Acellular Dermal Matrix Use in Cleft Palate and Palatal Fistula Repair: A Potential Benefit?

Effect of Acellular Dermal Matrix on Long-Term Speech Outcomes in Primary Palatoplasty with Radical Intravelar Veloplasty

OBJECTIVE

This study investigates whether the use of acellular dermal matrix (ADM) affects the long-term speech outcomes in patients undergoing primary palatoplasty with radical intravelar veloplasty.

DESIGN

Retrospective cohort study.

SETTING

Tertiary university-affiliated hospital.

PARTICIPANTS

A consecutive cohort of 112 patients who underwent primary palatoplasty with radical intravelar veloplasty from August 2014 to March 2018 were included.

MAIN OUTCOME MEASURES

A 2 × 2 cm-sized ADM was incorporated as an interpositional graft between the oral and nasal lining at the soft-hard palate junction. The perceptual analysis of hypernasality and articulation was performed when the age of the patient reached at least 36 months. Cleft-related characteristics and surgical factors affecting the speech outcomes were investigated.

RESULTS

The ADM was applied in 57 patients with a mean follow-up of45.76 months (SD, 10.69), while no ADM was used in 55 patients with a mean follow-up of 48.43 months (SD, 14.98). Regarding the hypernasality outcome, 33.3% (19 of 57 patients) of the ADM group and 27.3% (15 of 55 patients) of the control group showed a greater than mild-to-moderate degree. The distribution of hypernasality and articulation grade showed no significant difference between the two groups. After controlling for potential risk factors that may affect the speech outcomes, the use of ADM showed no significant relationship with velopharyngeal insufficiency.

CONCLUSION

The use of ADM use in primary palatoplasty with radical intravelar veloplasty is not associated with the alteration of speech function in early childhood.

Secondary Procedures on the Palate to Correct/Improve Speech: Past, Present and Future

Speech production in general and in patients with cleft palate in particular is multifactorial. In addition to the complex velopharyngeal mechanism, all structures of the oral cavity have some contribution for correct speech production. Therefore, in addition to the velopharynx the surgeons and other cleft/craniofacial team members need to perform a thorough and complete evaluation of all structures to fully appreciate the causative factor(s) responsible for inadequate speech production after palatoplasty and to prescribe the most appropriate, personalized management plan. The purpose of this communication is to stress the importance of areas other than the velopharyngx that could have a negative impact on speech. More specifically, the issues of palatoplasty failures and palatal revisions will be presented. This is an area of significant importance and could represent the first line of defense before considering procedures altering the anatomy of the velopharynx, such as pharyngeal flaps, pharyngoplasties, and others. Issues covering the effects of skeletal and dental problems, such as malocclusion, partial or complete edentulism can also affect speech but are outside the scope of this communication.

Outcome of Nasal Layer Reinforcement With Autologous Dermis in Cleft Palate Repair on Postoperative Fistula Formation

Palatal fistulae are challenging complications following cleft palate repair. The addition of acellular dermal matrix (ADM) to cleft palate repair has been shown to reduce fistula formation in previous studies. The use of autologous dermal graft has all the structural advantages of ADM, has less rejection and immunogenic potential, and is cost effective.

A prospective study.

Patients with Group II and III cleft palate (Nagpur Classification) without prior intervention for palatal repair in the Department of Plastic Surgery at PGIMER from January 2020 till June 2021.

The addition of autologous dermal graft for palatoplasty.

Outcome of the study was fistula development or exposure of dermal graft.

Autologous dermal graft was harvested of average dimension of 8.73 cm2 (range 5.25-18 cm2) from groin region. Sixteen patients were included in the study. Among them, 2 patients (12.5%) developed postoperative fistula (Type III &V Pittsburgh Classification).

Our study showed that the rates of postoperative fistula formation are comparable with prior literature using artificial dermal matrices.

