title: A successful algorithm for limiting postoperative fistulae following palatal procedures in the patient with orofacial clefting.
abstract: 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.
authors.affiliation: Pittsburgh, Pa. From the Division of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh.
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Losee
authors.forename: Darren M
authors.initials: DM
authors.lastname: Smith
authors.forename: Ahmed M
authors.initials: AM
authors.lastname: Afifi
authors.forename: Shao
authors.initials: S
authors.lastname: Jiang
authors.forename: Matthew
authors.initials: M
authors.lastname: Ford
authors.forename: Lisa
authors.initials: L
authors.lastname: Vecchione
authors.forename: Gregory M
authors.initials: GM
authors.lastname: Cooper
authors.forename: Sanjay
authors.initials: S
authors.lastname: Naran
authors.forename: Mark P
authors.initials: MP
authors.lastname: Mooney
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Serletti
mesh_terms: D000293:Adolescent; D000465:Algorithms; D002648:Child; D002675:Child, Preschool; D002971:Cleft Lip / Q000601:surgery*; D002972:Cleft Palate / Q000601:surgery*; D005260:Female; D005402:Fistula / Q000517:prevention & control*; D006801:Humans; D007223:Infant; D008297:Male; D009668:Nose Diseases / Q000517:prevention & control*; D016155:Oral Fistula / Q000517:prevention & control*; D010159:Palate / Q000601:surgery; D011183:Postoperative Complications / Q000517:prevention & control* / Q000601:surgery; D012189:Retrospective Studies; D014681:Velopharyngeal Insufficiency / Q000601:surgery*; D055815:Young Adult