CONDITION / JAWS, MOUTH AND NECK

Palate defects after plastic surgery.

Defects of the palate after cleft plastic surgery — an opening between the mouth and the nose (fistula) or hoarseness, when the palate does not block the path to the nose during speech. They are corrected by classes with a speech therapist and repeated operations.

Discuss your case How it is treated in the clinic ↓

CONCEPTUAL VISUALIZATION

OVERVIEW

What it is: Palate problems left after cleft surgery: fistula, soreness, scars.
How common: Fistula — in 8.6% (review of 44 studies), signs of pus — in 20% (review of 35 studies).
How we treat: Speech therapist, closure of fistula, speech operations; sometimes — a removable obturator plate.
Who leads: A surgeon and a speech therapist together; the decision about the operation is made after the language assessment.

01 / WHAT IS IT

What remains
after plastic surgery of the palate.

Cleft palate is closed at an early age. Plastic surgery significantly reduces the likelihood of speech disorders, but in some patients, the palate does not work as it should even after it. The most frequent problems are two: fistula and velopharyngeal insufficiency. They are related to each other, so they are evaluated together.

A fistula is an opening between the mouth and the nose that remains or appears after surgery. In a review of studies, 37.3% of fistulas were on the hard palate, 29.3% on the hard-soft border, and 16.2% on the soft palate.

Velopharyngeal insufficiency — when the soft palate does not reach the back wall of the pharynx during speech and does not block the path to the nose. The voice becomes hoarse, and speech becomes less intelligible. Such insufficiency may occur despite the first operation.

These problems occur in children, adolescents and adults: in some patients, they are not corrected immediately, but years after the first operation.

This is general information. What will suit you or your child, the doctor will tell after the examination.

02 / SIGNS

What they notice
parents and patients.

Language often indicates a problem. A hole in the palate is visible during an examination of the mouth, but a small one may not be noticed.

A humming voice

The sound seems to come through the nose, the air comes out through the nose during a conversation.

Unclear language

Some of the sounds are difficult to pronounce, and the person is less understood.

A hole in the palate

Liquid or food can enter the nose through the fistula, and air can enter during speech.

A gap near the gums

If the hole is in the front part, at the level of the gap in the gum, it helps to close it with bone plastic of the gum.

Clear cleft

Scars

The palate may be short, taut and immobile due to scarring after surgery.

Snoring after speech surgery

Loud snoring or pauses in breathing during sleep are a reason to tell the surgeon the same day: sleep apnea occurs after some operations.

03 / REASONS

Why it
happens.

It is not always possible to name the exact reason for a specific patient. It is known that the frequency of fistulas depends on the type of fissure.

Type of cleft

In a review of 44 studies (9294 patients), fistula after combined cleft lip and palate occurred in 17.9% of patients, after cleft palate alone — in 5.4%.

Cleft palate

The extent of the cleft

In another review, fistulas increased with the degree of cleft according to the Veau classification: from 2% when the cleft was only in the soft palate to 12.5% with complete bilateral cleft lip and palate.

Methodology and age

According to these reviews, the frequency of fistulas did not differ depending on the technique of the first operation, on whether the palate was closed in one or two stages, and on the age at the time of operation.

Movement and scarring of the palate

It is important for the language how much space remains between the palate and the pharynx, how the palate muscle is located, how mobile and scarred it is.

04 / SEEK MEDICAL ADVICE

When to seek medical advice?

Fistula, swelling or scars in themselves do not require emergency care: they are treated in a planned manner. Urgent help may be needed after surgery on the palate or pharynx - due to bleeding, difficulty breathing or severe infection.

103 immediately if:

it is difficult to breathe: breathing is very frequent, the child croaks or his stomach collapses when he inhales;
swollen lips, tongue or throat, difficulty swallowing or speaking;
heavy bleeding from the mouth does not stop;
the blood is bright red, spurting and difficult to stop;
the skin, lips, or tongue have turned blue, gray, pale, or marbled;
skin is cold or sticky to the touch;
a rash that does not fade if you press on it;
the person fainted, it is difficult to wake him or he does not wake up;
confusion, slurred speech or the person speaks illogically;
weak, shrill or continuous crying in a child under 5 years old;
convulsions;
a child under the age of 5 has not urinated for 12 hours;
very high temperature (38 °C and above in a baby under 3 months, 39 °C and above in 3-6 months) or very low - below 36 °C, the body is cold to the touch, shaking.