Interposition grafting of collagen-gelatin sponge impregnated with basic fibroblast growth factor in primary palatoplasty

INTRODUCTION

An oronasal fistula is a challenging post-operative complication of palatoplasty due to impaired velopharyngeal function or its high recurrence rate. Muscle repositioning, a key procedure in palatoplasty, causes dead space at the junction between the hard and soft palates. Consequently, thin oral and nasal mucosae are prone to break down and form fistulas. In this study, we used basic fibroblast growth factor-impregnated collagen gelatin sponge (bFGF-CGS) in primary palatoplasty to reduce fistula formation.

METHODS

This retrospective study assessed the complications and efficacy of bFGF-CGS to reduce fistula formation. Patients who underwent primary palatoplasty with bFGF-CGS were included. The same number of patients who underwent primary palatoplasty without bFGF-CGS was included as a control group. The outcomes included post-operative oronasal fistula formation, delayed healing, bleeding, and infection.

RESULTS

Both groups included 44 patients. Except for age at palatoplasty, there were no statistically significant demographic differences between the two groups; however, the rates of fistula formation in the study and control group were 2.3% and 13.6%, respectively. There were no infections among the patients.

CONCLUSIONS

The grafting of bFGF-CGS in primary palatoplasty was safe and probably effective in reducing post-operative oronasal fistula formation.

Tissue adjuncts in primary cleft palate reconstruction: A systematic review

BACKGROUND

Tissue adjunct is non-palatal tissue used to manage tension at the defect site by providing additional coverage. This review aimed to compare outcomes of various adjuncts employed in primary palatoplasty.

METHODS

A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library with keywords cleft palate, palatoplasty, surgical flaps, and allografts. Data extracted included demographics, cleft severity, primary/adjunctive techniques, outcomes, and follow-up periods. Logistic regression analyses and chi-squared tests were performed to investigate associations among variables.

RESULTS

A total of 1332 patients (aged 3 months-5 years) with follow-up of 1 month to 21 years were included. Cleft severity included submucous cleft (1.7%), Veau I/II (33.3%), Veau III (46.3%), and Veau IV (15.1%). Most reported techniques were Furlow (52%) and intravelar veloplasty (14.3%) for soft palate, Bardach (27.2%), and V-Y Pushback (11.1%) for hard palate. Buccal myomucosal flap (BMMF) was performed in 45.4% of cases, followed by buccal fat pad flap/graft (BFP) in 40.8% and acellular dermal matrix (ADM) in 14%. Severe clefts (Veau III/IV) were repaired more frequently with BMMF compared with ADM (p = 0.003) and BFP (p = 0.01). Oronasal fistula occurred in 3.1% of patients, and velopharyngeal insufficiency (VPI) in 4%, both associated with Veau IV (fistula: p = 0.002, VPI: p = 0.0002). No significant differences were found in fistula (p = 0.79) or VPI (p = 0.14) rates between adjuncts. In severe clefts (Veau III/IV), ADM was associated with fistula formation (p = 0.03).

CONCLUSIONS

Adjuncts in primary palatoplasty may mitigate unfavorable outcomes associated with severe clefts. BMMF is superior, given its inherent tissue properties, whereas BFP is effective in reducing fistula formation.

Current insights in the preclinical study of palatal wound healing and oronasal fistula after cleft palate repair

Poor palatal wound healing after cleft palate repair could lead to unfavorable prognosis such as oronasal fistula (ONF), which might affect the patient's velopharyngeal function as well as their quality of life. Thus, restoring poor palatal wound healing for avoiding the occurrence of ONF should be considered the key to postoperative care after cleft palate repair. This review provided current insights in the preclinical study of poor palatal wound healing after cleft palate repair. This review comprehensively introduced the animal model establishment for palatal wound healing and related ONF, including the models by mice, rats, piglets, and dogs, and then demonstrated the aspects for investigating poor palatal wound healing and related treatments, including possible signaling pathways that could be involved in the formation of poor palatal wound healing, the related microbiota changes because of the deformity of palatal structure, and the studies for potential therapeutic strategies for palatal wound healing and ONF. The purpose of this review was to show the state of the art in preclinical studies about palatal wound healing after cleft palate repair and to show the promising aspects for better management of palatal wound healing.

