The use of acellular dermal matrix in palatoplasty to decrease the rate of postoperative oronasal fistula.

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.

Two-Layer Palatal Reconstruction Reduces Postoperative Intraoral Complications in Head and Neck Surgery.

BACKGROUND: Although microvascular free flaps are commonly performed and have high success rates, postoperative oronasal fistulas or infections do occur. The authors hypothesized that a two-layer closure is effective for prevention of intraoral complications. METHODS: Patients who underwent palatal reconstruction with a microvascular free flap were evaluated retrospectively. The cases were divided into two groups (palatal reconstruction with or without a two-layer closure). A two-layer closure involves unilateral reconstruction with a free flap, then reconstruction of the nasal lining with a local flap or folding free flap. The postoperative complication rates between these two groups were compared. RESULTS: One hundred fifty-five cases were evaluated. A two-layer closure was performed in 65 cases (41.9 percent). The incidence of infections, dehiscence of the recipient site, and oronasal fistula were significantly higher in the single-layer closure group than in the two-layer closure group [10.0 percent versus 0 percent (p = 0.011); 15.6 percent versus 4.6 percent (p = 0.036); and 17.8 percent versus 4.6 percent (p = 0.013), respectively]. CONCLUSIONS: A two-layer closure in palatal reconstruction was shown to reduce the rate of infection, intraoral wound dehiscence, and oronasal fistula in the current study. A two-layer closure provides greater support and stability and reduces the risk of failure in reconstruction of the palate with a microvascular free flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Prevention and management of oronasal fistulas.

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.

Effects of phenytoin spray in prevention of fistula formation following cleft palate repair.

BACKGROUND: The effectiveness of topical phenytoin has been reported for the treatment of oral biopsy ulcers, chemotherapy-induced oral mucositis, and chronic periodontitis. This study aimed to investigate the effects of topical phenytoin 2% on the prevention of fistula formation after cleft palate repair. METHOD: This randomized clinical trial studied patients with nonsyndromic cleft palate who were referred to a tertiary center and underwent cleft palate repair from March 2010 to February 2015. Patients in the phenytoin group received phenytoin spray 2% for 8 weeks and were compared with an age- and sex-matched control group. RESULTS: A total of 160 patients in two phenytoin and control groups (n = 80 for each group) were recruited to the study. The mean ages of patients in the phenytoin and control groups were 11.42 ± 1.30 and 11.08 ± 1.25 months, respectively. The results showed that six patients (7.5%) in the phenytoin group and 15 patients (18.8%) in the control group formed fistulas during the 6-month follow-up period. There was a significant difference in fistula formation between the phenytoin and control groups (p = 0.035). Furthermore, fistula size was significantly smaller in the phenytoin group compared with the control group (p < 0.001). CONCLUSION: More frequent use of phenytoin spray can be considered, although there is insufficient information on the long-term side-effects of the chosen drug.

Anatomical Nasal Lining Flaps for Closure of the Nasal Floor in Unilateral and Bilateral Cleft Lip Repairs Reduce Fistulas at the Alveolus.

BACKGROUND: Techniques vary for addressing the nasal floor during cleft lip repair in patients with a cleft lip and palate. Sometimes, no closure is performed, leaving a symptomatic alveolar fistula until the time of alveolar bone grafting. Often, medial and lateral skin flaps are used, but these are often thin and unreliable. Anatomical nasal lining flaps are used to improve closure with robust, well-vascularized flaps that anatomically close the nasal floor. METHODS: A retrospective chart review was performed to identify patients with a unilateral or bilateral cleft lip and palate who underwent primary cleft lip repair with nasal lining flaps or with medial and lateral flaps. The primary outcome was presence of a symptomatic and/or visible oronasal fistula. RESULTS: Sixty-four patients were included. Thirty-seven underwent closure with nasal lining flaps, whereas 27 underwent closure using Millard medial and lateral flaps. The rate of symptomatic/visible fistulas after cleft palate repair was 19 percent (seven of 37) for patients with nasal lining flaps and 44 percent (12 of 27) for patients with medial and lateral flaps (p = 0.0509, Fisher's exact test). The alveolar fistula rate was 3 percent (one of 37) for patients with nasal lining flaps and 30 percent (eight of 27) for patients with medial and lateral flaps (p = 0.0032, Fisher's exact test). CONCLUSIONS: Nasal lining flaps at the time of cleft lip repair effectively close the anterior nasal floor in patients with a unilateral or bilateral cleft lip and palate. Decreasing the presence of alveolar fistulas after cleft palate repair improves the quality of life for patients with cleft deformities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Cleft Palate Repair: Description of an Approach, Its Evolution, and Analysis of Postoperative Fistulas.