Do not delay if:

Immediately - to the surgeon who operated, and if it does not work - to the waiting room: after surgery, bleeding from the mouth is weak, but does not stop; pain or swelling in the mouth is severe or increasing, and pain relievers do not help. On the same day - call the surgeon: after a speech operation, the child snores loudly, breathing stops and resumes in sleep or gasps for air (blueness, heavy breathing when awake or if the child is difficult to wake up - signs for 103, see above); there is an unpleasant taste or pus from the wound in the mouth, the seam has come apart, the temperature has risen, or the child generally feels bad. Planned: if your voice is hoarse, your speech is slurred, or food gets into your nose through a hole in the roof of your mouth, make an appointment with a surgeon and a speech therapist.

05 / DIAGNOSTICS

As defined,
what to fix

Conversation and extracts
What operations were performed and when, whether there were classes with a speech therapist, what bothers you the most - speech, food, breathing.
Language assessment
A speech and language therapist evaluates hoarseness, nasal discharge, and speech intelligibility.
Examination of the mouth
Is there a fistula, where is it and what size; how movable the palate is, are there scars.
How the palate closes
If necessary, an instrumental examination, for example, with a thin endoscope through the nose. It shows how much space remains between the palate and the pharynx.
Sleep and breathing
If the child snores or stops breathing in his sleep, this is taken into account when choosing an operation.

06 / TREATMENT

How to fix
fistulas and snoring.

There is no single rule: the plan depends on what exactly is wrong - the hole, insufficient closure of the palate or pronunciation habits. The surgeon and the speech therapist compose it together, sometimes the plan includes a removable plate.

speech therapist

The first step when the problem is pronunciation.

Who needs: According to a review of studies, approximately half of children with clefts at age 5 are referred to a speech therapist because of speech difficulties.
What classes give: In a meta-analysis of individual data of 343 patients, pronunciation improved significantly during classes in many, and some spoke at the level of their peers after classes.
Occupation limit: If the palate does not physically block the path to the nose, one session is not enough, and then surgery is discussed.

Fistula

Whether to close and how - depends on the size, location and whether it interferes.

Repeat operation: The opening is closed with the mouth's own tissues, sometimes with additional materials such as a dermal matrix. In a review of 12 studies after fistula closure with dermal matrix, it recurred in 11%, but the quality of the studies is low.
Complicated fistulas: If the fistula is large or returns after several operations, the tissue is transferred from another part of the body, most often from the forearm. In a review of 65 such patients, the fistula recurred in 13.8%, and reoperation closed it in all those who returned to it.
Near the gums: The opening in the front part, at the level of the gap in the gum, helps to close the bone graft - gum bone grafting.
Obturator plate: A removable plate closes the opening without surgery. It is considered along with speech therapy and surgery when planning.

Language operations

When the palate does not block the way to the nose.

Which are: Pharyngeal flap (a strip of tissue from the back of the pharynx is sewn to the palate), sphincter pharyngoplasty (narrowing the entrance to the nasopharynx), replasty of the palate, buccal flaps that lengthen the palate, and augmentation of the back of the pharynx with own fat.
The result: In a review of 83 studies (4011 patients, patient groups are heterogeneous), normal voice resonance reached 70.7%. The authors did not find a noticeable difference between the types of operations in terms of language, repeated interventions and sleep apnea.
Comparison of methods: In a meta-analysis of 31 studies (1774 patients), hoarseness decreased after repeated Z-plasty of the palate in 85.06%, pharyngeal flap — in 84.50%, sphincter pharyngoplasty — in 83.04%, buccal flaps — in 59.69–77.61%. The studies differed greatly, so the authors advise selecting the operation individually.
Repeat plastic surgery of the palate: In a meta-analysis of 18 studies, 61% of patients had no persistent wheezing after it, 21% required another operation, and 28% had sleep apnea.
Own fat: In a review of 15 small studies (251 patients), after injection of fat into the back wall of the pharynx, speech improved in the majority, serious complications were rare. The method was studied mainly for mild and moderate insufficiency.

