Annals of Pediatric Surgery, Vol 5, No 2, April 2009, PP 104-108 Original Article Closure of Palatal Fistula with Bucco-labial Myomucosal Pedicled Flap Mohamed M. EL-Leathy* and Mohamed F. Attia** Pediatric Surgery Unit*, ENT Department**, Al-Azhar University ABSTRACT: Background/Purpose: Oro-nasal fistula is not uncommon complication of palatoplasty. Current methods for fistula repair utilize mucoperiosteal flaps or pedicled flaps. These procedures are often cumbersome and leave a raw nasal or oral surface, which may increase the incidence of postoperative problems. In addition, the recurrence rate of the fistula is as high as 34% following such procedures. In this study, the authors innovates a simple bucco-labial myomucosal pedicled flap method for fistula repair to avoid recurrences. Patients and Method: twenty patients with palatal fistulae were included, all were previously operated for cleft palate using a palatal mucoperiosteal flap. Patients with palatal fistulas were operated on at least 6 months after palatoplasty and were all followed up for more than 2 years. A standard bucco-labial myomucosal pedicled flap from the nearest area to the fistula is raised on the oral side. Fashioning of a raw area all around the fistula then suturing the pedicled flap to the created raw area centering the hole of the fistula. Weaning of the flap can be done after suitable time i.e. after 3 months after operation. Results: In all cases, the fistula was healed completely at first attempt without complications. All patients were followed for at least 2 years, without evidence of recurrence. Conclusion: The authors recommend using the bucco-labial myomucosal pedicled flap for the repair of postpalatoplasty oronasal fistulas Index words: palatal fistula, bucco-labial myomucosal pedicled flap. INTRODUCTION Fistula formation is not uncommon complication of primary palatoplasty. The actual reported incidence of this complication varies widely, ranging from 0% to 68% in published reports. 1 Although postpalatoplasty fistulas may occur anywhere along the site of the original cleft(s), they are more common on the hard palate (Fig.1) and at the junction of the hard and soft palate (Fig.2). 2 Multiple etiologies have been proposed for the formation of fistula following cleft palate repair: 1- Tissue breakdown due to tension at the site of wound closure. 5 2- Tension after maxillary orthodontics. 3- Infection. 3 4- Hypoxemia. 2, and, rarely, 5- hematoma formation. However, it appears that necrosis of the mucoperiosteal flap, used for cleft closure, is the most common cause of simple fistula formation, especially when the greater palatine arteries have been injured. 5 Controversy exists regarding the possible predisposing factors for post palatoplasty fistula formation. Although Emory et al 1 reported a slight increase in the incidence of fistulas for patients operated prior to the age of 12 months, the relevance is unclear since the argument was made that the more experienced surgeon tended to operate on these younger patients. Other reports emphasize the importance of the size 2 and type of original defect, whether unilateral or bilateral clefts were present 9, the technique used to close the cleft 2, patient sex 6, Correspondence to: Mohamed M. EL-Leathy, Pediatric Surgery Unit, Al-Azhar University.
