Palatal Fistula Formation Research Articles

Assessing the impact of palatal fistula formation and cleft width on speech outcomes following double opposing Z-plasty in patients with cleft palate

This retrospective study investigated the influence of palatal fistula (PF) formation after double opposing Z-plasty (DOZ) on speech outcomes in patients with cleft palate (CP), focusing on cleft width and palatal length as predictors of velopharyngeal insufficiency (VPI). This study included 1117 patients with CP (579 males, 538 females) who underwent DOZ, performed by a single surgeon, between 1988 and 2017. Demographic characteristics, cleft dimensions, history of PF formation, and speech outcomes were investigated. Speech evaluations were performed at a minimum age of five to assess nasal emission, hypernasality, compensatory articulation, intelligibility, necessity for VPI surgery, and speech therapy. Logistic regression analysis was performed. Speech assessments were conducted at the median age of five (interquartile range [IQR], 5-6 years). Overall, 96.5% of patients achieved 'socially acceptable speech' after DOZ. Patients with PF history showed greater cleft width and experienced higher rates of hypernasality, nasal emission, and VPI on videofluoroscopy (VFS) compared to those without PF history (mean, 11.4mm vs. 7.1mm; 28.4% vs. 23.6%; 34.8% vs. 14.9%, 38.5% vs. 14.0%, 40.6% vs. 28.3%, respectively; all p<0.0001). Cleft width was significantly associated with VPI-related speech outcomes in the multivariate logistic regression analysis, affecting both perceptual and VFS-measured outcomes. A wider CP gap significantly increased the risk of VPI-related speech difficulties after DOZ. Cleft width is a more critical predictor of adverse speech outcomes than the presence of small-to-medium-sized PFs. Patients with a history of PF and wider cleft gaps require targeted interventions and intensified follow-up to effectively manage and improve speech outcomes.

The Effect of Presurgical Nasoalveolar Molding on Oronasal Fistula Following Primary Palatoplasty.

Presurgical nasoalveolar molding (PNAM) is widely used in cleft care protocol. This study investigated the correlation between PNAM and oronasal fistula after primary palatoplasty. A case-controlled study of 80 unilateral and bilateral complete cleft palate patients who underwent cleft palate repair were enrolled. Patients were divided into 2 groups: (1) no PNAM use and (2) PNAM use. The incidence of oronasal fistula and postoperative complications were compared between groups. Forty patients in each group demonstrated the same baseline characteristics. The PNAM group showed a significantly lower postoperative oronasal fistula rate (15% versus 50%, P =0.003). Palatal cleft width wider than 12.5mm increases the odds ratio of fistula formation by 1.19-fold ( P =0.037), and the PNAM protected against postoperative palatal fistula formation (odds ratio 0.20, P =0.003). Presurgical nasoalveolar molding can reduce postoperative oronasal fistula in wide-gap Veau type III and IV cleft palate.

Buccal Fat Pad: Adjunctive Procedure for Lateral Defect Coverage following Primary Palatoplasty.

The buccal fat flap is an encapsulated mass originating from a specific fat tissue that is easily accessed and richly vascularized. The aim of this study was to report the effect of using the buccal fat flap on the oronasal fistula rate in primary palatoplasty. A case-controlled study of 94 patients who underwent primary cleft palate repair. Patients were divided into two groups: (1) two-flap palatoplasty with buccal fat flap for coverage of lateral hard palate defect and (2) conventional two-flap palatoplasty. The incidence of oronasal fistula and postoperative complications were compared between groups. Multivariate analysis was performed to determine the risk factors of oronasal fistula development. Forty-seven patients in each group demonstrated the same baseline characteristics. The buccal fat group showed a significant lower postoperative oronasal fistula rate (2.13 percent versus 21.28 percent, p = 0.008) and smaller fistula size (2 mm versus 4 mm, p = 0.049). A cleft width wider than 11.5 mm increased the odds ratio of fistula formation by 8.44-fold (p = 0.047), and the use of buccal fat protected against postoperative palatal fistula formation (OR, 0.08, p = 0.019). The use of buccal fat flaps for lateral hard palatal defect coverage in primary palatoplasty can reduce the rate of postoperative palatal fistula, especially in cases of wide palatal cleft. Therapeutic, III.

