Outcomes of Surgical Management of Palatal Fistulae in Patients With Repaired Cleft Palate

Outcomes of Palatal Fistula Closure with Tongue Flap Using a Parachute Technique

OBJECTIVE

To evaluate the efficacy of tongue flaps in closing large palatal fistulas secondary to cleft palate repair in terms of functionality, esthetics, and donor site morbidity.

DESIGN

Tertiary academic center.

SETTING

We report our 8-year surgical experience with tongue flaps, with our parachute suture technique in flap inset, and not using tongue fixation methods or feeding tubes.

PARTICIPANTS

Nineteen patients having recurrent secondary palatal fistula, post-cleft treatment were treated with anteriorly based dorsal tongue flaps.

MAIN OUTCOME MEASURE

Patients were evaluated for outcome in terms of flap uptake and effectiveness, correction of oronasal regurgitation, speech and nasality improvement, donor site morbidity, and esthetics.

RESULTS

A total of 19 patients in the age range of 1.5 to 34 years were treated with anteriorly based tongue flap. Detachment of the tongue flap was observed in 1 patient. Furthermore, tongue flap necrosis was not observed in any of the patients. Nasal regurgitation was resolved completely in 15 cases (78.9%), and 2 out of 4 failed cases were due to fistula presence in a position out of flap territory. In addition, fistula persists in the case of flap detachment and another case at the location of pedicle division. Speech intelligibility and hypernasality changes were reported as noticeable improvement in 9 (47.4%) and no obvious change in 10 patients (52.6%).

CONCLUSION

Using parachute suturing technique can facilitate successful lingual tissue inset in palatal defects with negligible remnant fistula. Moreover, avoiding tongue fixation methods and nasogastric tube-assisted feeding wasn't associated with increased flap dehiscence or suture loosening.

Managing massive palatial defect secondary to palatoplasty failures: an in-depth analysis

PURPOSE OF REVIEW

Massive palatal defects resulting from palatoplasty failures arising from cleft palate repair complications present ongoing challenges in clinical practice. The purpose of this review is to provide up-to-date insights into aetiology, risk factors, surgical techniques, and adjunctive therapies, aiming to enhance the understanding of such complex cases, and optimize patient outcomes.

RECENT FINDINGS

Primary palatoplasty has fistula recurrence rates ranging from 2.4% to 55%. Factors such as cleft width, surgical repair method, and patient characteristics, influence the likelihood of failure. Classifications such as the Pakistan Comprehensive Classification and Richardson's criteria aid in assessing defects. Surgical options range from local flaps and revision palatoplasty to regional flaps (e.g., buccinator myomucosal, facial artery-based flaps, tongue flaps, nasal septal flaps) to free microvascular flaps. Alternative approaches include obturator prostheses, and acellular dermal matrix has been used as an adjuvant to multiple repair techniques. Hyperbaric oxygen therapy has emerged as an adjunctive therapy to enhance tissue healing.

SUMMARY

This comprehensive review underscores the intricate challenges associated with massive palatal defects resulting from palatoplasty failures. The diverse range of surgical and nonsurgical options emphasizes the importance of patient-centric, individualized approaches. Practitioners, armed with evidence-based insights, can navigate these complexities, offering tailored interventions for improved patient outcomes.

Outcomes of Facial Artery Musculomucosal Flap in Repair of Post-palatoplasty Fistula - A Retrospective Study

Introduction

Closure of palatal fistula is difficult due to excessive scarring of the palate after previous surgery. The facial artery musculomucosal (FAMM) flap is considered a better option for palatal fistula closure due to its axial blood supply and minimal donor site morbidity. The aim of this study was to evaluate the results of harvesting FAMM flap for closure of medium and large palatal fistulas in terms of its versatility, reliability, feeding and speech assessment.

Materials and Methods

A retrospective analysis was performed on patients with post-palatoplasty fistula admitted to the outpatient clinics of the Department of Plastic Surgery and the Department of Maxillofacial Surgery of Assiut University Hospital from March 2022 to February 2024.

Results

Twenty patients aged 3-11 years, with female:male = 3:2 ratio, were included in the study. Two flaps experienced venous congestion and then partial flap necrosis. In addition, two flaps had wound dehiscence with mild infection. One patient experienced complete flap loss and then a late recurrent fistula. Most patients were able to feed well, except one patient was unable to swallow and had nasal regurgitation of fluids, that was relieved after second surgery by dorsally based tongue flap. Most patients had intelligible speech during verbal communication, only one patient had nasal tone and hypernasality and two patients were unable to communicate verbally.

