Re-evaluating fistula management in cleft palate: longitudinal changes and risk determinants after double-opposing Z-plasty

Abstract

Longitudinal follow-up data of 1557 patients with cleft palate (CP) was used to identify risk factors for palatal fistula (PF) formation after double-opposing Z-plasty (DOZ), performed by a single surgeon. Overall, 104 (6.7%) of the patients developed PF, all of which were identified within the first month following DOZ. The incidence of PF for clefts of Veau class 1, 2, 3, and 4 was 0%, 6.5%, 4.4%, and 20.3%, respectively. The PFs were pinpoint-shaped in 38.5% of cases, slit-shaped in 40.4% (2–8 mm), and other (10–96 mm²) in 21.1% . Among patients with PF, 14 (13.5%) chose surgical repair; recurrence was observed in four patients, of whom two showed secondary healing. Among the 90 unrepaired cases, 68 (75.6%) showed symptom resolution, mostly within 1–3 years. Recovery varied by PF size category: 81.1% of pinpoint, 71.4% of slit-shaped, and 100% of other fistulas healed spontaneously over a median 9, 3, and 21.5 months, respectively. Multivariate logistic regression analysis identified cleft width as the most significant predictor of PF development (odds ratio 1.25, P < 0.001), while the Veau classification was not a significant determinant. This study identified cleft width as a critical determinant of the risk of PF following DOZ. A conservative strategy that prioritizes symptomatology over PF size (for PFs <1 cm²) is worthy of consideration.