Oronasal Fistula Repair Research Articles

A Review of the Use of Buccal Fat Pad in Cleft Palate Repair.

To review the available evidence on the use of the Buccal Fat Pad in primary and secondary Cleft Palate repair. This is a narrative review. A computerized literature search was conducted for articles published till February 2022 using the Mesh phrases buccal fat pad AND cleft palate, Bichat's Fat pad AND cleft palate, buccal fat pad OR Bichats Fat pad AND cleft palate. A total of 35 articles were included in this review based on the set eligibility criteria. Most of the studies were retrospective case reviews (n = 16, 45.7%), and the aggregate number of patients from all included studies was 666. Reported uses of the buccal fat pad (BFP) in association with cleft palate repair include the closure of central cleft palate defect and nasal floor in primary cleft palate repair, oronasal fistula repair following primary repair of cleft palate, and closure of relieving incision defect in primary repair of cleft palate. Complications reported were 24 cases of Oronasal Fistula (ONF), 2 dehiscences, and 4 transient mucosal defects. The high success rate, vascularity, ease of tissue harvest, and low donor site morbidity all support its use as an adjunct flap in cleft palate repair, especially in the closure of wide palatal clefts, to prevent post-palatal repair fistula, wound contracture, and subsequently velopharyngeal insufficiency and possibly midface hypoplasia.

Oronasal fistula repair with Combined Endoscopic & Transoral Approach (3 layer): Case report & Review of Literature

Oronasal fistula repair with Combined Endoscopic & Transoral Approach (3 layer): Case report & Review of Literature

Changes in the microbiome during oral wound healing

• Given that microbes in the oral cavity can impact health and disease, manipulating the oral microbiome may be a viable option in health. • Results demonstrate that identifying candidate beneficial microbes that promote oronasal fistula healing is critical to developing new therapies that promote healing. • Overuse of antibiotics during oronasal fistula repair surgery has significant long -term effects in pediatric populations. • Use of novel methodologies for delivering probiotics to oral wounds using hydrogel and porous scaffold technologies are clearly warranted. • Improving oral wound healing may limit the devastating impact of oronasal fistulas on the quality of life of children. The microbiome is a numerically vast and taxonomically diverse microbial community that includes bacteria, fungi and viruses. The microbiome inhabits all exposed surfaces of the body and exist in a symbiosis with the host in health individuals. The microbiome can affect normal physiology of a number of host organs and systems, while a disturbance in the microbiota community structure, or failure of host responsive mechanisms to the microbiome have been implicated in a variety of disease etiologies. One of the least well-funded areas of microbiota research in relation to health and disease is the community of microbes that inhabits the oral cavity. Here, we outline the importance of the influence of the oral microbiome on healthy oral tissue homeostasis, the therapeutic options of treatment with live bacteria for diseased states within the oral cavity, and how the oral microbiome may influence healing of oral wounds resulting from oroantral and oronasal fistulas. In addition, we discuss the oral microbiome in relation to its influence on bodily organs distant from the alimentary canal, and on systemic health and disease.

Racial Disparities Affect Timing of Alveolar Bone Grafting for Patients With Cleft Lip and Palate: An Analysis of the 2012 Kids’ Inpatient Database

Objective: The timing of alveolar bone graft (ABG) for patients with cleft lip and palate is critical to the success of the operation. Sociodemographic factors have been implicated in delaying surgery for other diagnoses but their impact on patients undergoing ABG is unknown. The purpose of this study is to examine the association of sociodemographic factors on the age of patients undergoing ABG. Methods: The Kids’ Inpatient Database (KID) from 2012 was used to define a cohort of patients with cleft lip and/or palate between the ages of 5 and 14. Patients were selected using ICD-9 procedure codes for repair of oronasal fistula and bone graft. Gender, race, income quartile, hospital region, and type of insurance were used as independent variables. Time to ABG was then calculated as hazard ratios (HR) of having surgery using Cox regression models with 95% confidence intervals. Results: A cohort of 395 patients was identified. Median age at ABG was 9 ± 0.15 years. On univariate analysis, Non-Hispanic Black (NHB) patients underwent surgery later than Non-Hispanic White (NHW) patients (11.13 ± 0.44 years vs 9.67 ± 0.19 years, P = .0026). Patients in the higher 2 income quartiles were more likely to have an early surgery as compared to those in the lowest quartile (9.16 ± 0.43 and 9.32 ± 0.43 years vs 10.20 ± 0.33, P = .016 and 0.043 respectively). No factor was significant on multivariate analysis. Conclusions: Patients who are NHB are associated with delayed time to ABG as compared to NHW. Conversely, those in the upper income quartile by zip code underwent surgery at an earlier age. While this study identifies demographic factors associated with delay of ABG, more research is needed to understand the direct causal effects for this delay in surgery and its implication for future growth and need for orthognathic surgery.