A predictor of a postoperative fistula after double-opposing Z-plasty in bilateral cleft lip and palate patients

Furlow double-opposing Z-plasty (FDOZ) as primary palatoplasty for the bilateral cleft lip and palate (BCLP) closure often leads to a palatal fistula formation in cases with wide clefts. We examined the utility of the calculated maximum closable cleft width to determine the feasibility of a direct palatal closure without lateral incisions. In this retrospective study, we analyzed consecutive patients with a BCLP who were treated for 5 years from 2009. In sixty-three BCLP patients, the following dimensions were measured preoperatively: an actual distance between maxillary tuberosities (Actual X); actual cleft height, calculated from the line joining the maxillary tuberosities to the cleft edge (Actual Y); and actual cleft width at the hard-soft palate junction (Actual Z) and calculated maximum cleft width requiring a direct closure (CMZ). Six months postoperatively, the relationships between the fistula occurrence and actual Z/CMZ were examined. Median values (interquartile range) of Actual X, Y, and Z and CMZ were 35.0 (33.0-39.0) mm, 7.0 (6.0-8.0) mm, 10.0 (8.0-11.0) mm, and 4.6 (2.7-5.7) mm, respectively. The median age at operation was 8.0 (7.0-17.0) months. Fistulae at the hard-soft palate junction developed postoperatively in three cases with more than a 10-mm cleft width (4.76%). A receiver operating characteristic (ROC) curve analysis indicated that actual Z was a better predictor of a postoperative fistula formation than CMZ. An actual cleft width was a better predictor of the fistula occurrence than a calculated maximum cleft width after FDOZ for a BCLP repair. The low fistula rate of FDOZ suggested that FDOZ could be used to close the palate with less than a 10-mm cleft width.

The Maxillary Swing: An Efficacious Approach to Surgical Management of Advanced Stage Juvenile Nasopharyngeal Angiofibroma.

The objective of this study was to evaluate the efficacy and outcome using the maxillary swing approach for the management of extensive nasopharyngeal angiofibroma. A retrospective case series analysis in a tertiary care centre revealed eighteen cases with extensive nasal angiofibroma operated using the maxillary swing approach between 2011 and 2017. All patients had tumour extension to the lateral most portions of the infratemporal fossa with complete occupation and destruction of the lateral wall of the sphenoid sinus causing abutment to the cavernous sinus and complete involvement of the pterygopalatine fossa and pterygoid base. One patient displayed full occupancy of the maxillary sinus as a consequence of erosion of the posterior and medial walls of the maxillary sinus. All patients underwent tumour excision using the maxillary swing approach. Patients were followed up for a minimum period of 1year after surgery. The maxillary swing approach gave optimal exposure of the entire central skull base including the infratemporal fossa and its extreme lateral and superior aspects. Adequate tumour exposure and vascular control could be achieved in all cases resulting in complete tumour excision. The mean operative time was 3h 15min. Post-operative healing was satisfactory with palatal fistula formation in four cases and all patients remaining disease-free up to the present time. One had minimal misalignment of the halves of the upper jaw and two had epiphora, of which one required dacryocystorhinostomy. The maxillary swing is an effective approach in the management of extensive nasopharyngeal angiofibroma and leads to optimal anatomical exposure with minimal morbidity.

The Effect of Buccal Fat Pad Graft in the Palatoplasty and the Risk Factor of Postoperative Palatal Fistula.

The aim of this study was to evaluate the effect of buccal fat pad (BFP) in the palatoplasty and to investigate the risk factors associated with postoperative palatal fistula formation. Sixty-five cleft palate patients were enrolled for this study. Clinical data regarding sex, age, type of cleft, surgical technique, the ratio of cleft width, and BFP graft were collected. The ratio of cleft width was measured and calculated using preoperative clinical photographs. In 36 patients, the BFP was harvested and grafted on the cleft palate to prevent palatal fistula formation. The patients were followed up, the incidence of fistula formation was investigated, and the risk factors related with the fistula were evaluated. Four patients had postoperative palatal fistula and were not BFP grafted during operation. The BFP graft and ratio of cleft width are significant factors in palatal fistula formation (P = .035, .003). There was a significant difference in the ratio of cleft width between the normal and fistula groups (P = .006). In the logistic regression analysis, there was significant association between high ratio of cleft width and palatal fistula formation in the no BFP group (odds ratio; 11.15, P = .036). The ratio of cleft width and BFP graft was a significant factor in palatal fistula formation. The BFP graft is a reliable procedure to prevent palatal fistula formation and increase the success of palatoplasty.

The spectrum of intraoral bacteria seen in patients with cleft palates in an African setting.

