Closure of palatal fistulas using a dermis-fat graft

[Palato velar fistulae in cleft palate]

Palatal fistulas after primary closure of a cleft palate are extremely variable ranging from 15 to 35%. When they are symptomatic, these fistulas affect feeding (nasal regurgitation to liquids, discharge, bad smells) and phonation (hypernasality that can hinder the precise assessment of velar incompetence). First of all, it is important to analyze the cause of the fistula, it helps to avoid early recurrences. The correction must apply to respect the 2 mucosal planes (nasal mucosa and oral mucosa), the only guarantee of surgical success. Different techniques are usually described: lingual flap, lifting of all palatal mucosa, flap hinge, blaster, FAMM. In all cases, postoperative care plays a key role in the success of the surgical correction.

Assessment of outcomes and complications of posterior pharyngeal wall augmentation with dermal fat graft in patients with Velopharyngeal Insufficiency (VPI) after primary cleft palate repair: A pilot study

Introduction

Materials used for posterior pharyngeal wall augmentation have been associated with important complications (exogenous materials) or variable and unpredictable durability (exogenous and endogenous materials); therefore, introducing a different material for augmenting the posterior pharyngeal wall seems necessary for reviving this relatively forgotten technique.

The purpose of this study was to emphasize on the use of a material associated with minimal complications and maximum recovery and durability in correcting VPI and the use of evaluative adjuncts such as nasoendoscopy and videofluoroscopy to assess surgical outcomes.

Methods

In a pilot study, 24 patients underwent posterior pharyngeal wall augmentation with dermal fat graft harvested from the low crease abdominal region. Early and late complications, autologous graft durability in posterior pharynx, and speech improvement were assessed.

Results

There was a significant improvement in hypernasality, nasal emission, and nasal grimace after posterior pharyngeal wall augmentation with dermal fat graft (p<0.0001). The authors observed no significant life-threatening complication. The most evident short-term complication was snoring, which occurred in five patients, and all relieved uneventfully.

Conclusion

The authors believe that augmenting the posterior pharyngeal wall with dermal fat graft is effective in improving hypernasality in patients with moderate velopharyngeal gap size and relatively adequate velar motion. This method has minimal complication profile because of autologous tissue application.

Three-layer oronasal fistula repair with sandwiched mastoid fascia graft

Oronasal fistula can cause speech problems, hearing loss, velopharyngeal insufficiency, and social problems related with fetor oris and oronasal fluid leakage. The purpose of this study was to achieve 3-layer closure with autogenous mastoid fascia graft in a group of patients with recalcitrant oronasal fistulas.Sixteen patients, aged between 2 and 56 years (mean, 13.9 y), with recalcitrant palatal fistula were operated on and included into the study in a tertiary clinic. Nine patients had previous fistula repairs. The patients' mean follow-up period was 6.8 months.Fistula closure was obtained in 14 of 16 patients. All 2 failures had type IV + V fistulas according to Pittsburgh Classification. A 3-layer technique for the closure of fistulas with autogenous mastoid fascia graft allows three-dimensional repair of the defect without tension. Using mastoid fascia via postauricular sulcus incision is a good alternative regarding hiding incision scars and not requiring intraoperative repositioning.

Repair of Recurrent Cleft Palate with Free Vastus Lateralis Muscle Flap

A 6-year-old girl presented with a large recalcitrant oronasal fistula after bilateral cleft lip and palate repair and numerous secondary attempts at fistula closure. Incomplete palmar arches precluded a free radial forearm flap. A free vastus lateralis muscle flap was successfully transferred. No fistula recurrence was observed at 18 months. There was no perceived thigh weakness. The surgical scar healed inconspicuously. Free flaps should no longer be considered the last resort for treatment of recalcitrant fistulas after cleft palate repair. A free vastus lateralis muscle flap is an excellent alternative, and possibly a superior option, to other previously described free flaps.

[Repair of palatal fistulae in cleft patients]

OBJECTIVES

Treatment of oronasal fistulae in cleft patients remains a surgical challenge because of its high failure rate. The authors report the results of an aggressive surgical technique using the total elevation of palatal mucoperiosteum, even for small fistulae.

METHODS

This approach was used on twelve consecutive patients, from five to 33 years of age, presenting with a Pittsburgh classification type IV palatal fistulae. The surgical procedure was total elevation of the hard palate mucoperiosteum starting from the dental sulcus combined with sealed double layer sutures. Clinical and photographical control was made at least 6 months after to detect a possible relapse.

RESULTS

The success rate was 100%. No relapsing fistula was observed with follow-up ranging from 6 to 36 months.

DISCUSSION

This technique allows wide exposure and safe closure of the nasal layer. It is simple and leaves no raw bone surface exposed and no additional scar. The authors think it can be used in all type IV fistulae less than 1cm wide. Several other surgical techniques have been described to close palatal fistulae: local turnover flaps, pedicled flaps from adjacent oral tissue, tongue flaps, tissue expansion, and even free flaps. Obturator prostheses have also been used. The technique we report, even if more aggressive, seems to be more reliable with fewer relapse and sequelae.