and associated anomalies. Palatal fistulas are often symptomatic, depending on the size and location of the fistula. Symptoms include hypernasality of phonation due to audible nasal air escape during speech, leakage of fluids into the nasal cavity, and lodging of food with risk of infection. Depending on the extent of functional impairment, a palatal fistula may have psychological, social, and developmental consequences and should be repaired. Surgical repair of palatal fistulas can be technically difficult, most often due to the paucity of local tissue for closure or excessive scarring in the same area as a result of the previous repair or repairs. Several techniques have been described to circumvent these problems, including the use of tongue flaps 7, buccal musculomucosal flaps 8, mucoperiosteal alveolar ridge tissue, and mucoperiosteal elevations. 9 Although these methods may have their advantages in certain cases, most are relatively cumbersome and are often complicated by postoperative risks an d problems; examples include tissue loss elsewhere, hindering of maxillary growth as a result of scar contracture, poor aesthetic result and most importantly, recurrence of the fistula with an incidence as high as 34%. 2 We have, therefore, developed a simple and efficacious way to close postpalatoplasty fistulas in an attempt to avoid these problems. PATIENTS AND METHODS Subjects: The study included twenty patients, sixteen males and four females. Their ages ranged from 16months to 8 years. All patients had undergone their cleft palatal repair between 10 months and 2 years of age, using a palatal mucoperiosteal flap (Veau-Wardill-Killner type) at our facility. All patients had originally been operated on to repair the cleft palate by the pediatric or plastic surgery specialist in a well equipped centers. An oro-nasal fistula was defined as any palatal defect posterior to the incisive foramen. Patients with palatal fistulas were operated on at least 6 months after palatoplasty and were all followed up for more than 2 years. The original cleft palatal defects included 12 cases of bilateral cleft lip and palate and 8 cases of unilateral cleft lip and palate. Procedure: Proper classic preoperative preparation for all patients was done including clinical assessment and laboratory investigations in the form of complete blood count, renal and liver function tests, serum proteins, blood sugar level and local swab for culture and sensitivity test. Well informed written consents were taken from the parents. Operations were performed under general endotracheal intubation anesthesia supplemented with local infiltration of 0.5% Xylocaine with 1:100,000 epinephrine into the palate mucosa all around the fistula opening. A myomucosal pedicled flap from buccal surface of the upper lip or the oral surface of the cheek was elevated up to the gingivo-labial fold with no importance to the base, length and breadth proportionality (Fig.3). The edges of the palatal fistula from 3 to 5 mm all around were desquamated with dermabrasion instrument (Fig.4). The flap was fixed on to the raw area of the palate with fistulous opening in the center. The flap was sutured to the raw desquamated area using the Vicryl sutures 5/0 rounded needle by simple interrupted sutures (Fig.5). In six cases, the crossing pedicles of the flaps crossed the alveolar margin at the site of alveolar margin defects. These pedicles were used to repair the defects after de-epithelialization of the defected sites (Fig.6) In the other fourteen cases, the pedicle crossed a healthy normal alveolar margin. So weaning of the pedicle was done easily 3 months after repair of the fistula as no synechea were formed at the crossing site (Fig. 7&8). The buccal donor site was closed primarily with interrupted 5-0 Vicryl sutures. I.V fluids were given postoperatively for 24 hours, fluid diet was allowed for 1 week then oral semisolid foods for another 1 week before normal feeding was achieved. Children were followed up postoperatively weekly for one month then follow-up appointments at 3, 6, 12, and 24 months RESULTS Fistula sizes ranged from 5mm to 16 mm (mean 7.3 mm). Fistulas were located at the middle to posterior aspect of the hard palate in five patients, and at the anterior part of the hard palate in fifteen patients. In all cases, the fistula was completely healed at first attempt, with excellent functional results and no evidence of recurrence with a follow up of at least 24 months (Fig.9) 105 Vol 5, No 2, April 2009
Fig 1. A photograph showing an anterior oro-nasal fistula in the hard palate after palatoplasty. Fig 2. A photograph showing oro-nasal fistula at the junction between soft and hard palate opposite the greater palatine artery. Fig 3. A Photograph showing myomucosal pedicled flap separated from the inner surface of the upper lip with good vascularity. Fig 4. A Photograph showing dermabrasion during creation the de-epithelialised area all around the fistula opening Fig 5. A photograph showing a non tension arrest of the pedicled flap as recipient area with proper covering of the fistula opening. Fig 6. A photograph showing the flap after suturing using vicryl stitch with its pedicle placed to correct the alveolar margin defect. Annals of Pediatric Surgery 106