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.

Placement of an antibiotic oral pack on the hard palate after primary cleft palatoplasty: a randomized controlled trial into the effect on fistula rates.

OBJECTIVE: The objective of this study is to determine whether placement of an antibiotic oral pack on the hard palate reduces fistula rates after primary cleft palatoplasty. SUBJECTS AND METHODS: This study was a parallel blocked randomized controlled trial. The study consisted of two groups of 100 patients each with non-syndromic unilateral complete cleft lip, alveolus, and hard and soft palate that underwent primary palatoplasty. Group A had an oral pack placed on the hard palate for 5 days postoperatively while group B did not. Occurrence of fistulae between both groups was tested using odds ratios (OR). RESULTS: In 2% of the patients in group A, a fistula was found 6 months after palatal surgery. In contrast, in 21% of the patients in group B, a palatal fistula could be confirmed. The fistula occurrence in group A was statistically significantly lower than that in group B (OR = 0.0768, CI = [0.02 … 0.34], p < 0.001). CONCLUSION: The findings of this study provide evidence that the rate of fistula formation after primary palatoplasty is significantly reduced if a pack soaked with antibiotic cream is placed on the palate postoperatively for 5 days. CLINICAL RELEVANCE: The use of an antibiotic pack after cleft palate repair can be recommended to prevent occurrence of oronasal fistulae.

Gelfoam Interposition Minimizes Risk of Fistula and Postoperative Bleeding in Modified-Furlow Palatoplasty.

Failure to accomplish a tension-free, watertight closure predisposes the palatoplasty patient to fistula formation. Perioperative bleeding also places the patient at risk for adverse airway events (AAE). This study introduces the incorporation of a hemostatic gelatin sponge (Gelfoam) into layered palatoplasty to minimize adverse postoperative bleeding and fistula formation. A retrospective chart review was performed to identify subjects who underwent Furlow palatoplasty with insertion of Gelfoam from 2010 to 2015. Exclusion criteria include age >3 years, prior palate surgery, <30-day follow-up, immunosuppressive state, and diagnosis of Treacher-Collins or Apert Syndrome. Demographic data include age, sex, cleft laterality, prior surgeries, Veau classification, Pierre Robin status, and tracheostomy dependence. Primary outcome was fistula formation. Secondary outcomes included perioperative metrics and AAE.One hundred subjects met criteria, 45% female. Average age was 14.6 months. Subjects with syndromes comprised 28%, with 16% diagnosed with Pierre Robin. Two subjects were tracheostomy-dependent. Prior cleft and mandibular procedures were performed in 55%. Isolated palatal defects were seen in 46%, unilateral lip and palate in 41%, and bilateral lip and palate in 13%. The majority of defects were Veau II and III (35% and 34%, respectively). Adverse airway events occurred in 2%, one of which resulted in reintubation. One subject (1%) was found to have a postoperative fistula.The incorporation of Gelfoam in the modified-Furlow palatoplasty results in a low rate of oronasal fistula (1%) and low perioperative risk of AAE. Further prospective comparison of this method to others will be the focus of future work.

The free scapular flap with latissimus muscle reduces fistulas in mandibular reconstruction.

INTRODUCTION: The free scapular chimeric flap is a less common choice for facial reconstruction. This study aimed to evaluate the versatility and safety of the flap, the procedure for a two-team approach, the safety of the osteotomies, the possibility of dental implants and donor-site sequelae and complications. PATIENT AND METHODS: We analysed 34 consecutive patients with oral cancer undergoing large resections in the maxillofacial region as well as scapular chimeric free flap reconstruction. We performed 26 mandibular, six maxillary and two orbital reconstructions using a two-team approach, mainly without repositioning the patient. RESULTS: No flaps were lost. Three patients with a scapular bone and fasciocutaneous flap developed a post-operative fistula, whereas no fistulas developed when the flaps included a muscular component. All osteotomies showed confirmed osseal consolidation. Seven patients received a total of 23 dental implants for oral rehabilitation; no implants were lost. CONCLUSIONS: The scapular flap is reliable and contains sufficient bone to tolerate both multiple osteotomies and osseointegrated dental implants. The flap can be harvested in a slightly tilted decubital position, thus shortening the theatre time. The use of a separate muscle around the scapular bone in mandibular reconstruction is associated with a lower risk of oral fistulas.

