Post-Palatoplasty Fistulae
Surgical Complications of Cleft Palate Surgery § § § § §
Operative mortality : 0.5% Postop bleeding Respiratory compromise URI Fistulas 0-76%
Cleft Palate Fistulae q q
3-50% after primary cleft palate repair Multiple factors: § Surgeon § Type of repair § Cleft size § Timing of repair
26.
Anterior Palate Fistulae § § §
§ §
Regurgitation liquids into nose Speech disruption Food impaction § Malodor § Gingivitis Hypertrophic adjacent nasal mucosa Nasal discharge
Palatal Fistula §
Wound breakdown after palate repair § Closure under tension § Infection § Flap trauma § Hematoma § Compromise of the vascular supply resulting in flap ischemia § Patency between oral and nasal cavities Symptomatic Palatal Fistula § § § § §
Nasal air escape Speech distortion Hearing loss Regurgitation of food and fluid Halitosis
Prevention Complete Nasal Closure §
Dissection and release of nasal layer from hard palate § Possible vomer flaps for anterior closure Tension Free Oral Mucosal Closure §
Mucoperiosteal anterior flaps closed the level of anterior alveolar cleft § Lateral relaxing incisions § Full release greater palantine pedicles for improved medialization Adequate Flap Size §
Anterior mucosal flaps involve the entire oral mucosa of the hard palate
Two-Flap Palatoplasty § §
§
Anterior mucosal flaps involve entire oral mucosa of hard palate Incisions along the medial edge of the alveolar ridge to the alveolar cleft and along the cleft margin at the junction of oral and nasal mucosa. Including the entire oral palatal mucosa allows maximal tissue to close the cleft to the level of the alveolar cleft anteriorly
Vomer Flap(s) § § § §
Complete unilateral and bilateral clefts Incision along free margin of vomer Unilateral or bilateral septal-mucosa flaps raised, sutured to nasal mucosa Anterior vomer flap § Starting anterior edge of cleft back to junction hard and soft palate
Acellular Dermal Matrix and Palate Fistula Repair
Repair of Palatal Fistula: Indications for Treatment Fistula should be closed in those patients when they cause problems § Symptommatic palatal fistula Repair § § § § § § §
Turnover flaps Gingivoperiostial flap(s) Buccal myomucosal flap Local flaps and bone graft Tongue flap FAMM flap Obturator
Considerations in Repair § Fistula location § Size § Status of nearby tissues § Availability of donor sites § Type of original cleft § Prior surgical procedures § Surgeon preference
 Nasal Closure: Turnover Flaps Oral Closure: Palatal Transposition Flap
Medial Pairing Incision and Lateral Release
Rotation Flap
Mucoperiostal Flaps
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Bipedicled Labial Buccal Transposition Flap
Tongue Flap
Anteriorly Based
Buccal Mucosal Flap §
§ § §
Random flaps § Mucosa § Submucosa Base 1.5-2cm based behind upper alveolus Care parotid duct and buccal fat pad Donor site closed primarily
Posteriorly Based
Augment Nasal Layer §
Increase Palatal Length
Flap passed in submucosal tunnel
Buccinator Myomucosal Flap Posteriorly Based § § § § § §
Buccal artery (branch IMA) Posterior buccal branches facial artery Upper border from posterior border maxilla to oral commissure § 3-10mm blow parotid duct orifice Flap width 1-3cm and possible length 10cm Mucosa and muscle incised to lift flap in areolar plane above deep buccopharyngeal fascia Donor site closed primarily
Facial Artery MyoMucosal Flap (FAMM Flap) Superiorly Based FAMM Flap § § §
Hard Palate Lip Nose
Alloderm:
Inferiorly Based FAMM Flap § § §
Hard Palate Soft Palate Floor of Mouth
Radial Forearm Free Flap
Palatal Fistula: Principles of Repair Soft palate § Excision and 2 or 3 layer closure Hard palate § Large flaps, tension free Alveolus /anterior hard palate § Bone graft at appropriate age Large or difficult fistulas § Mucosal flap § Tongue flap § Free flap
Suggested Reading: Lossee J, et al. (2009) Post-Palatoplasty Fistulae: Diagnosis, Treatment, and Prevention. In: Losse J, Kirschner R: Comprehensive Cleft Care (pp. 525-554). McGraw-Hill Companies. Diah E, et al. Cleft oronasal fistula: a review of treatment results and a surgical management algorithm proposal. Chang Gung Med J. 2007 Nov-Dec;30(6):529-37. Choen S, Kalinowski J, LaRossa D, Randall P. Cleft palate fistulas: a multivariate statistical analysis of prevalence, etiology, and surgical management. Plast Reconstr Surg. 1991 Jun;87(6):1041-7. Sadhu P. Oronasal fistula in cleft palate surgery. Indian J Plast Surg. 2009 October; 42(Suppl): S123–S128. Deshpande G, Dobie H, Jacobson L, Restrepo C, Campbell A. Early Complications After Cleft Palate Repair: A Multivariate Statistical Analysis of 709 Consecutive Patients