Achieving low cleft palate fistula rates: Surgical results and techniques

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