A 5-Year Retrospective Review of Primary Palatoplasty Cases Utilizing an Acellular Collagen Interpositional Graft.

PURPOSE: Multiple palatoplasty techniques have been developed, but a technique involving a partial 2-layer soft tissue closure of the posterior hard palate and nasal floor and a 3-layer soft tissue closure of the soft palate with reorientation of the levator and tensor veli muscles across the midline has been the gold standard for cleft repair. This report describes a series of primary palatoplasties reconstructed with a middle layer of acellular collagen membrane that aided in maintaining closure between the oral and nasal cavities without the development of an oronasal fistula. MATERIALS AND METHODS: An acellular collagen membrane was placed between the muscular layer and the oral mucosa during primary palatoplasty. Six patients with primary cleft palatoplasty were identified and followed for 1 year (patient 1, a 10-month-old boy; patient 2, a 12-month-old girl; patient 3, a 12-month-old girl; patient 4, a 6-year-old boy; patient 5, a 12-month-old girl; and patient 6, an 18-month-old girl). RESULTS: At 1 year, no oronasal fistulas had developed where augmentation with the acellular collagen membrane was used. CONCLUSIONS: The use of an acellular collagen graft to aid in the 3-layer closure of primary palatoplasty surgery is a very effective strategy in primary and secondary healing and in preventing oronasal fistulation. The risk associated with the use of acellular collagen membranes appears nonexistent.

Calvarial periosteal graft for second-stage cleft palate surgery: a preliminary report.

OBJECTIVE: The objectives of cleft palate surgery are to achieve optimal outcomes regarding speech development, hearing, maxillary arch development and facial skull growth. Early two-stage cleft palate repair has been the most recent protocol of choice to achieve good maxillary arch growth without compromising speech development. Hard palate closure occurs within one year of soft palate surgery. However, in some cases the residual hard palate cleft width is larger than 15 mm at the age of two. As previously reported, integrated speech development starts around that age and it is a challenge since we know that early mobilization of the mucoperiosteum interferes with normal facial growth on the long-term. In children with large residual hard palate clefts at the age 2, we report the use of calvarial periosteal grafts to close the cleft. MATERIAL AND METHODS: With a retrospective 6-year study (2006-2012) we first analyzed the outcomes regarding impermeability of hard palate closure on 45 patients who at the age of two presented a residual cleft of the hard palate larger than 15 mm and benefited from a periosteal graft. We then studied the maxillary growth in these children. In order to compare long-term results, we included 14 patients (age range: 8-20) treated between 1994 & 2006. Two analyses were conducted, the first one on dental casts from birth to the age of 6 and the other one based on lateral cephalograms following Delaire's principles and TRIDIM software. RESULTS: After the systematic cephalometric analysis of 14 patients, we found no evidence of retrognathia or Class 3 dental malocclusion. In the population of 45 children who benefited from calvarial periosteal grafts the rate of palate fistula was 17% vs. 10% in the overall series. CONCLUSION: Despite major advances in understanding cleft defects, the issues of timing and choice of the surgical procedure remain widely debated. In second-stage surgery for hard palate closure, using a calvarial periosteal graft could be the solution for large residual clefts without compromising adequate speech development by encouraging proper maxillary arch growth.

The Children's Hospital of Philadelphia modification of the Furlow double-opposing Z-palatoplasty: 30-year experience and long-term speech outcomes.

