Closure of Palatal Fistula with Bucco-labial Myomucosal Pedicled Flap

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.

El-Leathy M, Attia M
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)
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El-Leathy M, Attia M
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

El-Leathy M, Attia M
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
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El-Leathy M, Attia M
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