Dehiscence or palatal fistula formation following palatoplasty is a complication that has grave consequences for the patient that include tissue loss, emotional distress to the parents and patient, and further medical costs. Palatal dehiscence or fistula formation is multifactorial following surgery—tension of wound closure, poor patient adherence to postoperative orders and wound infection are the most common causes for this. Oral colonization with pathogenic organisms could play a role in wound healing complications. Identification of intraoral bacteria among patients with cleft palates has thus far not been performed. To identify the spectrum of intraoral bacteria in cleft palate patients in an African setting; a retrospective, chart review was performed at Inkosi Albert Luthuli Central Hospital—a quaternary hospital in Durban, South Africa. All patients with unrepaired cleft palates who underwent palatoplasty in 2015 were included. Fifty‐two patients were included. Preoperative throat/palatal swabs were taken prior to palatoplasty. The various bacteria cultured from the aforementioned swabs were cataloged. Various bacteria were cultured. In total, 23 patients (44.2%) had positive swab cultures. Eighteen cultures (34.6%) had gram‐positive growth only, four cultures (7.7%) had gram‐negative growth only, while one patient (1.9%) cultured both a gram‐positive and a gram‐negative organism. Streptococcus viridans was the most commonly cultured organism (19.2%) while beta‐hemolytic streptococci were cultured from only 4 swabs (7.7%). Our study cataloged the commonly occurring bacteria found in unrepaired cleft palate patients in Africa. Further research into the clinical significance of each bacteria is advised.

A Prospective Study Investigating Fistula Rate Following Primary Palatoplasty Using Acellular Dermal Matrix

Acellular dermal matrix (ADM) has been described as an adjunct in primary cleft palate repair to reduce the fistula rate in several retrospective studies (level III or lower); however, current data are insufficient to definitively conclude its efficacy for this purpose. The goal of the present study was to provide prospective, higher level of evidence data investigating the effect of ADM on fistula rate following primary palatoplasty. A prospective clinical trial was conducted in which ADM was used uniformly in all primary cleft palate repairs that met inclusion criteria. For comparison, a matched control group was identified (retrospectively) from the same center/surgeon's database. Primary outcome was the rate of palatal fistula formation. Secondary outcomes included bleeding, infection, and delayed healing. A total of 130 patients were included in the analysis consisting of 65 in both the study and control groups. There were no statistically significant differences in patient demographics or cleft /surgical characteristics. The results demonstrated a fistula rate of 1.5% in the study group versus 12.3% in the control group (P = 0.03). The other complications (infection, bleeding, delayed healing) were similar between the groups. The study provides the highest level of evidence currently available (level II, prospective data) investigating the effect of ADM on fistula rate following primary palatoplasty. The results demonstrate a low overall fistula rate (1.5%) and suggest there may be a clinically significant reduction in fistula formation associated with the routine use of ADM in all primary palate repairs.

Incidence of palatal fistula formation after primary palatoplasty in northern Finland.

The purpose of this retrospective study was to determine the incidence of palatal fistulas after primary cleft palate repair. The study included 136 patients who were treated at the Oulu University Hospital cleft lip and palate center between 1998 and 2011. All patients were treated by the same surgeons with 1-stage palatoplasty closing the hard and soft palate concurrently. The overall frequency of postoperative fistula was 9.6% of patients. Patients with cleft lip and palate (20.0%) were more likely to develop postoperative palatal fistulas than patients with cleft palate (6.6%). Surgical technique and cleft severity were not significant factors for the development of palatal fistulas. The majority of patients undergoing primary palatal repair do not develop palatal fistulas.

Morbidities and Quality of Life after Maxillary Swing Nasopharyngectomy for Recurrent Nasopharyngeal Carcinoma

Background: The maxillary swing approach provides a good access that allows maximal resection of recurrent NPC. The aim of the current study was to report the morbidities and quality of life of patients after surgery. Methods: A prospective study of the early and late morbidities after surgery was performed. A longitudinal investigation of the quality of life before and 1 year after surgery was performed using the self-reported, EORTC questionnaire. Results: Salvage nasopharyngectomy was performed for 338 patients during 1990 to 2012. There was no hospital mortality. The morbidities were actively prevented by modifications of surgical techniques, leading to a significant reduction in the incidence of postoperative trismus (42.1 vs. 9.2%, p = 0.01) and palatal fistula formation (24.0 vs.3.7%, p = 0.01). Patients with locally advanced tumor, particularly those who required adjuvant chemoradiation, had higher chance of facial numbness, nasal blockage, and swallowing problem after surgery. There was no significant change in the mean global health system score after surgery, except those after palliative resection requiring adjuvant chemoradiation. Social functioning had the lowest scores among the five functioning scales in all groups of patients. Palatal fistula significantly affected social eating and weight loss, and osteoradionecrosis caused more pain and nasal discharge, severely affecting the social life of the patients. Conclusions: QOL of patients after salvage nasopharyngectomy.