BACKGROUND: The purpose of this study was to evaluate the long-term outcomes following modified Furlow palatoplasty over a 30-year experience at a single institution. METHODS: A retrospective review was performed of all nonsyndromic patients undergoing primary modified Furlow palatoplasty at The Children's Hospital of Philadelphia between 1980 and 2011. Surgical success was evaluated by the rate of postoperative oronasal fistula, speech outcomes assessed at a minimum of age 5 years, and the need for secondary surgery for velopharyngeal dysfunction. Results were analyzed by surgeon, Veau cleft type, age at repair, and over time. RESULTS: Eight hundred sixty-nine patients who underwent modified Furlow repair were included in this study. The mean age at palatoplasty was 1.1 years, and the mean length of follow-up was 6.7 years. Repairs were performed by 11 surgeons, with 44.3 percent performed by a single surgeon. The overall oronasal fistula rate was 5.2 percent, and this improved significantly over the 30-year period (p = 0.003). Speech results at age 5 or older were available for 559 patients. Of these 559 patients, 72.4 percent had a competent velopharyngeal mechanism, and 21.5 percent had a borderline mechanism consistent with socially acceptable speech. Secondary pharyngeal surgery was indicated in 8.1 percent of patients. Speech results were stable (p = 0.10), and rates of secondary surgery for velopharyngeal dysfunction declined significantly over the study period (p = 0.005). CONCLUSIONS: The authors' 30-year experience with the modified Furlow palatoplasty shows stable speech results, decreasing rates of secondary surgery, and an acceptable rate of postoperative oronasal fistula.

Acellular dermal matrix in palatoplasty.

The primary goal of palatoplasty is to allow normal speech through the correction of velopharyngeal incompetence. Failure to accomplish a tension-free, watertight closure predisposes the palatoplasty patient to postoperative fistula formation. Fistulas may in turn contribute to velopharyngeal incompetence. Reported fistula rates vary widely, ranging from 0% to greater than 70%; recurrence rates after attempted repair approach 65% in some series. These lesions therefore represent a significant clinical burden. Acellular dermal matrix materials have been introduced into various phases of palatoplasty as a strategy to augment repairs and minimize postoperative fistula formation, as well as repair fistulas when they do occur. In this article, the authors review the existing literature regarding acellular dermal matrix in palatoplasty and describe their own algorithm and results for primary and secondary palatoplasty in which acellular dermal matrix plays a central role.

The use of buccal fat pad (BFP) as a pedicled graft in cleft palate surgery.

The buccal fat pad (BFP) as pedicled graft was originally used in reconstructing medium sized intraoral defects. Promising results concerning the use of BFP in cleft palate surgery have been published recently. The aim of this article is to report on the use of BFP as a pedicled graft in cleft palate surgery and to discuss promising results for this reconstructive surgical concept. A retrospective evaluation of 24 patients who had BFP pedicled flaps used for the prevention and repair of Type III (Pittsburgh Fistula Classification) cleft palate fistulas, to obstruct the retromolar space of Ernst and in case of wide clefts, from 2005 to 2010, was conducted. In all cleft palate patients, the recipient area fully epithelialized within 4 weeks or less. No recurrence was seen and the donor site healed well without aesthetic or significant functional impairment. This series confirms the excellent and predictable healing of BFP intraorally and the minimal morbidity associated with the use of such grafts. The results of this study allow the authors to recommend that the BFP pedicled flap is considered as a reliable alternative procedure to expand the therapeutic options. The BFP graft provides an advantage in reconstructive cleft palate surgery.

The role of reconstruction for transoral robotic pharyngectomy and concomitant neck dissection.

OBJECTIVE: To evaluate the impact of primary reconstruction of postablative defects following transoral robotic surgery on function and the risk of orocutaneous fistula. DESIGN: Prospective nonrandomized clinical trial. SETTING: Tertiary academic medical center. PATIENTS: Thirty-one patients treated with transoral robotic pharyngectomy for malignant disease. Each case was analyzed for patient age, sex, primary site of the tumor, pathologic characteristics, stage of disease, complications, fistula rate, and functional outcomes. Functional outcomes were assessed using the Performance Status Scale for Head and Neck Cancer Patients and the Functional Oral Intake Scale. INTERVENTIONS: In 25 patients, the primary treatment was with transoral robotic pharyngectomy, and 6 cases were salvage procedures performed for recurrent disease following radiation (3 patients) or chemoradiation (3 patients). Twenty-six patients underwent a concomitant unilateral selective neck dissection, and 3 patients underwent concomitant bilateral selective neck dissections; 2 patients did not require a neck dissection for treatment of the primary malignant tumor. MAIN OUTCOME MEASURES: Complication rate, fistula rate, and oral function. RESULTS: Primary intraoral reconstruction was performed in all 31 patients. Musculomucosal advancement flap pharyngoplasty was performed in 25 patients with a concomitant velopharyngopasty (6 patients), and radial forearm free flap reconstruction was performed in 6 patients. There were no intraoperative complications; however, postoperatively, 1 patient developed a neck hematoma that was treated with bedside drainage and 4 patients sustained minor musculomucosal flap necrosis of the superior aspect of the flap. None of the patients developed a neck infection of salivary fistula. Endoscopic evaluation of swallowing demonstrated that none of the patients experienced aspiration or velopharyngeal reflux, and the performance Status Scale for Head and Neck Cancer Patients and the Functional Oral Intake Scale at 2 weeks, 2 months, 6 months, 9 months, and 1 year demonstrated a progressive improvement in diet, swallowing, and oral function. CONCLUSIONS: Primary transoral robotic reconstruction may provide a benefit by decreasing the fistula rate in patients undergoing concomitant neck dissection. Patients regain excellent function following surgery and adjuvant therapy.