How to choose an operation

What is taken into account: The size of the gap between the palate and the pharynx, the position of the palatine muscle, its mobility and scars, the nature of the closure and the age of the patient.
Sleep apnea: In a meta-analysis of 4 studies (751 patients), sleep apnea occurred more often after a pharyngeal flap than after other speech operations (relative risk 2.45); there was no difference with sphincter pharyngoplasty, and in another meta-analysis (531 patients) apnea occurred more often after pharyngeal flap than after sphincter pharyngoplasty. If apnea is already present or the risk is high, the authors believe that it may be wise to start with operations that lengthen the palate.

07 / AT THE VALIKHNOVSKYI INSTITUTE

How
we treat it.

Palate defects after cleft plastic surgery are corrected at Dr. Valikhnovskyi's Institute of Surgery in the field of "Congenital Defects Surgery". Repeated cleft operations are a predictable part of the long-term plan; the operation is chosen together with a speech therapist, and pronunciation classes are conducted by specialized specialists.

CLINIC SERVICE Surgery of birth defects Congenital defects of the face and body in children and adults — from the first operation to the correction of the consequences. View service

What we do for this condition

Closure of the palate fistula — repeated operation when the opening allows food or air into the nose or prevents speech.
Pharyngeal flap — speech operation for hoarseness, when the palate does not cover the nasopharynx.
Sphincter pharyngoplasty — another language operation with similar results; the choice depends on the examination and opinion of the speech therapist.
Bone plastic is clear — if the fistula is in the front part, at the level of the gap in the gum.

Rostislav Valikhnovskyi

Plastic surgeon, candidate of medical sciences, founder of Dr. Valikhnovskyi Institute of Surgery.

About the doctor ORCID

How treatment works with us

Speech and transcript recording onlineSend the statements of previous operations and a short video of how the child or you speak - the doctor will pre-evaluate the situation.
ConsultationExamination of the palate, assessment of speech, talk about sleep and breathing.
PlanDo you need classes with a speech therapist first, which operation to choose, or to close the fistula.
SurgeryFistula closure or speech surgery — under general anesthesia; the child is not left without parents in the hospital.
Recovery and supervisionThe special diet will be explained before discharge; then a speech therapist and control examinations.

Discuss your case Call

08 / QUESTIONS AND ANSWERS

Common
questions

Short answers. What is right for you, the doctor will tell you during the consultation.

Why is the voice hoarse, although the palate has already been operated on?

It happens that the soft palate closes the opening after surgery, but does not reach the pharynx during speech. Then the air goes into the nose, and the voice becomes hoarse. In a review of 35 studies, 20% of patients had signs of this.

Is it possible to get by with classes with a speech therapist?

Sometimes yes, especially if the problem is pronunciation habits. If the palate does not physically close with the pharynx, an operation is usually required, and a speech therapist helps after it.

Is it necessary to close the fistula?

Not always. The solution depends on the size and location of the opening and whether food and air enter the nose through it and whether speech is affected.

Can the fistula reappear?

Yes, this is possible. In reviews of studies, the fistula returned in 11% of patients after closure with dermal matrix and in 13.8% after transplantation of tissue from another part of the body. A repeat operation can close it again.

Which language operation to choose?

There is no single rule: in large reviews, the results of different operations were similar. The surgeon and the speech therapist choose the method according to the examination — the size of the gap, mobility of the palate, scars and breathing in sleep.

Can snoring occur after surgery?

Yes. After speech operations, especially pharyngeal flap, there is sleep apnea. If the child snores loudly or stops breathing in his sleep, tell the surgeon about it on the same day.

Can an adult correct this?

Yes. For example, in a review of patients with complex fistulas who had tissue transplanted from another part of the body, the average age was 19.3, and the oldest was 55.