The Progress of Decellularized Scaffold in Stomatology

The oral and maxillofacial region contains oral organs and facial soft tissues. Due to the complexity of the structures and functions of this region, the repair of related defects is complicated. Different degrees of defects require different repair methods, which involve a great combination of medicine and art, and the material requirements are extremely high. Hence, clinicians are plagued by contemporary oral repair materials due to the limitations of bone harvesting, immune rejection, low osteogenic activity and other problems. Decellularized extracellular matrix has attracted much attention as a bioactive scaffold material because of its nonimmunogenic properties, good osteogenic properties, slow release of growth factors, promotion of seed cell adhesion and maintenance of stem cell characteristics. This article reviews the sources, preparation methods, application and research progress of extracellular matrix materials in the repair of oral and maxillofacial defects to provide an overview for fundamental research and clinical development.

An Algorithmic Approach for Deploying Buccal Fat Pad Flaps and Buccal Myomucosal Flaps Strategically in Primary and Secondary Palatoplasty

OBJECTIVE

Recent publications have introduced the use of buccal myomucosal and fat pad flaps to augment palatal repairs with autologous tissue. We propose a workflow for intraoperative decision-making to introduce these adjuncts into standard palatoplasty procedures.

DESIGN/PATIENTS

A retrospective chart review of a single-surgeon series of patients undergoing primary and secondary palatoplasties performed between October 2017 and November 2020 was completed after Institutional Review Board approval.

MAIN OUTCOME MEASURES

Patient demographics, phenotype, operative details, and postoperative complications were recorded.

RESULTS

Fifty-eight patients were included in a review. For those undergoing primary repair, 23.3% underwent a Furlow palatoplasty alone, 46.3% had a Furlow palatoplasty accompanied with acellular dermal matrix (ADM) and/or a buccal fat flap (BFF). A unilateral buccal myomucosal flap (BMMF) with or without augmentation with BFF or ADM was employed in 16.3% of the cases. Fourteen percent required a bilateral BMMF+/- ADM. Fistula occurrence was 2.3% (n = 1). For revisions, 27% underwent only a conversion Furlow palatoplasty, 26% had a conversion Furlow palatoplasty accompanied with ADM and/or a BFF, 33% had a unilateral BMMF or BMMF/ADM, and 14% required a bilateral BMMF+/- ADM.

CONCLUSIONS

In severe phenotypes or complicated cases, buccal fat flaps and myomucosal flaps may be utilized. This approach has mostly replaced the use of ADM over time. An algorithmic approach to palatoplasty allows surgeons to tailor the extent of surgery to the needs of each patient.

Long-term Results of Three-layered Closure of Oronasal Fistula: A Case Report

An oronasal fistula is an interconnection between the oral and nasal cavities. It interferes with normal functioning and affects quality of life by impeding eating and speech. The most common management strategy is surgical treatment. The aim of our study was to present the results of a long-term follow-up of effective treatment of a case of oronasal fistula that occurred without any cause and comorbidities. A 46-year-old woman reported the sudden appearance of a painless oronasal fistula. She demonstrated nasal regurgitation—that is, loss of fluids through the nose while drinking—and slurred‚ nasal speech. Clinical examination revealed a soft tissue defect (diameter: 5 mm) on the left side of the palate. Computed tomography revealed a gap in the hard palate bone, measuring 25 × 30 mm. No complications were noted following the procedure, nor at 10-year follow-up. It seems that the use of bone substitute and palatal flap for spontaneous oronasal fistula closure was fully justified. The patient may have had an undiagnosed congenital defect of the hard palate, and the deficit may have appeared due to bone loss occurring in her forties. However, no consensus exists regarding the best treatment management for oronasal fistulae located in the palatal region, and further comparative studies between the existing techniques are needed.