Conclusion

The FAMM flap is suitable for closing medium and large fistulas due to its versatility and vascular reliability. It has fewer complications and sufficient functional and aesthetic results.

Unraveling a Major Burden of Orofacial Clefts Analyses: Classification of Cleft Palate Fistulas by Cleft Surgeons

OBJECTIVE

The objective of this study was to investigate how cleft surgeons classify palatal fistulas. We focused on three different anatomical locations (ie, hard palate, soft palate, junction hard/soft palate) to analyze agreement/disagreement at various anatomical locations.

DESIGN

Cross-sectional survey study.

PARTICIPANTS

Participants in an international webinar that focused on palatal fistula treatment were included.

INTERVENTION

Participants were presented with a survey pre- and post-webinar.

MAIN OUTCOMES

Frequency of used classification systems for classifying oronasal fistulas and the inter-rater reliability of the Pittsburgh classification system.

RESULTS

A total of 141 participants completed the questionnaires prior to the webinar and 109 participants completed the survey after the webinar. In total, four classification systems were used (ie, Pittsburgh, Pakistan Comprehensive Fistula Classification [PCFC], anatomical and 'other'). The Pittsburgh classification was the most commonly used system in all cases. However, Pittsburgh inter-rater reliability was low (κ = 0.136 pre-webinar, and κ = 0.174 post-webinar). Surprisingly, a substantial shift was observed from the anatomical to Pittsburgh classification after the webinar, indicating increased awareness of the usability of the Pittsburgh classification system.

CONCLUSIONS

This study demonstrates a large heterogeneity with regards to the classification of cleft palate fistulas. Interestingly, a shift was observed from the anatomical to Pittsburgh classification after the webinar. However, the inter-rater reliability for using the Pittsburgh classification was low. Classifying palatal fistulas in a homogenous fashion could enhance comparison of primary palate repair and could improve treatment of palatal fistulas.

Impact of a Palatal Fistula After Cleft Palate Repair on Velopharyngeal Closure

PURPOSE

A palatal fistula is an adverse outcome of cleft palate repair. It is unknown if a palatal fistula will influence velopharyngeal closure, even after repair of the fistula. This study determines the effect of a soft palate fistula on the risk of developing velopharyngeal insufficiency.

METHODS

A retrospective chart review was conducted on patients who underwent primary cleft palate repair between 2000 and 2015, with complete records at 4 years of age. Fistulae involving the secondary palate following primary palatoplasty were classified as the soft or hard palate. A forced-entry multivariate logistic regression model was built to detect predictors of velopharyngeal dysfunction.

RESULTS

Records of 329 patients were analyzed with a mean follow-up of 8.7 years. A palatal fistula was identified in 89/329 patients (27%) and 29/329 patients (9%) underwent an independent fistula repair. Of the patients with fistula, 44% were located in the hard palate only and 56% had soft palate involvement. Compared to patients without a fistula, rates of velopharyngeal dysfunction were significantly higher in patients with a fistula involving the soft palate (OR 3.875, CI: 1.964-7.648, P < .001) but not in patients with a hard palate fistula (OR 1.140, CI: 0.497-2.613, P = .757). Veau class, age at primary repair, and syndromic status were not significant predictors of VPI (0.128≤P ≤ .975).

CONCLUSIONS

A palatal fistula involving the soft palate is a significant predictor for development of velopharyngeal dysfunction after primary palatoplasty. Surgical intervention, at the time of fistula repair, to add vascularized tissue may be indicated to prophylactically decrease the risk of velopharyngeal dysfunction.

Free Flap Reconstruction of Recalcitrant Defects in Cleft Palate Patients

INTRODUCTION

Defects of the palate can be as a result of oronasal fistula of cleft patients and the ablative surgery of tumors. There are many studies about reconstruction of the defects of plate in the literature and most of them are related to tumor surgery. Despite the use of free flaps in cleft patients being not a new approach, the articles in the literature are very few. The authors describe the experience of oronasal fistula reconstructions with free flaps with a new modification of tensionless inset of the free flap's pedicle.

