they may occur at any point and age along the line of the repaired cleft .
reported recurrence range , after surgical correction of cleft palate , varies between a wide range of 10% and 30% depending on the technique used and age at the time of primary repair .
small fistulas may be asymptomatic but patients commonly complain of regurgitation of liquids into the nose , and food may become impacted with resultant malodor .
palatal fistulas can be variedly located in reconstructed palate starting from alveolar margin to anterior third , middle third , or posterior one - third of palate .
the probable cause for occurrence of anterior palatal fistulas ( apfs ) is anatomically shorter lesser segment , wide palatal cleft defect with thin palatal shelves , improper reflection of subperiosteal flap , and improper closure .
this study is a retrospective record review of patients diagnosed with apf in 3.5 years ( which reported in our unit between january 2010 and july 2013 ) .
a total number of 91 patients with anterior palate fistula were operated in this duration .
there were forty cases of unilateral apf which were treated with one or another technique surgically depending on various factors influencing the choice of surgical technique .
patients were categorized in the study depending on the procedure followed for the apf closure .
analysis of preoperative , immediate postoperative , and 1-month follow - up pictures was done to check for the site of occurrence , type of cleft , evaluation of adjacent tissue , size of fistula , postoperative healing , and closure with various techniques to compare and evaluate the results and outcome along with complication if any . out of the forty patients included in the study ,
primary palate closure of ten patients was done in our unit ( bhagawan mahaveer jain hospital , bengaluru , india ) , whereas thirty were treated elsewhere for repair of cleft palate primarily . in the study ,
unilateral apfs were evaluated depending on their site of occurrence , type of cleft , evaluation of adjacent tissue , and the size of fistulae .
depending on the site of occurrence , apf were categorized into three locations : alveolar fistulae , alveolar fistulae extending to hard palate , and fistulae in hard palate [ figure 1 ] .
( c ) fistula in hard palate all the palatal fistulas were evaluated for the adjacent tissue in which the quality of tissue was assessed if it is a normal anatomical tissue or secondary mucolized tissue postpalatoplasty .
( b ) normal anatomical tissue techniques adopted for closure of apf were anterior palate redo with bardach 's principle [ figure 3 ] , closure with rotation of island flap [ figure 4 ] , closure with crevicular flap , closure with buccal advancement flap , and closure with tongue flap and vomer flap . ( a ) unrepaired anterior palatal fistula .
as shown in table 1 , forty cases were split for surgical correction into various options depending on their size , site , and quality of the tissue .
most of the cases were operated with a bardach 's redo for fistula closure ( n = 16 ) ( 40% ) and crevicular flap technique ( n = 13 ) ( 32.5% ) .
our overall success ( satisfactory results ) was 77.5% as observed in 31 out of 40 cases with individual success rates for bardach 's and crevicular being 75% and 77% , respectively . there was reduction in size of fistula in three cases ( 7.5% ) and a remnant pinpoint hole in four cases ( 10% ) among all the operated cases .
we observed just two breakdowns of repair in forty cases . during evaluation of all the three cases managed with vomer flap ,
results were considered satisfactory in case of the absence of any symptomatic or asymptomatic fistula , no particular complaints by patient or nasal regurgitation . indicating the split up of 40 cases into various surgical techniques adapted for apf closure and comparison of result
even today , cleft palate and its associated surgical repair are rated among the greatest challenges in reconstructive surgery . a successful treatment outcome expected after repair of cleft palate includes achieving normal speech without increasing maxillofacial growth disturbances .
factors predisposing to development of postoperative dehiscence or fistula include width of the palatal cleft , amount of deficiency of palatal segment , misplacement , and distortion of the cleft segment .
other extrinsic variables considered for the fistula formation are the timing of repair , sex of the patient , surgical procedures , and the operating surgeon .
early dehiscence and fistulas are primarily caused by errors in technique such as inadequate mobilization , closure under tension , injury at reintubation , poor handling of the tissue , failure to achieve a layered closure , and postoperative bleeding and infection .
denny and amm proposed closure of palatal fistula with anterior palate redo with bardach 's principle .
they documented the technique of total palatal elevation to be a safe and reproducible technique for closure of hard palate fistulas using local palatal flaps .
the authors were of the opinion that this technique possesses added advantage of allowing direct visualization of all the elements essential for a successful repair .