Effect of antibiotic pack on hard palate after fistula closure on nasal airflow and reoccurrence rate

This parallel blocked randomized controlled trial was done in two groups of 30 patients each to determine if placement of an antibiotic oral pack on the hard palate after hard palatal fistula repair reduces nasal air emission and fistula re-occurrence. Group A had an oral pack on the hard palate for 5 days post-operatively while group B did not. In group A, percentage of nasal air emission was tested using nasometry with and without pack. Paired t-tests were performed to compare nasal emissions for patients with and without pack. Recurrence of fistulas after 6 months between group A and B was tested using odds ratio. Effect of nasal air emission on fistula rates was tested using paired t-tests. There was a significant increase (p < 0.0001) in nasal emission after removal of the pack in group A. Fistula re-occurrence tended to be higher in group B (no pack) than group A but this was not significant (p = 0.242). There was no correlation between nasal air emission and fistula rates. In patients with recurrent fistulae, placement of an oral pack after fistula repair diminishes nasal air emission. Whether this has an impact on re-occurrence of fistulae needs to be investigated further.

Use of a buccinator myomucosal flap and bilateral pedicled buccal fat pad transfer in wide palatal fistula repair: a case report

Primary palatoplasty for cleft palate places patients at high risk for scarring, altered vascularity, and persistent tension. Palatal fistulas are a challenging complication of primary palatoplasty that typically form around the hard palate–soft palate junction. Repairing palatal fistulas, particularly wide fistulas, is extremely difficult because there are not many choices for closure. However, a few techniques are commonly used to close the remaining fistula after primary palatoplasty. Herein, we report the revision of a palatal fistula using a pedicled buccal fat pad and palatal lengthening with a buccinator myomucosal flap and sphincter pharyngoplasty to treat a patient with a wide palatal fistula. Tension-free closure of the palatal fistula was achieved, as well as velopharyngeal insufficiency (VPI) correction. This surgical method enhanced healing, minimized palatal contracture and shortening, and reduced the risk of infection. The palate healed with mucosalization at 2 weeks, and no complications were noted after 4 years of follow-up. Therefore, these flaps should be considered as an option for closure of large oronasal fistulas and VPI correction in young patients with wide palatal defects and VPI.

Modified two-flaps palatoplasty with lateral mucus relaxing incision in cleft repair: A STROBE-compliant retrospective study

STUDY DESIGN

clinical results of A STROBE-compliant retrospective study OBJECTIVE:: To achieving adequate pharyngeal closure and improve the pharyngeal function by a modified two-flap palatoplasty.

SUMMARY OF BACKGROUND

Excessive tension in soft palate is the main factor causing the dysphonia after cleft palate. The tension-free suture of the soft palate is the key to achieving adequate pharyngeal closure. In this paper, a modified two-flap palatoplasty improved the pharyngeal function METHODS:: From August 2016 to December 2017, 20 patients with cleft palate were treated with a modified two-flap palatoplasty of the posterolateral symmetrical mucosal relaxation incision. The mucosal relaxation incision was performed on both posterolateral sides of the soft palate.

RESULTS

All cases had good healing of mucosal flap and the palate. All patients underwent endoscopic examination at 6 months after operation. The postoperative results were satisfactory, with no complications. Twelve patients had bilateral exudative otitis media before operation, 4 patients returned to normal postoperatively, and 8 patients underwent bilateral tympanic membrane catheterization; 2 patients had abnormal function of bilateral eustachian tube before operation and returned to normal postoperatively; 3 patients had unilateral exudative otitis media before operation, and all of them returned to normal; the acoustic impedance test was normal in 3 children before operation. Most children begin to learn to speak, parents are satisfied with their pronunciation, and 3 children are in speech rehabilitation due to unclear pronunciation.

CONCLUSIONS

We propose a technique to improve the function of the velopharyngeal closure which effectively reduces the incidence of pharyngeal insufficiency and occurrence of operative correction of pharyngeal closure dysfunction. The modifed two-flap palatoplasty with posterior lateral symmetric mucosal relaxation incision is beneficial for better velopharyngeal closure.

The Use of Acellular Dermal Matrix in Combination With Pedicled Buccal Fat Pad in Wide Cleft Palate Repair: A Case Report and Literature Review

We describe a case of the combined use of acellular dermal matrix and pedicled buccal fat pad (BFP) in a wide U-shaped cleft palate repair. Acellular dermal matrix was used as a "patch" repair for the nasal mucosa defect as opposed to the conventional inlay graft. The advantages include reduced cost and a smaller avascular graft load. Lateral relaxing incisions were made to ensure tension-free closure of oromucosa at midline. Lateral oromucosa defect closure with well-vascularized pedicled BFP ensures enhanced healing, less palatal contracture and shortening, and reduced infection. The palate healed with mucosalization at 2 weeks, and no complications were noted at 6 months follow-up.