09 / SOURCES

Sources

21 sources · reviews, meta-analyses and NHS pagesshowCollapse

Fistula incidence after primary cleft palate repair: a systematic review of the literaturePlastic and Reconstructive Surgery, 2014doi:10.1097/PRS.0000000000000548 ↗
On the Frequency of Oronasal Fistulation After Primary Cleft Palate RepairThe Cleft Palate-Craniofacial Journal, 2019doi:10.1177/1055665619856243 ↗
Repair of Primary Cleft Palate and Oronasal Fistula With Acellular Dermal Matrix: A Systematic Review and Surgeon SurveyThe Cleft Palate-Craniofacial Journal, 2019doi:10.1177/1055665618774028 ↗
What Free Flaps Are Surgeons Using for Palatal Fistula Repair in Patients with Cleft Palate? A Systematic ReviewThe Cleft Palate-Craniofacial Journal, 2025doi:10.1177/10556656241266243 ↗
Revision Palate SurgeryFacial Plastic Surgery Clinics of North America, 2024doi:10.1016/j.fsc.2023.05.003 ↗
Systematic Review of Postoperative Velopharyngeal Insufficiency: Incidence and Association With Palatoplasty Timing and TechniqueJournal of Craniofacial Surgery, 2023doi:10.1097/SCS.0000000000009555 ↗
Surgery for Velopharyngeal Dysfunction: A Systematic Review of Interventions and OutcomesThe Cleft Palate-Craniofacial Journal, 2018doi:10.1177/1055665617735102 ↗
Pharyngeal Flap and Sphincter Pharyngoplasty for Velopharyngeal Insufficiency in Cleft Patients: A Systematic Review and Meta-AnalysisJournal of Craniofacial Surgery, 2026doi:10.1097/SCS.0000000000012460 ↗
The Effectiveness of Palate Re-Repair for Treating Velopharyngeal Insufficiency: A Systematic Review and Meta-AnalysisThe Cleft Palate-Craniofacial Journal, 2020doi:10.1177/1055665620902883 ↗
The Most Efficient Surgical Technique to Treat Velopharyngeal Insufficiency After Primary Cleft Palate Repair: A Systematic Review and Meta-AnalysisThe Cleft Palate-Craniofacial Journal, 2026doi:10.1177/10556656251413361 ↗
Speech Outcomes of Buccal Myomucosal Flap Palatal Lengthening for Treatment of Velopharyngeal Insufficiency: Systematic Literature Review and Meta-AnalysisThe Cleft Palate-Craniofacial Journal, 2025doi:10.1177/10556656231216834 ↗
Autologous Fat Injection for Treatment of Velopharyngeal InsufficiencyJournal of Craniofacial Surgery, 2017doi:10.1097/SCS.0000000000003702 ↗
Do Pharyngeal Flaps Have a Greater Risk of Obstructive Sleep Apnea Than Other Speech Procedures? A Systematic Review and Meta-AnalysisJournal of Oral and Maxillofacial Surgery, 2026doi:10.1016/j.joms.2025.12.007 ↗
Treatment algorithm for velopharyngeal dysfunction in patients with cleft palate: a systematic reviewBritish Journal of Oral and Maxillofacial Surgery, 2023doi:10.1016/j.bjoms.2023.03.002 ↗
On the Benefits of Speech-Language Therapy for Individuals Born With Cleft Palate: A Systematic Review and Meta-Analysis of Individual Participant DataJournal of Speech, Language, and Hearing Research, 2022doi:10.1044/2021_JSLHR-21-00367 ↗
Cleft lip and palate: TreatmentNHS, 2023nhs.uk/conditions/cleft-lip-and-palate/treatment ↗
When to get urgent medical help for babies and children under 5NHS, 2026nhs.uk/baby/health/when-to-get-urgent-medical-help-for-babies-and-children-under-5 ↗
SepsisNHS, 2026nhs.uk/conditions/sepsis ↗
Cuts and grazesNHS, 2026nhs.uk/conditions/cuts-and-grazes ↗
Wisdom tooth removalNHS, 2024nhs.uk/tests-and-treatments/wisdom-tooth-removal ↗
Sleep apnoeaNHS, 2026nhs.uk/conditions/sleep-apnoea ↗

The figures on the page are from these sources.

VALIKHNOVSKI SURGERY PARTNERS

The voice is hoarse
after plastic surgery of the palate?

Submit transcripts of previous operations and a short speech video. The doctor will tell you whether the classes will help, whether an operation is needed and which one.

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