Morbidities after maxillary swing nasopharyngectomy for recurrent nasopharyngeal carcinoma

The purpose of this study was to investigate the complications after maxillary swing nasopharyngectomy. Salvage nasopharyngectomy was performed for 338 patients during 1990 to 2012. Patient and tumor characteristics, perioperative and intraoperative information, and long-term morbidities were analyzed. There were significantly more patients with locally advanced tumors (rT3 and rT4) operated during the recent study period (2002-2012). However, the mean operative time and blood loss was significantly lower than in the earlier period (1990-2001). There was no hospital mortality. There was a significant reduction in the postoperative trismus and palatal fistula formation. Patients with locally advanced tumor, particularly those who required adjuvant chemoradiation, had a higher chance of facial numbness, nasal blockage, and swallowing problems after surgery. Salvage nasopharyngectomy via the maxillary swing approach is safe with acceptable long-term morbidities. Prevention of complications associated with surgery, particularly for patients with locally advanced tumors, is crucial to ensure the best outcome of surgery.

Extensive nasopharyngeal angiofibromas: the maxillary swing approach

The objective of this study was to evaluate the efficacy and outcome using the maxillary swing approach for the management of extensive nasopharyngeal angiofibromas. A retrospective analysis in a tertiary care center revealed five cases with extensive nasal angiofibromas operated using the maxillary swing approach between 2010 and 2012. All patients had tumor extension to the lateral-most portions of the infratemporal fossa with complete occupation and destruction of the lateral wall of the sphenoid sinus causing abutment to the cavernous sinus and complete involvement of the pterygopalatine fossa and pterygoid base. One patient displayed full occupancy of the maxillary sinus as a consequence of erosion of the posterior and medial walls of the maxillary sinus, while another had severe temporal lobe compression through the roof of the infratemporal fossa. All patients underwent tumor excision using the maxillary swing approach. Patients were followed up for a minimum period of 1 year after surgery. The maxillary swing approach gave optimal exposure of the entire central skull base including the infratemporal fossa and its extreme lateral and superior aspects. Adequate tumor exposure and vascular control could be achieved in all cases resulting in complete tumor excision. The mean operative time was 4.5 h. Post-operative healing was satisfactory with palatal fistula formation in two cases and all patients remaining disease-free up to the present time. One had minimal misalignment of the halves of the upper jaw and two had epiphora, of which one required dacryocystorhinostomy. The maxillary swing is an effective approach in the management of extensive nasopharyngeal angiofibromas and leads to optimal anatomical exposure with minimal morbidity.

Extensive Nasopharyngeal Angiofibromas: The Maxillary Swing Approach

Objectives: Evaluate the efficacy and outcome of the maxillary swing approach for management of extensive nasopharyngeal angiofibromas. Methods: Retrospective analysis in a tertiary care center revealed 5 patients with extensive nasal angiofibromas operated on using the maxillary swing approach between 2010 and 2012. All patients had tumor extension to lateralmost portions of infratemporal fossa with complete occupation, destruction of lateral wall of sphenoid sinus causing abutment to cavernous sinus, and complete involvement of pterygopalatine fossa and pterygoid base. One patient displayed full occupancy of maxillary sinus in consequence to erosion of posterior and medial walls of maxillary sinus, with another causing severe temporal lobe compression through roof of infratemporal fossa. All patients underwent tumor excision with the maxillary swing approach. Patients were followed up for a minimum period of one year after surgery. Results: The maxillary swing resulted in an optimal exposure of the entire central skull base including the infratemporal fossa and its far lateral and superior aspects. An adequate tumor exposure and vascular control could be achieved in all cases resulting in complete tumor excision. The mean operative time was 4.1 hrs. Postoperative healing was satisfactory with palatal fistula formation in 2 cases with all patients remaining disease free till present. One had minimal misalignment of the halves of upper jaw and two had epiphora, of which one required dacryocystorhinostomy. Conclusions: The maxillary swing is an effective approach in management of extensive nasopharyngeal angiofibromas and leads to an optimal anatomical exposure with minimal morbidity.