Harnessing Human Decellularized Blood Vessel Matrices and Cellular Construct Implants to Promote Bone Healing in an Ex Vivo Organotypic Bone Defect Model

Decellularized matrices offer a beneficial substitute for biomimetic scaffolds in tissue engineering. The current study examines the potential of decellularized placental vessel sleeves (PVS) as a periosteal protective sleeve to enhance bone regeneration in embryonic day 18 chick femurs contained within the PVS and cultured organotypically over a 10 day period. The femurs are inserted into decellularized biocompatibility-tested PVS and maintained in an organotypic culture for a period of 10 days. In femurs containing decellularized PVS, a significant increase in bone volume (p < 0.001) is evident, demonstrated by microcomputed tomography (µCT) compared to femurs without PVS. Histological and immunohistological analyses reveal extensive integration of decellularized PVS with the bone periosteum, and enhanced conservation of bone architecture within the PVS. In addition, the expressions of hypoxia inducible factor-1 alpha (HIF-1α), type II collagen (COL-II), and proteoglycans are observed, indicating a possible repair mechanism via a cartilaginous stage of the bone tissue within the sleeve. The use of decellularized matrices like PVS offers a promising therapeutic strategy in surgical tissue replacement, promoting biocompatibility and architecture of the tissue as well as a factor-rich niche environment with negligible immunogenicity.

Gelfoam Interposition Minimizes Risk of Fistula and Postoperative Bleeding in Modified-Furlow Palatoplasty

Failure to accomplish a tension-free, watertight closure predisposes the palatoplasty patient to fistula formation. Perioperative bleeding also places the patient at risk for adverse airway events (AAE). This study introduces the incorporation of a hemostatic gelatin sponge (Gelfoam) into layered palatoplasty to minimize adverse postoperative bleeding and fistula formation. A retrospective chart review was performed to identify subjects who underwent Furlow palatoplasty with insertion of Gelfoam from 2010 to 2015. Exclusion criteria include age >3 years, prior palate surgery, <30-day follow-up, immunosuppressive state, and diagnosis of Treacher-Collins or Apert Syndrome. Demographic data include age, sex, cleft laterality, prior surgeries, Veau classification, Pierre Robin status, and tracheostomy dependence. Primary outcome was fistula formation. Secondary outcomes included perioperative metrics and AAE.One hundred subjects met criteria, 45% female. Average age was 14.6 months. Subjects with syndromes comprised 28%, with 16% diagnosed with Pierre Robin. Two subjects were tracheostomy-dependent. Prior cleft and mandibular procedures were performed in 55%. Isolated palatal defects were seen in 46%, unilateral lip and palate in 41%, and bilateral lip and palate in 13%. The majority of defects were Veau II and III (35% and 34%, respectively). Adverse airway events occurred in 2%, one of which resulted in reintubation. One subject (1%) was found to have a postoperative fistula.The incorporation of Gelfoam in the modified-Furlow palatoplasty results in a low rate of oronasal fistula (1%) and low perioperative risk of AAE. Further prospective comparison of this method to others will be the focus of future work.

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

OBJECTIVE

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.

DESIGN

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.

STUDY SELECTION

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.

RESULTS

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.

CONCLUSION

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.

Cleft Palate Fistula Closure Utilizing Acellular Dermal Matrix

Fistulas represent failure of cleft palate repair. Secondary and tertiary fistula repair is challenging, with high recurrence rates. In the present retrospective study, we review the efficacy of using acellular dermal matrix as an interposition layer for cleft palate fistula closure in 20 consecutive patients between 2013 and 2016. Complete fistula closure was obtained in 16 patients; 1 patient had asymptomatic recurrent fistula; 2 patients had partial closure with reduction of fistula size and minimal nasal regurgitation; 1 patient developed a recurrent fistula without changes in symptoms (success rate of 85%). We conclude that utilizing acellular dermal matrix for cleft palate fistula repair is safe and simple with a high success rate.

