surgical closure of end-stage palatal fistulas using anterio
DESCRIPTION
palatal fistulaTRANSCRIPT
Surgical Closure Of End-Stage Palatal Fistulas Using Anteriorly-Based Dorsal Tongue Flaps
Jeffrey C.Posnick,
Stanley B.Getz, Jr
ETIOLOGY
Tension at the site of closure Necrosis(Greater Palatine nerve injury) Infection Hematoma Mechanical trauma
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
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