Prevention and management of oronasal fistulas.

The aim of this article is to present the current opinion on the prevention and management of oronasal fistulas in cleft palate patients. 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. 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.

Maxillofacial morphology in post-pubertal patients with unilateral cleft lip and palate following early vs. late secondary alveolar bone grafting

The study aimed at comparing maxillofacial morphology and burden of surgical treatment in post-pubertal patients with unilateral cleft lip and palate (UCLP) following early vs. late secondary alveolar bone grafting (SABG).In this retrospective study maxillofacial morphology was assessed on lateral cephalograms of skeletally matured patients with UCLP operated on consecutively in one center by the same method of one-stage primary cleft repair followed by SABG. Cephalometric analysis comprised 8 angular and 7 linear measurements. Maxillary growth restriction was evaluated by measuring SNA angle and Co-A and PNS-A distances. Five linear regression models with SNA, SNB, ANB, Co-A, and MP/SN as dependent variables and age at primary cleft repair, age at SABG, age at taking cephalogram, surgeon, and total number of surgical interventions as independent variables were also created.135 patients were included in the study - 70 patients (47 males and 23 females) had early SABG (E-SABG group) and 65 patients (40 males and 25 females) had late SABG (L-SABG group). Mean age at bone grafting procedure was 2.7 years (range 1.5–5.9, SD 1.1) and 10.3 years (range 6.1–18.8, SD 3.2) in E-SABG and LSABG group respectively. The variables describing the degree of maxillary growth restriction – SNA, Co-A, and PNS-A – were comparable in both groups (p = 0.707, 0.116, and 0.932, respectively). Regression models demonstrated that independent variables were not associated with the values of SNA angle, SNB angle, ANB angle, MP/SN angle, and Co-A distance (p = 0.761, 0.088, 0.249, 0.380, and 0.363, respectively). The percentages of oronasal fistula repair, VPI repair, repeated SABG, upper lip correction, rhinoplasty, orthognathic surgery were 22.9, 7.1, 15.7, 24.3, 42.9, 2.9 in E-SABG group and 27.7, 7.7, 9.2, 36.9, 47.7, 3.1 in L-SABG group respectively. Mean number of all surgical interventions was 3.2 in E-SABG and 3.4 in L-SABG group, respectively (p = 0.271).Considering the comparable maxillofacial morphology and burden of surgical care in matured patients after early and late SABG, the choice of timing of bone grafting surgery could be left to the discretion of the surgeon.

Is Risk of Secondary Surgery for Oronasal Fistula Following Primary Cleft Palate Repair Associated With Hospital Case Volume and Cost-to-Charge Ratio?

This study assesses the association between risk of secondary surgery for oronasal fistula following primary cleft palate repair and 2 hospital characteristics-cost-to-charge ratio (RCC) and case volume of cleft palate repair. Retrospective cohort study. This study utilized the Pediatric Health Information System (PHIS) database, which consists of clinical and resource-utilization data from >49 hospitals in the United States. Patients undergoing primary cleft palate repair from 2004 to 2009 were abstracted from the PHIS database and followed up for oronasal fistula repair between 2004 and 2015. The primary outcome measure was whether patients underwent oronasal fistula repair after primary cleft palate repair. Among 5745 patients from 45 institutions whom met inclusion criteria, 166 (3%) underwent oronasal fistula repair within 6 to 11 years of primary cleft palate repair. Primary palatoplasty at high-RCC facilities was associated with a higher rate of subsequent oronasal fistula repair (odds ratio [OR] = 1.84 [1.32-2.56], adjusted odds ratio [AOR] = 1.81 [1.28-2.59]; P ≤ .001). Likelihood of surgery for oronasal fistula was independent of hospital case volume (OR = 0.83 [0.61-1.13], P = .233; AOR = 0.86 [0.62-1.20], P = .386). Patients with complete unilateral or bilateral cleft palate were more likely to receive oronasal fistula closure compared to those with unilateral-incomplete cleft palate (AOR = 2.09 [1.27-3.56], P = .005; AOR = 3.14 [1.80-5.58], P < .001). Subsequent need for oronasal fistula repair, while independent of hospital case volume for cleft palate repair, increased with increasing hospital RCC. Our study also corroborates complete cleft palate and cleft lip as risk factors for oronasal fistula.