Modified Von Langenbeck cleft palate repair using an anterior triangular flap: decreased incidence of anterior oronasal fistulas.

OBJECTIVE: A complication following cleft palate surgery is the development of oronasal fistulas. Despite recent advances aimed at addressing this concern, rates of postoperative fistulas have remained unchanged and are reported at between 3% and 60%. Oronasal fistulas commonly occur between the hard and soft palate and at the anterior portion of the cleft. These fistulas lead to functional problems with nasal emission, hypernasal speech, and food regurgitation through the nose. For clefts of the secondary palate, we developed a modification of the Von Langenbeck technique in which an anterior triangular flap is used to decrease the incidence of postoperative fistulas. METHOD: A triangular flap composed of oromucosa was designed for isolated clefts of the secondary palate only. It is based at the anterior margin of the cleft and is used as a turnover flap to allow closure of the often very tight anterior nasal side. A retrospective chart analysis was performed from 2000 to 2007. All patients who had isolated clefts of the secondary palate and had undergone a modified Von Langenbeck procedure were included in the study. Patients were evaluated 4 to 8 weeks postoperatively for the presence of oronasal fistulas. RESULTS: With the introduction of the anterior triangular flap, we show that 0 of 182 patients developed a postoperative oronasal fistula. CONCLUSIONS: This modification of the standard Von Langenbeck uses an anterior triangular flap and confers the advantage of assisting in nasal side closure of the anterior margin of the cleft; in doing so, it reduces the rate of fistula formation.

Superior results using the islandized hemipalatal flap in palatoplasty: experience with 500 cases.

BACKGROUND: The double-opposing Z-plasty palatal repair, as reported by Dr. Furlow, is one of the most popular methods of primary cleft palate repair. However, the repair as originally described is difficult to perform on wide palatal clefts. The authors have modified the original repair by altering the hard palatal flap design to allow for better mobilization and improved closure of the cleft. METHODS: The authors performed a retrospective review of 500 consecutive children undergoing double-opposing Z-plasty cleft palate repairs with or without islandization of the hemipalate on its vascular pedicle over a 10-year period at Children's Hospital Los Angeles. Children were evaluated based on their age at the time of repair, extent of cleft, and occurrence of postoperative fistulas. RESULTS: Three hundred thirty-two children underwent pedicle lengthening and 168 children did not. The overall fistula rate in this series was 5.0 percent. When the experience of the five cleft surgeons in this series was combined, patients undergoing pedicle lengthening had significantly lower fistula rates (2.1 percent) than patients undergoing palatoplasty without pedicle lengthening (10.6 percent). Patient gender, age, and extent of clefting did not correlate with the rate of fistula formation in this study. There was only one partial flap loss, early in the authors' series. CONCLUSION: The authors' data suggest that a double-opposing Z-plasty palate repair performed with islandization results in lower postoperative fistula rates when compared with repair performed without islandization.

A successful algorithm for limiting postoperative fistulae following palatal procedures in the patient with orofacial clefting.

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 potential 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 performed 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 veloplasty, (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 palatoplasty fistula (0.76 percent) (acellular dermal matrix was used in 39.4 percent of primary palatoplasties); (2) 55 oronasal fistula repairs yielding two symptomatic 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 velopharyngeal 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 Furlow palatoplasty.