Palatal fistulae: a comprehensive classification and difficulty index.

Palatal fistula formation is a known complication of palatoplasty. Numerous classifications have been proposed that help in identifying the location of fistula and systematically arrange data for record keeping. They do not assess the difficulty level of the fistula. Management of fistulae can be very tricky and a definitive success cannot be guaranteed even in the best of hands. Hence we devised a classification system and a difficulty index to help evaluate the difficulty level and plan the treatment accordingly to predict the prognosis prior to surgery. We reviewed 610 cases of palatal fistula operated at our center with a minimum follow-up of 6months from May 2003 to May 2010. They were classified according to our classification. Difficulty index was also assessed. The data was tabulated and analysed. Longitudinal fistulae showed a recurrence rate of 7.87% whereas transverse fistulae showed a recurrence rate of 19.66%. Total recurrence rate was 11.31%. Unilateral clefts with fistulae showed a recurrence of 6.55% whereas bilateral clefts with fistulae showed a recurrence of 14.17%. A total of 220 Grade 1 and 390 Grade 2 fistulae were managed. Out of these, 7 (3.18%) Grade 1 and 62 (15.90%) Grade 2 fistulae recurred. 90 % of failed fistulae showed decrease in the size of the fistula. Classification and evaluation of difficulty of palatal fistula is essential to plan the surgical treatment so as to give better results. Bidimensional fistulae in the anterior hard palate are associated with higher recurrence rate. Also, fistulae in bilateral clefts are more difficult to close than those in unilateral clefts. Classification of fistulae according to the difficulty index helps in pre-operative judgment of the outcome.

The Necessity of Nasal Layer Closure in Cleft Palate Repair

Sir:FigureWe read with keen interest the article entitled “Is Nasal Mucoperiosteal Closure Necessary in Cleft Palate Repair?” by Steinbacher et al. (Plast Reconstr Surg. 2011;127:768–773). This potentially groundbreaking concept of single-layer closure in the hard palate region offers a theoretical advantage of lesser midfacial growth disturbances. In addition, there is significant reduction in operating time. However, certain questions need to be clarified before incorporating this concept in “standard of care practice” for cleft palate patients. It is important for the authors to explain why they chose to perform single-layer palatal closure in this retrospective study. Was this group of patients having narrower cleft palatal widths to merit single-layer closure? This is pertinent, as the rate of palatal fistula formation does correlate with the cleft width and available palatal shelf width.1–3 The reason we suggest this selection bias is the considerable difference in surgical duration between the two groups (84 minutes for the single-layer closure group and 135 minutes in those with two-layer closure). Nasal mucosal elevation and closure alone in the hard palatal region is unlikely to account for such a disparity in duration in otherwise comparable group 1 patients. Thus, the application of the “null hypothesis” in this retrospective study without excluding the selection bias relating to palatal and cleft dimensions could have confounded the study results. Another issue relates to the management of lateral oronasal communication after mucoperiosteal flap mobilization in patients undergoing single-layer closure. This communication can be of significant dimensions to close spontaneously in the absence of perfect apposition of the undersurface of sutured palatal flaps to the hard palate bone. This situation is likely in the single-layer closure group patients with a wider cleft or vertically oriented palatal shelves. A prospective, randomized, controlled trial can effectively and convincingly answer the apprehensions regarding the concept put forward by the authors. Ramesh Kumar Sharma, M.Ch., D.N.B.(Plast. Surg.) Surinder Singh Makkar, M.Ch.(Plast. Surg.) Atul Parashar, M.Ch.(Plast. Surg.) Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

A rare complication after septoplasty procedure in a misdiagnosed submucous cleft palate case: Palatal fistula

Nasal septoplasty is a common and low-risk procedure performed very frequently in plastic surgery as well as in otorhinolaryngology. The development of a palatal perforation following a nasal septoplasty procedure is a very rare event with only a few cases reported in the literature. A patient with palatal fistula formation after septoplasty procedure is presented here, who was later on diagnosed with submucous cleft palate during the repair of the palatal fistula.

Width of cleft palate and postoperative palatal fistula – do they correlate?

