Palatal Fistula and Syndromes associated with CLCP

Part - II

Dr. Amit T. Suryawanshi

Oral and Maxillofacial Surgeon

Pune, India

Contact details :Email ID - amitsuryawanshi999@gmail.com

Mobile No - 9405622455

Treatment Modalities for palatal fistula

Surgical Treatment

Local Flaps

Palatal flap

Vomer flap

V-Y ward Kilner Procedure

Distant flaps

Tongue Flap

Nasolabial flap

Buccal musculomucosal flap

Recent Techniques

Tissue expander

Microvascular surgery

Conservative Treatment

Obturators

Fixed

Removal

Other material

Local Flaps

Palatal Flap

• Palatal flap

Axial flap based on the

Greater palatine artery,

Macronet – Connection

between two greater

palatine arteries across

the midline

• Palatal flaps have been used routinely for the

correction of hard palatal, partial soft palatal,

and retromolar defects.

• The ultimate flap design is dependent on the

size and location of the area to be reconstructed.

The flap has the ability at maximum to provide

approximately 10 cm2 of tissue

The recipient site is prepared with the creation of

surgical margins for flap placement,

The greater palatine foramen with its vascular

supply is identified by manual palpation of the

palate.

A full-thickness incision is made lateral to the

vascular supply and can extend to 1 mm short of

the palatal side of the teeth.

In the absence of dentition, the flap can be

raised to the point of the palatal alveolar crest.

This incision is carried anteriorly and can extend

up to the palatal mucosa of the central incisors if

necessary. A similar incision can be made on the

contralateral side if the entire palate is to be

used in the flap.

• Care is taken as the vascular supply is

approached. Once the flap is elevated, it is

rotated or inverted into place. Care should be

taken to ensure that the flap is free from

tension, which may cause dehiscence or

vascular compromise and flap necrosis.

If increased laxity is necessary, the hamulus can

be fractured, which will provide additional length

to the flap. Once in place, the flap is sewn to the

prepared mucosal edges.

Care should be taken to avoid any pressure on

the vascular pedicle

• Postoperatively, patients begin with clear

liquids, which are advanced to a regular diet

on postoperative day 3.

• Advantages

Relatively easy to harvest

Rotation about a 180-degree axis and the ability to

invert the flap allow coverage in any direction.

(Oral Maxillofacial Surg Clin N Am 15 (2003) 467–473 )

• Disadvantages

The flap is limited by its neurovascular supply,

which emerges from the bony canal of the

greater palatine foramen.

(Oral Maxillofacial Surg Clin N Am 15 (2003) 467–473 )

Vomer Flap

• Vomer flap

Midline Structure

Used for reconstruction of palatal fistula

Very easy to use

• Classification:

Vomer flap

• Advantage

Simplicity & ease of execution of flap,

Minimal surgical trauma & time,

Provide effective nasal lining,

Quality of tissue is very similar to nasal mucosa,

Good vascularity of flap.

• Disadvantage

The technique can be used only when the vomer is

of an adequate size or when it is readily visible.

May cause growth disturbance in midface.

Cleft palate- craniofacial journal january 2006, vol.43 no.1

Veau- Wardill- Kilner Flap

• V-Y pushback repair ( Veau- Wardill- Kilner )

(International Journal of Pediatric Otorhinolaryngology 74 (2010) 1054–1057)

Marking for incision

Pre Operative Palatal fistula

Intra-operativeImmediate Post-operative

Post operative After 7 days

Distant flap

Buccal Musculomucosal Flap

• Buccal Musculomucosal Flap

First palatal mucosa around fistula is deepithealised,

Flap developed from the side of buccal mucosa, ( width < 1.5 cm).

(British Journal ofPlastic Surgery (1990). 43,452-456)

Care must be taken not to injure the orifice of

parotid duct,

Flap is musculomucosal includes the buccinator

muscle

Donor site is closed primarily,

Plastic protector made to prevent flap bitten by

teeth,

Flap pedicle divided approx. after 10-14 days.

Blood supply – Facial artery

(British Journal ofPlastic Surgery (1990). 43,452-456)

British Journal ofPlastic Surgery (1990). 43,452-456

Outline of flap Raised Flap

British Journal ofPlastic Surgery (1990). 43,452-456

Attached flapSecond Stage- Flap detachment

• Advantages:

1. No detrimental after-effects occur at the donor site.

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

speech. With our buccal musculomucosal flap, special attention is

not necessary if a bite block is used.

