Fistula formation and repair after palatal closure: an institutional perspective

We retrospectively reviewed 119 consecutive patients who underwent cleft palate repair at the Mayo Clinic to determine the incidence of postoperative fistula formation, to assess possible contributing factors, and to review the methods of surgical management. Fistulas of the secondary palate were included, but nasal-alveolar fistulas and intentionally unrepaired anterior palatal fistulas were excluded. Six patients whose repairs were performed after 2.5 years of age were excluded to ensure a more uniform patient population. Cleft palate fistulas occurred in 13 of the 113 patients (11.5 percent). The median age at repair was 8.2 months, and the median follow-up period was 5.2 years. Several variables were analyzed by means of the log-rank test to determine their significance in postoperative fistula formation. Sex, extent of clefting (as estimated by the Veau classification), and type of palatal closure did not significantly affect the rate of fistula formation. However, patients who had palatal closure at an age younger than 12 months had a lower incidence of fistula formation (7.8 percent) than children whose closures were performed between the ages of 12 and 25 months (19.4 percent) (p = 0.058). The strongest predictor of the occurrence of a cleft palate fistula was the surgeon performing the procedure (p = 0.008). Fistula repair was deemed necessary in 11 of 13 patients, and 91 percent of these fistulas were healed with a single operation. Most of these fistulas were closed by using local flaps and two-layered closures. Cleft palate repair carries a significant but acceptable risk of fistula formation, which can be managed with local flaps. Fistula occurrence is related most to the experience level of the operating surgeon.