Two-flap technique with interpositional dermofat graft for anterior oronasal fistula closure in patients with cleft: A case series

BACKGROUND

Oronasal fistula at the anterior hard palate is one of the common sequelae after cleft surgery, and the leakage negatively affects the patient's quality of life. Although several surgical techniques have been proposed for reconstruction, it remains challenging because of the scarred regional tissue with a high rate of fistula recurrence. In this study, we present the anterior oronasal fistula repair using a two-flap technique with an interpositional dermofat graft (DFG).

METHODS

A retrospective review of anterior oronasal fistula repair performed by the senior author between April 2018 and August 2022 at the Craniofacial Center was conducted. Patients who underwent a fistula repair using the technique were further identified and investigated.

RESULTS

Thirty-four operations were performed using the technique, and 31 fistulas were completely closed, with a success rate of 91.2%. The fistula symptom improved but persisted postoperatively in 3 patients, of whom 2 patients underwent a second fistula repair using the same procedure, resulting in successful closure. Fistula recurrence was significantly correlated with fistula size (p = 0.04). The DFG was simultaneously utilized for nasal dorsum and/or vermillion reconstruction in 28 cases.

CONCLUSION

The two-flap technique enabled tension-free approximation, and the interpositional DFG facilitated watertight closure of the fistula, resulting in a high success rate of anterior oronasal fistula repair. The fistula closure could be combined with other revisional procedures for cleft-related deformities, where the DFG was simultaneously utilized.

Using Dermofat Grafting in Revision Rhinoplasty

BACKGROUND

For revision surgeries due to complications associated with alloplastic materials, autologous tissues including dermofat are considered. However, graft absorption, shaping, and donor site morbidity remain crucial challenges. This study aimed to present several surgical techniques of dermofat grafting for rhinoplasty to overcome these challenges.

METHODS

Patients who underwent autologous dermofat grafting from January 2015 to October 2019 were retrospectively studied, and those who underwent primary rhinoplasty were excluded. The mid-sacral dermis (with the thickest dermal layer) was selected as the main donor site. During dermal harvesting, fat was resected into a wedge shape, to minimize flap tension and dead space risk. A molding technique was applied to improve graft shape and height and minimize graft absorption. Patient records were reviewed for assessing preoperative evaluations, surgical methods, and complications. For evaluating aesthetic outcomes, three rhinoplasty surgeons, blinded to the study purpose, compared preoperative and postoperative photographs.

RESULTS

Among 331 cases undergoing dermofat grafting for revision rhinoplasty, 25 underwent revisions; of these, five, one, and nine cases experienced over-absorption, over-correction, and deviation, respectively. One and eight cases underwent revision due to a widening scar at the dermofat donor site and wound dehiscence, respectively. Notably, one case had inflamed sinus formation.

CONCLUSIONS

The advanced dermofat graft technique provided favorable results with selection of appropriate donor site and a dermofat graft with subdermal fat. The application of this molding technique and proper management of donor site ameliorated critical disadvantages, thereby providing a safe and effective alternative for revision rhinoplasty.

EBM LEVEL IV

Rhinoplasty.

Persistent symptomatic anterior oronasal fistulae in patients with Veau type III and IV clefts: A therapeutic protocol and outcomes

BACKGROUND

The anterior oronasal fistulae neighboring the alveolar cleft could persist or reappear after the alveolar reconstruction with cancellous bone grafting. The persistent symptomatic anterior oronasal fistulae need to be repaired, but surgery remains a challenge in cleft care. Surprisingly, this issue has rarely been reported in the literature. The purpose of this long-term study was to report a single surgeon experience with a therapeutic protocol for persistent symptomatic anterior oronasal fistula repair.

METHODS

This is a retrospective study of consecutive patients with Veau type III and IV clefts and persistent symptomatic anterior oronasal fistulae managed according to a therapeutic protocol from 1997 to 2018. Depending on fistula size, patients were treated with local flaps associated with an interpositional graft or two-stage tongue flaps (small/medium or large fistulae, respectively). The surgical outcomes were classified as "good" (complete fistula closure with no symptoms), "fair" (asymptomatic narrow fistula remained), or "poor" (failure with persistent symptoms).

RESULTS

Forty-four patients with persistent symptomatic anterior oronasal fistulae were reconstructed with local flaps associated with interpositional fascia or dermal fat grafting (52.3%) or two-stage tongue flaps (47.7%). Most of patients (93.2%) presented "good" outcomes, ranging from 87% to 100% (local and tongue flaps, respectively). Three (6.8%) patients presented symptomatic residual fistula ("poor" outcomes).

CONCLUSIONS

For the repair of persistent symptomatic anterior oronasal fistulae, this therapeutic protocol provided satisfactory outcome with low fistula recurrence rate.