Free Auricular Cartilage Autograft for Repair of an Oronasal Fistula in a Dog

An eight-year-old female/spayed Pomeranian dog was presented for surgical treatment of an acquired right oronasal fistula. The maxillary right canine tooth had been extracted non-surgically 7-weeks prior to presentation. Clinical signs were consistent with an oronasal fistula during this time period. Oral examination showed an oronasal fistula in the area of the extracted tooth. The referring veterinarian performed simple debridement and suturing with subsequent recurrence of the oronasal fistula. This case report describes the successful surgical treatment of an acquired oronasal fistula with a free auricular cartilage autograft and reviews techniques described for oronasal fistula repair, including free auricular cartilage autografts.

[Oronasal fistula in sequels of labialalveolarvelopalatine clefts]

Labial and palatine maxillary clefts are treated by surgery, as for oronasal fistula. One of the most important parts of management is the timing of primary surgery in order to avoid growth disturbance. The authors describe the various possibilities to close secondary oronasal fistula. The timing and choice of surgical techniques are still debated and being improved. Various surgical techniques are available, from mucoperiosteal palatal flap to a free flap. Nevertheless, the mucoperiosteal palatal flap is the most commonly used. In some cases mucoperiosteal flaps are impossible to perform, so other options for extreme cases are discussed.

The use of decellularized dermal grafting (AlloDerm) in persistent oro-nasal fistulas after tertiary cleft palate repair

To assess the efficacy of decellularized dermal grafting as an adjunct to the closure of recurrent oro-nasal fistulas. Five consecutive patients with recurrent oro-nasal fistulas were repaired with decellularized dermal grafting sandwiched between oral and nasal flaps of a von Langenbeck palatal repair. All patients had previously undergone a minimum of three prior palatal repairs with the recurrence of their oro-nasal fistula in the post-alveolar area. Decellularized dermal graft was placed between the nasal mucosa and the levator veli palatine muscle. Patients were followed postoperatively and assessed for infection, dehiscence, signs of rejection, and fistula recurrence. All patients were followed for an average of three months. Clinical examination revealed no recurrence of their oro-nasal fistula nor associated symptoms of nasal reflux. Decellularized dermal grafts were not rejected nor extruded from the site of surgical repair. Decellularized dermal graft should be considered for use in the treatment of recurrent oro-nasal fistula after cleft palate repair. We would also like to encourage further clinical study.

Repair of oronasal fistulae with acellular dermal matrices

BACKGROUND

The authors examined the efficacy of a novel technique for oronasal fistula repair using acellular dermal matrix grafts. In part I, an animal model was used to demonstrate proof-of-concept; in part II, the method was applied to oronasal fistula repair in the clinical setting.

METHODS

In part I, oronasal fistulas were created in Yorkshire piglets (n = 6) and allowed to mature for 2 weeks. In three animals, acellular dermal grafts were interposed between the oral and nasal mucosa traversing the palatal fistulas. Mucosal edges were not closed. Three weeks postoperatively, the palates were examined histologically. The fistulas of control piglets (n = 3) remained unrepaired and were examined 5 weeks after their creation. In part II, acellular dermal grafts were interposed between the oral and nasal mucosa in nine consecutive patients undergoing oronasal fistula repair. Complete closure of the oral and nasal mucosa was achieved in two patients. In the remainder, nasal closure was affected by interposition of the dermal matrices beneath a complete oral mucosal closure.

RESULTS

All animals that underwent fistula repair demonstrated successful healing with revascularization, complete reepithelialization, and cellular infiltration into the grafts. All control fistulas remained patent. Successful fistula closure was observed in all patients. In two patients, early oral mucosal dehiscence and exposure of the dermal graft was followed by complete healing.

CONCLUSIONS

This study demonstrates successful closure of palatal fistulas in an animal model and in cleft palate patients using interposition grafts of acellular dermis. This novel method offers promise as a simple and effective technique for tension-free closure of oronasal fistulas.

Palatal fistula repair using acellular dermal matrix: the University of Florida experience

Palatal fistulas represent a challenging problem for surgeons caring for patients with cleft palate. The purpose of this study was to examine the rate of fistula closure using conventional surgical techniques (Group 1) versus a newer technique (Group 2) employing the use of acellular dermal matrix (AlloDerm). We reviewed the charts of all patients who underwent palatal fistula repair between July 1994 and February 2005. The surgical techniques in Group 1 varied and were considered a historical control. In the second group, a piece of dermal matrix was interposed between the nasal and oral mucoperiosteum after closure of these layers. The primary fistula closure rate for Group 1 was 83.3% (10/12 patients). Fistula closure was obtained in 100% of the patients in Group 2. There were no complications noted other that the failure of the 2 patients in Group 1. The use of AlloDerm in palatal fistula repair has reduced our failure rate from 16.7% to 0%. The use of AlloDerm during palatal fistula repair is safe, effective over time, and has the potential to reduce palatal fistula recurrence rates.