Fig7. A photograph showing the healed buccal flap with a guide wire under its pedicle as there is no fibrosis or adhesions below. Fig 8. A photograph showing the buccal flap after cutting its pedicle (weaning) Fig 9. A photograph showing a completely healed pedicle with good vascularity sealing the alveolar margin defect which needs no weaning. DISCUSSION Methods currently employed for fistula repair can be broadly divided in two groups: those that use mucoperiosteal flaps in one way or another, e.g., hinge flaps 10, and those that make use of additional tissue to close the defect. Sources of additional tissue are usually in the form of pedicled flaps from elsewhere in the mouth, according to the site of fistula e.g., buccal mucosa 8 or tongue flaps. 7 The simplest way to close a fistula is by raising a mucoperiosteal flap, as in primary cleft palate repair; but it is not the most successful one due to variable local causes e.g. scarring, inadequate palatal tissue and/or local ischemia. Reasonable results have been obtained in this study using virgin highly vascular new tissue from the neighboring buccal surface of the upper lip up to the gingivo-labial fold or buccal surface of the cheek. The used flap has a double blood supply, first supply is from the pedicle and the second supply is from the raw de-epithelialised surface done by dermabrasion all around the fistula opening. Intuitively, one-layer closures using mucoperiosteal flap i.e. hinge flap will leave a raw surface on the buccal side that is usually prone to bleeding and/or improper healing with high incidence of fistula recurrence. In this study there is no need to do that, so the net result repair of fistula is devoid of local tissue trauma or tension at sutures line. Postpalatoplasty oro-nasal fistulas in cleft palate patients are notoriously difficult to reconstruct, with an accepted treatment failure rate of at least 10%. 6 The 107 Vol 5, No 2, April 2009
complete absence of complications and, in particular, no recurrence of fistulas in the present study is extremely promising and encouraging for future application of this approach. Traditionally, the development of speech begins around 10 months of age. Quantization of the extent of functional impairment secondary to palatal fistula may be difficult. Nasality of speech is greatly influenced by the presence of a palatal fistula. This can be detrimental in the development of the child and should thus be corrected as soon as feasible. the authors therefore chose to perform fistula repair as early as possible but not before 6 months of diagnosis to allow enough time for the fistula to completely declare itself. Although the authors realize that prevention is always better than cure, fistula formation after cleft palate repair will probably continue to occur even in the best of hands. It is of the utmost importance to repair symptomatic fistulas as soon as possible, before further complications and long-term functional disability develops. The authors are convinced that the proposed technique is safe, relatively uncomplicated, and effective. The same technique could also be used in primary cleft palate repair when the defect is wide or in cases of crippled and neglected cases. CONCLUSION We have successfully treated twenty patients with palatal fistula using the described method without encountering any complications, immediate or longterm. Validation of our application will need to be shown with further use and, hopefully, consistent results. At the present time, The authors hope that the reader will consider our proposed method an appealing alternative possibility. REFERENCES 1. Emory RE, Clay RP, Bite U, et al. Fistula formation and repair after palatal closure: an institutional perspective. Plast Reconstr Surg. 99: 1535-1538, 1997 2. Cohen SR, Kalinowski J, LaRossa D,et al.cleft palate fistulas: a multivariate statistical analysis of prevalence, etiology and surgical management. Plast Reconstr Surg. 87:1041-1047, 1991 3. McClelland RMA, Patterson TJS. The influence of penicillin on the complication rate after repair of clefts of the lip and palate. Br J Plant Surg. 16:144-145, 1963 4. Wood FM. Hypoxia: another issue to consider when timing cleft repair. Ann Plast Surg. 32:15-20, 1994 5. Reid DAC. Fistulae in the hard palate following cleft palate surgery. Br J Plast Surg. 15:377-384, ١٩٦٢ 6. Amaratunga NA. Occurrence of oronasal fistulas in operated cleft palata patients. J Oral Maxillofacial Surg. 46:834-837, ١٩٩٨ 7. Argamaso R.V. The tongue flap: placement and fixation for closure of postpalatoplasty fistulae. Cleft Palate J. 27:402-410, ١٩٩٠ 8. Nakakita N, Maeda K, Ando S, et al. Use of a buccal musculomucosal flap to close palatal fistulae after cleft palate repair. Br J Plast Surg. 43:452-456, ١٩٩٠ 9. Stark RB. Cleft palate. In: Stark RB, ed. Plastic Surgery of the Head and Neck New York: Churchill Livingstone; 1300-1301, 1997. 10. Rintala AE. Surgical closure of palatal fistulae: follow-up of 84 personally treated cases. Scand J Plast Reconstr Surg. 14:235-238, ١٩٨٠ Annals of Pediatric Surgery 108