Evaluation of Platelet Rich Fibrin Sandwiching technique with mixture of alloplastic bone graft and Hyaluronic Acid in repair of Recurrent Oronasal Fistula

Aim: is to evaluate efficacy of platelet rich fibrin (PRF) sandwiching technique associated with hyaluronic acid (HyA) mixed with alloplastic bone graft in closure of recurrent oronasal fistula after previously alveolar cleft grafting. Subjects and Methods: Our study conducted on 24 patients with recurrent unilateral oronasal fistula complaining of oronasal leakage. They were divided into two random equal groups. Group I, alveolar cleft defect was packed with alloplastic bone graft ( osteon II collagen) between two layers of PRF gel. While, in group II, alveolar cleft defect was packed with a mixture of alloplastic bone graft (osteon II collagen) and HyA between the two layers of PRF gel. All patients were observed clinically and radiographically (CBCT) for evaluation after three and six months postoperatively. Results: Our clinical results revealed that, all patients had uneventful wound healing except 4 cases in group I and one case in group II which had wound dehiscence and graft exposure at 1-week postoperatively. The radiographic results by CBCT scans showed a better new bone formation and good osseous union obliterating the oronasal defect.in group II than group I. There was a significant difference between bone density and bone resorption values in both groups at all intervals. Conclusion : Our results demonstrated that PRF sandwiching technique combined with a mixture of alloplastic bone graft and HyA could provide a favorable bony and soft tissue barriers for closure of recurrent oronasal fistula in alveolar cleft patients.

Patients With a History of Oronasal Fistula Repair Exhibit Lower Oral Health Measured With Patient-Centric Outcomes Measures.

Oronasal fistulae following palatoplasty may affect patients' quality of life by impacting their ability to eat, speak, and maintain oral hygiene. We aimed to quantify the impact of previous oronasal fistula repair on patients' quality of life using patient-reported outcome psychometric tools. A cross-sectional study of 8- to 9-year-old patients with cleft palate and/or lip was completed. Patients who had a cleft team clinic between September 2018 and August 2019 were recruited. Participants were divided into 2 groups (no fistula, prior fistula repair). Differences in the individual CLEFT-Q and Child Oral Health Impact Profile-Short Form 19 (COHIP-SF 19) Oral Health scores between the 2 groups were evaluated using a multivariate analysis controlling for Veau classification and syndromic diagnosis. Sixty patients with a history of cleft palate were included. Forty-two (70%) patients had an associated cleft lip. Thirty-two (53.3%) patients had no history of fistula and 28 (46.7%) patients had undergone a fistula repair. CLEFT-Q Dental, Jaw, and Speech Function were all higher in patients without a history of a fistula repair; however, none of these differences were statistically significant. The COHIP-SF 19 Oral Health score demonstrated a significantly lower score in the fistula group, indicating poorer oral health (P = .05). One would expect that successful repair of a fistula would result in improved function and patient satisfaction, but the consistent trend toward lower CLEFT-Q scores and significantly increased COHIP-SF 19 Oral Health scores in our study group suggests that residual effects linger and that the morbidity of a fistula may not be completely treated with a secondary correction.

An Analysis of Procedural Medicare Reimbursement Rates in Craniofacial Plastic Surgery: 2000–2019