The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis

The aim of this retrospective clinical study is to present the clinical experience of using dermis-fat interpositional grafts in the surgical management of temporomandibular joint (TMJ) ankylosis in adult patients. Eleven adult patients who presented with ankylosis of the TMJ were identified and included in the study. All patients underwent a TMJ gap arthroplasty which involved the removal of a segment of bone and fibrous tissue between the glenoid fossa and neck of the mandibular condyle. The resultant gap was filled with an autogenous dermis-fat graft procured from the patient's groin. All patients were followed up for a minimum of 2 years. Five of the 11 patients were found to have osseous ankylosis while 6 patients had fibro-osseous ankylosis. Two patients had bilateral TMJ ankylosis that were also treated with costochondral grafts which were overlaid with dermis-fat graft. The average interincisal opening was 15.6 mm on presentation which improved to an average of 35.7 mm following surgery. Patients were followed up from 2 to 6 years post-operatively (mean 41.5 months) with only 1 re-ankylosis identified out of the 13 joints treated. This study found that the use of the autogenous dermis-fat interpositional graft is an effective procedure for the prevention of re-ankylosis up to 6 years following the surgical release of TMJ ankylosis.

Role of Free-Tissue Transfer in the Treatment of Recalcitrant Palatal Fistulae among Patients with Cleft Palates

Recurrent palatal fistulae present a particularly vexing problem for patients with cleft lips and palates and their surgeons. When primary closure fails, conventional wisdom and the standard of care suggest local flap techniques for defect closure. For the large majority of patients, this approach is successful. There is, however, a small subset of patients who undergo multiple surgical procedures in unsuccessful attempts to close recalcitrant fistulae, particularly at the anterior, densely scarred, hard palate. In this setting, repair calls for the introduction of well-vascularized pliable tissue to close the defect and to avoid hampering further palatal growth. Local muscle flaps and oral axial pattern flaps have been advocated and used successfully. However, those approaches have their own drawbacks, such as multiple surgical interventions, patient compliance, and intraoral scarring. In an effort to avoid the problems associated with local flaps, distant microvascular tissue transfers were investigated. During a 6-year period, six free-tissue transfers were performed as a primary means of treating recalcitrant palatal fistulae. Three dorsalis pedis flaps and three osseous angular scapular flaps were used. The conditions of all patients improved, with five patients achieving complete long-term closure of the palatal defect. This experience indicates that modern microvascular techniques have reached a level of success commensurate with that of other flap techniques; therefore, it is concluded that free-tissue transfer should be considered as a primary means of addressing these difficult cleft problems.

Use of cartilage grafts for closure of cleft palate fistulae

We describe the results of using a free cartilage graft in the closure of cleft palate fistulae in 14 patients with a mean follow-up of 8.6 months. Complete closure of the fistula was achieved in 11 patients (79%), with partial closure in the remaining three patients. This technique is simple, causes relatively little discomfort, involves little tissue dissection and can be performed as a day-case procedure. The success rate is comparable with or better than other methods, and we consider it the treatment of choice for small cleft palate fistulae.

Three-dimensional morphometric analysis of the effects of subperiosteal palatal soft-tissue expansion in growing cats

A prospective longitudinal study in 75 growing cats was conducted to evaluate palatal soft-tissue expansion in cleft lip and palate surgery. In 31 cats, palatal scars were induced by simulated Langenbeck surgery at the age of 8 weeks. At the age of 14 weeks, custom-made tissue expanders were inserted in 61 animals. Tissue expansion was performed by weekly inflation in 33 cats (16 without and 17 with scars) for an 8-week period. The remaining 28 cats (14 without and 14 with scars) served as sham groups. A control group was formed by 14 animals (without scars and without tissue expander). The effects of the experimental interventions were evaluated on a series of dental casts during the inflation period and until 8 weeks after removal of the tissue expander. The results indicate that soft-tissue expansion of the palatal mucoperiosteum is feasible. Until 20 weeks of age, no differences were found between both expansion and sham groups. Thereafter, significant soft-tissue surface-area gain was quantified in relation to the base surface and base diameter of the tissue expander. Iatrogenic side-effects of active tissue expansion consisted of significant transversal growth retardation in the anterior part of the bony palate and dentoalveolar structures. After removal of the tissue expanders, some accelerated growth in the tissue-expansion, scarred-tissue group was seen. It is concluded that palatal soft-tissue expansion is possible in growing cats, with and without the presence of palatal scars; however, this technique, like other kinds of palatal surgery, impairs dentomaxillary growth and development.