This study was conducted to evaluate any correlation between the measured width of cleft palates and postoperative fistula formation. Prospective study design was used where 43 consecutive cases of patients with cleft lip and palate or isolated palate who underwent cleft palate repair in an institution were observed. A preoperative or peroperative dental impression of the upper jaw was taken for the measurement of various cleft parameters. Palatoplasty was done using the Von-Langenbeck procedure or modified Veau-Wardil-Kilner-type repair. Among these, only 31 patients could be followed up for at least 4 weeks after the surgery and were included in the study. The patients developing fistulas were evaluated with respect to size, site and initial cleft dimensions. Statistical evaluation of multiple variables was performed. It was found that the width of the cleft palate has a bearing on the occurrence of postoperative palatal fistula formation, with a width of 15 mm or more having a statistically significant risk of fistula formation. The strongest association was found for the ratio of cleft width to the sum of the palatal shelves width. As this ratio increases to 0.48 or more, the risk of fistula becomes statistically significant. The ratio of cleft width to the posterior arch width is also a strong predictor of fistula formation with the risk becoming higher if the ratio is more than 0.41. Thus, the concept of wide-cleft is not vague or irrelevant but has a bearing on postoperative fistula formation, as shown in this study.

Elimination of palatal fistula after the maxillary swing procedure

The maxillary swing procedure has been used as an anterolateral approach to expose the nasopharynx, the central skull base, and its vicinity. The reported incidence of postoperative palatal fistula has ranged from 20% to 25%. The oronasal incompetence especially associated with a large fistula has adversely affected normal speech, eating, and swallowing functions. We describe a modified palatal incision to reduce the incidence of palatal fistula associated with the maxillary swing procedure. Fifteen consecutive patients who underwent maxillary swing procedures for salvage resection of recurrent nasopharyngeal carcinoma after radiotherapy had the modified palatal incision. The flap was raised as described, and the outcome was analyzed. Fourteen patients' palatal wound healed uneventfully. One patient experienced partial flap necrosis, which healed with conservative treatment. All 15 patients tolerated oral feeding 1 week after the surgery. No palatal fistulas occurred. The modified palatal incision as described has effectively prevented palatal fistula formation after the maxillary swing procedure.

Increased Fistula Risk Following Palatoplasty in Treacher Collins Syndrome

Abstract Objective: Patients with Treacher Collins syndrome have abnormal vascular supply to the palate, yet it is unknown whether there are increased postoperative healing problems following palatoplasty. This study investigated the correlation between Treacher Collins syndrome and postoperative palatal fistula formation. Design: Retrospective chart review was performed. Patients: Children undergoing palatoplasty at Childrens Hospital Los Angeles from 1987 to 2000 were evaluated. Ten children with Treacher Collins syndrome, 92 children with other syndromes and cleft palate, and 458 nonsyndromic patients with isolated cleft palate were studied. Interventions: All children were treated with a one-stage, double-reversing Z-plasty cleft palate repair. Main Outcome Measures: Outcome measures included intraoperative observations of surgical anatomy and postoperative clinic follow-up of fistula formation. Palatal fistula rates between patients with Treacher Collins syndrome, other syndromes, and no syndrome wer...

Increased fistula risk following palatoplasty in Treacher Collins syndrome.

Patients with Treacher Collins syndrome have abnormal vascular supply to the palate, yet it is unknown whether there are increased postoperative healing problems following palatoplasty. This study investigated the correlation between Treacher Collins syndrome and postoperative palatal fistula formation. Retrospective chart review was performed. Children undergoing palatoplasty at Children's Hospital Los Angeles from 1987 to 2000 were evaluated. Ten children with Treacher Collins syndrome, 92 children with other syndromes and cleft palate, and 458 nonsyndromic patients with isolated cleft palate were studied. All children were treated with a one-stage, double-reversing Z-plasty cleft palate repair. Outcome measures included intraoperative observations of surgical anatomy and postoperative clinic follow-up of fistula formation. Palatal fistula rates between patients with Treacher Collins syndrome, other syndromes, and no syndrome were compared with chi-square analysis. Children with Treacher Collins syndrome had significantly greater palatal fistula rates (50%) than children with other syndromes (8.7%) or no syndrome (4.1%). Treacher Collins patients demonstrated large palatal fistulas and poor flap vascularity. Children with Treacher Collins syndrome and cleft palate have significantly higher palatal fistula risk than other children with cleft palate when double-reversing Z-plasty palate repair is performed. Our findings suggest that children with Treacher Collins syndrome and cleft palate may have poor vascularity to palatal flaps created during palatoplasty. Furthermore, we recommend that surgeons performing palatoplasty minimize the dissection of mucoperiosteal flaps around the greater palatine arterial pedicle and utilize closure techniques creating the least vascular disruption of palatal tissue.