PURPOSE: An understanding of financial trends is important to advance agreeable reimbursement models in craniofacial surgery. This study aimed to evaluate trends in Medicare reimbursement rates for commonly billed craniofacial surgery procedures from 2000 to 2019. METHODS: Commonly billed craniofacial surgery procedures were identified by a pediatric craniofacial surgeon and referenced with The Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use File. Reimbursement data were extracted from The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services for each Current Procedural Terminology code. Monetary data was adjusted for inflation to 2019 US dollars utilizing changes to the United States consumer price index. The average annual and total percentage changes in reimbursement were calculated based on these adjusted trends. RESULTS: The average adjusted reimbursement for all procedures decreased by 14.17% from 2000 to 2019. The greatest mean decrease was observed in repair of oronasal fistula (−21.95%). The only procedure with an increased adjusted reimbursement rate was palatoplasty with attachment of pharyngeal flap (+2.62%). From 2000 to 2019, the adjusted reimbursement rate for all procedures decreased by an average of 0.71% annually. CONCLUSION: This is the first study evaluating trends in procedural Medicare reimbursement in craniofacial surgery. When adjusted for inflation, Medicare reimbursement for the included procedures has steadily decreased from 2000 to 2019. Increased consideration of these trends will be important for US policy-makers, hospitals, and surgeons to assure continued access to meaningful craniofacial surgery.

A Toolbox of Surgical Techniques for Palatal Fistula Repair.

To provide an inventory of oronasal fistula repair techniques alongside expert commentary on which techniques are appropriate for each fistula type. A 4-stage approach was used to develop a consensus on surgical techniques available for fistula repair: (1) in-person discussion of oronasal fistula cases among cleft surgeons, (2) development of a schema for fistula management using transcripts of the in-person case discussion, (3) evaluation of the preliminary schema via a web-based survey of additional cleft surgeons, and (4) revision of the management schema using survey responses. Six cleft surgeons participated in the in-person case discussion. Eleven additional surgeons participated in the web-based survey. Participants had diverse training experiences, having completed residency and fellowship at 20 different hospitals. A schema for fistula management was developed, organized by fistula location. The schema catalogues all viable approaches for each location. For fistulae involving the soft palate, the schema stresses the importance of evaluating for velopharyngeal insufficiency (VPI) and incorporating VPI management into fistula repair. For fistulae involving the hard palate, the schema separately enumerates the techniques available for nasal lining repair and for oral lining repair in each region. The schema also catalogues the diversity of approaches to lingual- and labioalveolar fistula, including variation in timing, orthodontic preparation, and simultaneous alveolar bone grafting. This study employed consensus methods to create a comprehensive inventory of available fistula repair techniques and to identify preferential techniques among a diverse group of surgeons.

Dissection in the Pyramidal Space for Effective Relief of Tension in Cleft Palate Repair.

Although several methods of note have been reported for the repair of cleft palate, wound separation and oronasal fistula can still occur. This study reports a useful technique of dissection in the pyramidal space for adequate release of tension and the prevention of palatal fistula. A total of 404 consecutive patients with cleft palate with or without cleft lip who had received standard surgical repair were evaluated. The mucoperiosteal flaps were raised from the hard palate. Dissection was performed in the pyramidal space to expose the greater palatine foramen, neurovascular pedicle, pyramidal process of the palatine bone, opening to the space of Ernst, and hamulus with tensor veli palatini aponeurosis. The restricting ligamentous fibers lateral and posterior to the pedicle were released. The hamulus process was divided at its root and pushed medially for further relief and medial mobilization of the flap. Closure of the flaps was achieved with minimal tension in the midline. The patients received regular postoperative follow-ups. Only 1 case was found to have postoperative palatal fistula, resulting in a fistula rate of 0.25% during the 11-year study period. Adequate dissection in the pyramidal space helped to close the palatal flaps with minimal tension and prevent the formation of palatal fistula.

Repair of Primary Cleft Palate and Oronasal Fistula With Acellular Dermal Matrix: A Systematic Review and Surgeon Survey

The current review and survey aim to assess the effectiveness of acellular dermal matrix (ADM) in the repair of cleft palate and oronasal fistula and to evaluate the current trends of ADM use in palate surgery. A systematic review of English articles was conducted using MEDLINE (1960 to July 1, 2016), the Cochrane Controlled Trials Register (1960 to July 1, 2016), and EMBASE (1991 to July 1, 2016). Additional studies were identified through a review of references cited in initially identified articles. Search terms included "cleft palate," "palatal," "oronasal fistula," "acellular dermal matrix," and "Alloderm®." An online survey was disseminated to members of the American Cleft Palate-Craniofacial Association to assess current trends in ADM use in palate surgery. All studies evaluating the outcome of primary palate repair or repair of oronasal fistula with the use of aceullar dermal matrix products were included in the review. Twelve studies met inclusion criteria for review. Studies were generally of low quality, as indicated by methodological index for non-randomized studies (MINORS) scores ranging from 7 to 14. The pooled estimate for fistula formation after primary palatoplasty following ADM use was 7.1%. The pooled estimate for recurrence of fistula after attempted repair using ADM was 11%. Thirty-six cleft surgeons responded to the online survey study. Of these, 45% used ADM in primary cleft palate repair, while 67% used ADM for repair of oronasal fistulae. Use of ADM products is commonplace in palate surgery. Despite this, there is a paucity of high-quality data demonstrating benefit. Further randomized controlled trials examining ADM in palate surgery are required to help develop structured guidelines and improve care.

