Surgical Closure Of End-Stage Palatal Fistulas Using Anteriorly-Based Dorsal Tongue Flaps

Jeffrey C.Posnick,

Stanley B.Getz, Jr

Klopp and Schurter-1956 Conley Guerrero-Santos Jackson-1972

ETIOLOGY

Tension at the site of closure Necrosis(Greater Palatine nerve injury) Infection Hematoma Mechanical trauma

CLASSIFICATIONCLASSIFICATION

SIMPLE SLITSMALL HOLELARGE HOLE

General methods of closure

Local transposition flap Tubed pedicle flaps Abdomen Arm Neck Cervicothoracic • Cheek• Nasolabial• Temporalis muscle

Specific procedures for closure of a residual palatal fistula

Simple slit-local flaps Vomer flaps are mobilised ,nasal mucosa is

freed before closure Adjacent mucoperiosteal flaps are raised and

advanced

Small holes

Extensive mobilization-For tension free two-layer closure

Fistula –does not extend alveolus Hinge flap Gives one layer,nasal side closure Raw surface –reepithelializes rapidly Acrylic appliance

LARGE HOLES(1.5-3.0cm)

Use of all available local tissue for nasal-side closure

Anteriorly-based dorsal tongue flap for oral side closure

Above 3cm defect –use of temporalis muscle flap(Tessier)

Tongue flap closure of a palatal fistula

Orotracheal intubation Dingman mouth gag LA with adrenaline(1:100,000) GRANULATION TISSUE removed Nasal side closure NS should be tension free and watertight Avoid perforation during flap elevation

Depending on location of fistula VOMER FLAPS used for the nasal side closure

Simple and mattress placed Oral side defect enlarged –to give a maximal,

secure insertion area for watertight closure of the tongue flap

Dingman mouth gag removed Orotracheal tube is placed to one side along

the buccal self Anteriorly based tongue flap elevated In adults-two thirds of the width of the

tongue,to make the flap about 5-6cm long 1cm thick Donar side –closed with vertical mattress

sutures

Palatal defect is covered completely with the anterior portion of the tongue

5-0 vicryl sutures are placed All the sutures are placed before any knots

are tied Extubation

Clear fluids for 24 hours Mechanically soft diet Discharged as soon as oral fluid intake is adequate Pedicle is cut under LA -10 to 14 days post-op If needed under LA or IV sedation donor site is

revised Recipient site may be debulked to improve esthetics

Case 1

7 Yr old girl with UCP Closure done with a von Langenbeck at 18

mths In post- op palatal fistula developed 3 attempts –failed Fistula resulted in nasal escape,affecting

speech and demanding a palatal prosthesis for obturation

Fistula finally closed by using all available tissue for nasal side closure

Anterior based tongue flap for oral side closure

No fistula recurred 6 months later Donor site healing satisfactory

Case 2

BCP,repaired at 15 mths of age with bilateral Pushback flaps Fistula, due to necrosis distal one third of both flaps At 5 yrs ,significant nasality with speech and nasal regurgitation

of fluids Palatal prosthesis for obturation was worn for several years Nasal side was closed using local flaps Oral side was closed with anteriorly based tongue flap 2yr later the fistula has not occurred and donor site has healed

well

DISCUSSION

Lack of complications High success rate in children and adults Importance of patient selection Large flaps to ensure vascularity and

considerable tongue movement without undue tension on the pedicle

Aggressive palatal shelf exposure around the defect

No airway problems or flap loss-encountered Limitation of speech needed to avoid undue

tension on pedicle After division ,no alteration in speech has

been detected

Use of a buccal musculomucosal flap to close palatal fistulae after cleft palate

repair

N .NAKAKITA,K. MAEDA,S.ANDO,H.OJIMI and UTSUGI

MATERIALS AND METHODS

42 patients operated 25 males and 17 females 4 to 13(mean 7years) Primary pushback operation with a palatal

mucosal or mucoperiosteal flap

Operative technique

Palatal mucosa around the fistula is hinged or de-epithelialized

A flap extending from the posterior end of the alveolar ridge to the oral commissure is designed

1.5cm Care –parotid duct Flap includes buccinator muscle 5-0/4-0 vicryl

Donor site-closed primarily Flap base should be secured –to prevent

post op herniation Plastic protector(0.8mm thick) over dentition Pedicle divided approx. 10-14 days

Overall results

Good-29(69%) Fair-7(17%) Poor-6(14%) Total-42(100%)

Results depending on the size of the fistula

Large Small

Good 9(56%) 20(77%)

Fair 5(31%) 2(8%)

Poor 2(13%) 4(15%)

Total 16 26

Result ,depending on the location of the fistula

Anterior Middle

Good 14(58%) 15(83%)

fair 6(17%) 1(6%)

Poor 4(17%) 2(11%)

Total 24 18

Results ,depending on both the size and the location of the fistula

Large Good results

small Good results

Anterior 11 4(36%) 13 10(77%)

Middle 5 5(100%) 13 10(77%)

DISCUSSION

GUERRERO-SANTOS-1966 Good circulation and sufficient volume Schmid (1958) cheek mucosal tube pedicle Padgett(1930)-lateral cheek flap for use in a

nasal lining

Advantages

1. No detrimental after-effects occur at the donor site.Mouth opening does not become limited.

2. No distress occurs during healing and it is not necessary to restrict speech

3. A normal diet may be resumed soon after operation

4. Ordinary oral intubation possible

5. Close resemblence to palatal mucosa

Shortcomings

Difficult to close fistulae which are located in the anterior hard palate

Foreign body sensation due to bulkiness of the flap

Thank you