Closure of Palatal Fistula with Bucco-labial Myomucosal Pedicled Flap

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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 107 Vol 5, No 2, April 2009
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
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Closure of Palatal Fistula with Bucco-labial Myomucosal Pedicled Flap

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