Custom-Made Palatal Shield Use in Cleft Palate and Fistula Repair: A Potential Benefit for Fast Postoperative Recovery

OBJECTIVE

To review our experience with a polymethylmethacrylate (PMMA) protective shield used as an adjunct to protect the newly restored palate in wide bilateral cleft and complex fistula closure without diet restrictions.

DESIGN

Clinical cohort study.

SETTING

Division of Plastic Surgery and Maxillary Surgery.

PATIENTS

A selection of 22 cleft palate children undergoing (tertiary) palatal fistula repair (n = 16) or closure of a complex wide primary palatal defect (n = 6).

INTERVENTIONS

One month prior to surgery, a plaster model of the palate was made adding a 5- to 8-mm-thick layer of dental putty to the level of the dental arch. On top of the putty, a 1.5-mm-thick PMMA shield was created to cover the postoperative elevated and restored palate.

MAIN OUTCOME MEASURES

Fistula recurrence rate, postoperative complications, days of hospitalization.

RESULTS

All patients maintained durable and safe palatal closure without fistula recurrence within the follow-up period, varying from 1 until 4 years. Recovery was fast, with a mean duration of hospitalization of 1.5 days. All patients could directly resume their normal diet.

CONCLUSIONS

A PMMA shield has been shown to be a safe and helpful adjunct in complex fistula repair and late anterior palate repair.

"Tissue Papers" from Organ-Specific Decellularized Extracellular Matrices

Using an innovative, tissue-independent approach to decellularized tissue processing and biomaterial fabrication, the development of a series of "tissue papers" derived from native porcine tissues/organs (heart, kidney, liver, muscle), native bovine tissue/organ (ovary and uterus), and purified bovine Achilles tendon collagen as a control from decellularized extracellular matrix particle ink suspensions cast into molds is described. Each tissue paper type has distinct microstructural characteristics as well as physical and mechanical properties, is capable of absorbing up to 300% of its own weight in liquid, and remains mechanically robust (E = 1-18 MPa) when hydrated; permitting it to be cut, rolled, folded, and sutured, as needed. In vitro characterization with human mesenchymal stem cells reveals that all tissue paper types support cell adhesion, viability, and proliferation over four weeks. Ovarian tissue papers support mouse ovarian follicle adhesion, viability, and health in vitro, as well as support, and maintain the viability and hormonal function of nonhuman primate and human follicle-containing, live ovarian cortical tissues ex vivo for eight weeks postmortem. "Tissue papers" can be further augmented with additional synthetic and natural biomaterials, as well as integrated with recently developed, advanced 3D-printable biomaterials, providing a versatile platform for future multi-biomaterial construct manufacturing.

Cleft relapse and oronasal fistula after Furlow palatoplasty in infants with cleft palate: incidence and risk factors

This study was performed to investigate the incidence of and risk factors for postoperative cleft relapse and oronasal fistula after Furlow palatoplasty in infants. Sixty-two infants with cleft palate, aged 6-12 months (mean 8.25 months), who underwent cleft repair by Furlow double opposing Z-plasty between March 2012 and August 2014, were enrolled in the study. Risk factors for postoperative cleft relapse and oronasal fistula after Furlow palatoplasty were identified by logistic regression analysis. The incidence rates of cleft relapse at 1 week and oronasal fistula at 3 months after surgery were 24.2% (15/62) and 9.7% (6/62), respectively. Among all of the variables screened, only the width of the cleft was significantly associated with the incidence of postoperative cleft relapse (P=0.001) and oronasal fistula (P=0.011); the incidence rates were positively correlated with the width of the cleft when it exceeded 6.8mm and 7.5mm, respectively. Based on these findings, in order to reduce the incidence of postoperative cleft relapse and oronasal fistula, Furlow repair is not recommended for patients with wide clefts. An appropriate angle between the Z-flap incision and the central axis, use of a bilateral relaxation incision, and postoperative nursing care can help reduce the incidence of postoperative cleft relapse.