PATIENTS AND METHODS

Between 2019 and 2022, 2 males and 1 female, 3 consecutive cleft patients underwent free flap surgery because of recalcitrant palatal defects. One patient had 5 and each of remain had 3 unsuccessful reconstructive attempts previously. The age of patients was ranged from 20 to 23 years old. Radial forearm flap was the option of oral lining reconstruction for all patients. In 2 patients, the flap was modified as a skin tail was linked to the flap for covering the pedicle as tensionless closure.

RESULTS

There was a mucosal swelling in first patient who underwent classical pedicle inset as mucosal tunneling. In 1 patient there was a spontaneous bleeding from the anterior side of the flap and it stopped without medical interventions, spontaneously. There was no additional complication. All flaps survived without anastomosis problems.

CONCLUSION

Incision of the mucosa rather than tunneling provides good surgical exposure and bleeding control and modified flap design may be beneficial and reliable for tensionless pedicle inset and covering.

Prevention and management of oronasal fistulas

PURPOSE OF REVIEW

The aim of this article is to present the current opinion on the prevention and management of oronasal fistulas in cleft palate patients.

RECENT FINDINGS

Though cleft palate repair has seen numerous modifications and improvements, oronasal fistulas remain one of the most common complications of palatoplasty. There are various techniques available for preventing and managing this complication.

SUMMARY

Oronasal fistulas can be minimized by employing proper principles for palatoplasty. Once a fistula occurs, the repair technique should be appropriate for the fistula type. Oronasal fistula classifications, various repair techniques, tissue adjuncts, and biomaterials used in both the primary palate repair and oronasal fistula repair are discussed in this review.

Evaluation of Prognostic Factors for Palatal Fistulae after Cleft Lip and Palate Surgery in a North-Western Romanian Population over a 10-Year Period

Cleft lip and palate is the most frequent birth anomaly, with increasing reported rates of complications, such as palate fistulae. Current studies concerning the occurrence rate of cleft lip and palate (CLP) report 2 to 10 cases in 10,000 births. The purpose of this study was to investigate the existence of factors that could predict the occurrence of fistulae after cleft lip and palate surgery. A retrospective study was performed by collecting and analyzing data from all patients who were operated for cleft lip and/or palate in the Maxillo-Facial Department of the Emergency Clinical County Hospital of Cluj-Napoca, Romania, between 2010 and 2020. We investigated the existing evidence for possible links between the number of fistulae observed after the primary palatoplasty and the age at which the primary palatoplasty was performed, the sex of the patient, the type of cleft, the timing of the surgical corrections, and the presence of comorbidities. A total of 137 cases were included for analysis. A significant link between the number of fistulae and the type of cleft was found (with fistulae occurring more frequently after the surgical correction of CLP—p < 0.001). No evidence was found for the existence of significant links between the number of fistulae and the patient’s sex, the timing of surgery, or the presence of comorbidities. This study concluded that the incidence of palatal fistulae appears to be influenced by the type of cleft (CLP), but not by the sex of the patient, the timing of surgery, or the presence of comorbidities.

A Toolbox of Surgical Techniques for Palatal Fistula Repair

OBJECTIVE

To provide an inventory of oronasal fistula repair techniques alongside expert commentary on which techniques are appropriate for each fistula type.

DESIGN

A 4-stage approach was used to develop a consensus on surgical techniques available for fistula repair: (1) in-person discussion of oronasal fistula cases among cleft surgeons, (2) development of a schema for fistula management using transcripts of the in-person case discussion, (3) evaluation of the preliminary schema via a web-based survey of additional cleft surgeons, and (4) revision of the management schema using survey responses.

PARTICIPANTS

Six cleft surgeons participated in the in-person case discussion. Eleven additional surgeons participated in the web-based survey. Participants had diverse training experiences, having completed residency and fellowship at 20 different hospitals.

RESULTS

A schema for fistula management was developed, organized by fistula location. The schema catalogues all viable approaches for each location. For fistulae involving the soft palate, the schema stresses the importance of evaluating for velopharyngeal insufficiency (VPI) and incorporating VPI management into fistula repair. For fistulae involving the hard palate, the schema separately enumerates the techniques available for nasal lining repair and for oral lining repair in each region. The schema also catalogues the diversity of approaches to lingual- and labioalveolar fistula, including variation in timing, orthodontic preparation, and simultaneous alveolar bone grafting.

CONCLUSIONS

This study employed consensus methods to create a comprehensive inventory of available fistula repair techniques and to identify preferential techniques among a diverse group of surgeons.