akron, OH 44308. E-mail: amurthy@chmca.org. Copyright © 2009 by Lippincott Williams & Wilkins ISSN: 0148-7043/09/6306-0001 DOI: 10.1097/SAP.0b013e318199669b Annals of Plastic Surgery • Volume 63, Number 6, December 2009 www.annalsplasticsurgery.com | 1