(British Journal ofPlastic Surgery (1990). 43,452-456)

4. A normal diet may be resumed soon after operation.

5. In anaesthesia, ordinary oral intubation is possible for

buccal masculomucosal flap.

6. The flap more closely resembles the palatal mucosa in

appearance than does a tongue flap.

(British Journal ofPlastic Surgery (1990). 43,452-456)

• disadvantages:

1. It is sometimes difficult to close fistulae which

are located in the anterior hard palate

2. Patients sometimes complain of a foreign body

sensation in their mouth due to the bulkiness

of the flap.

Pre Operative Ant. Palatal fistula

Intra-operative Post operative After 4 days

Tongue Flap

• Tongue Flap:

Guerrero-Santos & Altamirano ( 1966 )

Tongue flaps are excellent flaps for palatal fistula closure.

They use adjacent tissue, have an excellent blood supply, and

are associated with minimal morbidity1.

(Haneke E. Surgical treatment of defects on the tip

of the nose. Dermatol Surg 1998;24:711–7)

• A variety of flap designs have been described including anterior-

and posterior-based tongue flaps.

• Blood Supply – lingual artery

Marking

Tongue flapTongue flap

Tongue flap

Immediate Post operative

Post operative After 21 days

• Advantages of tongue flap

1. The tongue has excellent axial and collateral circulation.

2. Sufficient volume.

( Motamedi MH, Behnia H. Experience with regional flaps in the comprehensive

treatment of maxillofacial soft-tissue injuries in war victims. J Craniomaxillofac

Surg 1999;27:256–65)

Selection Criteria for Tongue Flaps

Failed Previous Attempts

Size of the Defect

Site of the Defect

Amount of Existing Scarring

Observation

1. Donor site deformities were minimal.

2. No detectable alteration in

a) Speech

b) Taste

c) Impaired tongue mobility

54

3. Improvement in feeding

4. Noticeable improvement in speech &

articulation

Complications of tongue flap

Palatal dehiscence

Recurrence of fistula

Bleeding

Flap detachment

56

Nasolabial Flap

• Nasolabial flap

Thiersch was first to use this flap for oral cavity

defect.

(Thiersch C: Verschluss eines loches im harten gaumen durch dic weichtheile der wange. Arch Heilkunde 9:159, 1868)

An inferiorly based nasolabial flap is preferred.

The medial incision line precisely follows the

nasofacial fold in its superior two thirds.

Blood supply – Angular artery

( Int. J. Oral Maxillofac. Surg. 1991; 20." 40-43 )

Incision Line

Base of flap <1.5-2.5cm

• Advantages

The nasolabial flap is a simple, effective, and

safe flap with a low complication rate.

Donor site morbidity is negligible

(J Oral Maxillofac Surg 58:1104-1108, 2000)

• Disadvantages

Infection,

Minor or major flap necrosis,

Wound dehiscence,

Asymmetry at the level of the nasolabial fold may

present in unilateral cases.

(J Oral Maxillofac Surg 58:1104-1108, 2000)

Microvascular Flap

• Free flaps used for Palatal defect are:

Fibula

Rectus abdominus

Scapular

Radial forarm

Lattisimus dorsi

• Advantages

Free-flap reconstruction of the palate provides reliable

permanent separation of the oral and sinonasal cavities in one

stage.

The potential for dental rehabilitation with the restoration of

masticatory function and normal phonation exists.

(Otolaryngology- Head & Neck June 1999, Vol 125, No. 6)

Tissue Expander

Tissue expander:

Two stage procedure under GA

First- Placement of tissue expander

Second – after 1 week, removal of tissue expander, palatal

revision, and closure of palatal fistula.

Advantages - Complication are minimal

(Cleft Palate Craniofac j. 2011 Mar;48(2):217-21. Epub 2010 Apr 23)

Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 414e421

Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 414e421

Tissue expander

Obturator

Anterior palatal fistula

Fixed type of Obturator

Removal type of obturator

Skin barrier adhesive patch

• Advantages:

• Improvement in Speech,

• Lesser chance of regurgitation.

(The cleft palate journal, october 1985, vol. 22 no. 4 )

Conclusion :

Prevention is always better than cure, fistulaformation after cleft palate repair willprobably continue to occur even in the best ofhands. It is of the utmost importance to repairsymptomatic fistulas as soon as possible,before further complications and long-termfunctional disability develops.

SYNDROMES ASSOCIATED

• Perry-Robinson Syndrome

• OFDS- More’s syndrome

• Down’s syndrome

Thank you