Incidence of Secondary Surgery after Modified Furlow Palatoplasty: A 20-Year Single-Surgeon Case Series.

Objective To determine the occurrence of velopharyngeal insufficiency (VPI) requiring surgery and fistula repair after primary palatoplasty using a "modified" Furlow technique. Study Design Case series with chart review. Setting Academic multidisciplinary cleft and craniofacial center. Subjects and Methods Children younger than 18 years at presentation, with unrepaired cleft palate, with or without cleft lip, including submucous clefts, who underwent palatoplasty were included. No cleft patients having primary repair were excluded. All operations were conducted by a single surgeon from March 1994 through December 2013. Charts were reviewed for demographics, cleft type, genetic syndrome, operations performed, and complications, including VPI and oronasal fistula. Results In total, 312 consecutive patients underwent primary palatoplasty (160 [51.3%] male) with a median age of repair of 0.95 (range, 0.47-17.6) years and followed for 6.49 (range, 4.0-20.2) years. Robin sequence was diagnosed in 109 (34.9%), 104 (33.4%) had alveolar clefts, and 27 (8.7%) had concomitant gingivoperiosteoplasty. A modified Furlow was performed in 289 (92.6%). Overall, 16 (5.1%) required subsequent pharyngeal flap for VPI, and 48 (15.4%) required oronasal fistula repair. Veau class II had higher pharyngeal flap rates ( P = .033). Fistula repair was lower in Veau I ( P < .001) but higher in Veau II ( P < .001) and IV ( P = .002). Older age ( P = .034) and Robin sequence ( P = .017) were associated with higher rates of oronasal fistula repair. Conclusions The modified Furlow palatoplasty yields acceptable rates of secondary surgery for VPI without selection based on cleft width. While our oronasal fistula repair rate is high, it is concordant with previous reports and is likely related to our rare use of lateral relaxing incisions.

Osteocutaneous Second-Toe Free Flap as Alternative Option for Repair of Anterior Oronasal Fistula

Palatal fistulas anterior to the incisive foramen, generally seen as a complication of cleft lip and cleft palate repair, can be extremely difficult to repair. The requirements of the defect necessitate nasal lining, oral lining, and bone for maxillary arch continuity. Local pedicled flap has limited use in such patients with extensive scarring from previous surgeries. The authors have recently described a technique involving osteocutaneous free-tissue transfer of second toe for anterior oronasal fistulas. The authors describe their experience of patients with anterior oronasal fistula who underwent osteocutaneous free-tissue transfer of second toe. Between 1991 and 2014, 3 patients with oronasal fistulas were operated utilizing bilaminar osteocutaneous free tissue transfer. Described are the surgical decision making, postoperative course, and surgical outcomes. The mean age of the patients at the time of the procedure was 45.3 years with a mean follow-up of 12.6 years. All the patients had significant improvement of their regurgitation and speech difficulty. One of the patients with very large fistula had recurrence of the fistula which was repaired by local advancement of the original free flap. Use of osteocutanous second-toe free flap can provide complete coverage of the fistula with nasal and oral skin lining and provides an alternative option for complicated anterior oronasal fistula.

Spacer Facial Artery Musculomucosal Flap: Simultaneous Closure of Oronasal Fistulas and Palatal Lengthening.

In this series, the authors describe a modification of the facial artery musculomucosal flap for oronasal fistula repair. The spacer facial artery musculomucosal flap technique is characterized by a pedicle inset into the retromolar trigone and palate, obviating a second operative stage. This was performed in 14 patients with a 5.2-cm mean fistula size. Average follow-up was 4.3 years, with one partial flap necrosis but no recurrent oronasal fistula. There was a mean decrease of 18 percent in the distance between the velum and the posterior pharyngeal wall. The spacer facial artery musculomucosal flap provides a single-stage reconstruction of oronasal fistula while lengthening the palate through a pushback mechanism. Although further study of velopharyngeal function is needed, the spacer facial artery musculomucosal flap may be beneficial for patients with a short velum and an oronasal fistula. Therapeutic, IV.