our results held resemblance to this concept since we were able to achieve a successful treatment outcome in 75% of the cases .
henderson discussed the use of advancement island flap for the closure of apf and named it as the  tadpole flap . 
although lesser number of defects were repaired in the current case series with island flap , but almost all of them showed satisfactory healing outcome .
carstens in his study put forward the sequential cleft management with sliding sulcus technique and alveolar extension palatoplasty .
he stated that conventional methods of cleft lip repair deprive the anterior ( buccolingual ) alveolar mucoperiosteum of blood supply from the facial - internal maxillary arcade .
after 6 months , while performing palatoplasty , the lingual incisions permanently isolate the lingual mucoperiosteum from vascular supply which is the greater palatine artery , thereby transforming the osteogenic alveolar mucoperiosteum from a richly supplied boundary zone between the two angiosomes into an isolated tissue surviving primarily on osseous backflow .
subperiosteal techniques that preserve the blood supply to this tissue is considered in a sequential plan of cleft management .
the authors were able to perform apf repair in 13 cases through this technique in our study with a predictable healing result in 77% cases .
another approach utilized by jackson for the management of small- and moderate - sized fistulae involved a combination of buccal and palatal flaps along with bone grafting .
however , such an intervention was performed in fewer number of patients in this study .
another attempt made by the surgeons to repair apfs with secondary mucolized tissue involved creating a vomer flap in small figure of three which was associated with significantly improved healing outcome in all the cases .
perhaps , an exclusive study on fate of vomer flap would provide more precise details regarding the predictability of this technique .
henceforth , the authors have made an effort to put forward treatment options for apf depending on their location by means of a simplified algorithm [ figure 5 ] .
for an apf , exclusively in alveolus buccal flap or crevicular flap can be used if patients ' age is over 11 years , whereas for patients ' younger than this secondary alveolar bone grafting with or without prior orthodontics or buccal flap appear to be more suitable . during management of fistulas extending to hard palate or into the hard palate , selection of the treatment modality depends on a major extent on the tissue quality . in case of normal palatine tissue ,
whereas in cases with secondary mucolised tissue , if it is present over greater segment , a vomer flap is advocated ; if it is bilateral , tongue flap is advised ; and in case of lesser segment , rotation of the greater segment is recommended .
the current study was based on a stringent protocol regarding the selection of a surgical treatment plan based on anatomical location of fistula and the quality of surrounding tissue .
postoperative follow - up of maximum number of cases revealed minimal complication or recurrence rate .
additional factors that could be included in future studies for similar clinical cases include speech , etiology of fistula , and width of palate at the time of primary closure .
furthermore , we believe that a long - term follow - up of at least 6 months would be better to provide more reliable result
 aim : aim of this retrospective study was to access the various surgical treatment options available for repair of anterior palatal fistula depending upon their size and presenting age , and also to anticipate the treatment outcome.materials and methods : the series include study report of forty patients with secondary anterior palatal fistula post cleft palate repair , reported in a single unit during a duration of 3 years . 
 all the cases were managed surgically under general anesthesia . 
 the patients were classified depending upon the location of anterior palatal fistula ( apf ) , the quality of tissue and age of patients to chalk out a justified treatment option outlay.results:forty cases were split for surgical correction into various options depending on their size , site , and quality of the tissue . 
 most of the cases were operated with a bardach 's redo for fistula closure ( n = 16 ) ( 40% ) and crevicular flap technique ( n = 13 ) ( 32.5% ) . 
 our overall success ( satisfactory results ) was 77.5% as observed in 31 out of 40 cases with individual success rates for bardach 's and crevicular being 75% and 77% , respectively . 
 there was reduction in size of fistula in three cases ( 7.5% ) and a remnant pinpoint hole in four cases ( 10% ) among all the operated cases.conclusion:management of post palatoplasty fistulas of the hard palate presents a challenging situation for a clinician following the surgical correction of cleft palate . 
 current paper describes the diagnosis and clinical management of forty cases reporting with unilateral apf following cleft palate surgery , over 3 years . 
 authors have attempted to propose different treatment modalities for surgical management of unilateral apf . 
 it was concluded in the primary review that the size of fistula was irrelevant in determining the clinical outcome . 
 instead , the quality and condition of the adjacent tissue appear to be the major governing factors for selecting treatment modality as well as the surgical consequences . 