Equine oronasal fistula repair: Clinical commentary from a human surgery perspective

Equine oronasal fistula repair: Clinical commentary from a human surgery perspective

Change in Quality of Life with Velopharyngeal Insufficiency Surgery.

(1) To define the minimal clinically important difference (MCID) of the Velopharyngeal Insufficiency (VPI) Effects on Life Outcomes (VELO) instrument, and (2) to test for the change in quality of life (QOL) after VPI surgery. Prospective observational cohort. VPI clinic at a tertiary pediatric medical center. Children with VPI and their parents completed the VELO instrument (higher score is better QOL) at enrollment and then underwent VPI surgery (Furlow palatoplasty or sphincter pharyngoplasty, n = 32), other treatments (obturator or oronasal fistula repair, n = 7), or no treatment (n = 18). They completed the VELO instrument again and an instrument of global rating of change in QOL at 1 year. The MCID was anchored to the global change instrument scores corresponding to "a little" or "somewhat" better. Within-group (paired t test) and between-group (Student t test) changes in VELO scores were tested for the VPI surgery and no treatment groups. The association between treatment group and change in VELO scores was tested with multivariate linear regression, adjusting for confounders. Follow-up was obtained for 37 of 57 (65%) patients. The mean (±standard deviation) change in VELO scores corresponding to the MCID anchor was 15 ± 13. The VELO score improved significantly more in the VPI surgery group (change, 22 ± 15; P < .001) than in the no treatment group (change, 9 ± 12; P = .04), after adjusting for confounders (P = .007 between groups). VPI surgery using the Furlow palatoplasty or sphincter pharyngoplasty improves VPI-specific QOL, and the improvement is clinically important.

Is alveolar cleft reconstruction still controversial? (Review of literature).

Cleft lip and palate (CL/P) is a frequent congenital malformation that manifests in several varieties including unilateral or bilateral and complete or incomplete. Alveolar cleft reconstruction remains controversial with regard to timing, graft materials, surgical techniques, and methods of evaluation. Many studies have been conducted addressing these points to develop an acceptable universal protocol for managing CL/P. The primary goal of alveolar cleft reconstruction in CL/P patients is to provide a bony bridge at the cleft site that allows maxillary arch continuity, oronasal fistula repair, eruption of the permanent dentition into the newly formed bone, enhances nasal symmetry through providing alar base support, orthodontic movement and placement of osseointegrated implants when indicated. Other goals include improving speech, improvement of periodontal conditions, establishing better oral hygiene, and limiting growth disturbances. In order to rehabilitate oral function in CL/P patients alveolar bone grafting is necessary. Secondary bone grafting is the most widely accepted method for treating alveolar clefts. Autogenous bone graft is the primary source for reconstructing alveolar cleft defects and is currently the preferred grafting material.

Inferior Turbinate Flap for Nasal-side Closure of Palatal Fistula in Cleft Patients: Technical Note.

Summary:Residual palatal fistula after repair of palatal cleft is common. Repair of residual oronasal fistula is not always successful. Two-layer closure techniques that close these fistulas with soft tissue are a common practice. Turnover flaps are the most used flaps and often the sole method for nasal-side closure of fistula. Anteriorly based inferior turbinate flap can be used to provide soft tissue for nasal-side closure when turnover flaps will not provide sufficient tissue for this purpose. Under general anesthesia with nasotracheal intubation, inferior turbinate was released from posterior attachment. After removing the inferior conchal bone, mucoperiosteal flap was used for nasal-side closure of anterior palatal fistula in patients with cleft. Anteriorly based inferior turbinate flap was used for nasal-side closure of residual palatal fistula in 3 patients with cleft. Age of the patients was 14, 16, and 18, and recurrence of palatal fistula has not occurred. Anteriorly based inferior turbinate flap is an axial pattern flap with appropriate surface of the paddle and vicinity to the oral cavity roof. It can be used in large anterior, palatal fistula for reconstruction of nasal floor. Considering appropriate another flap for oral side coverage of such fistula is mandatory.