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ETIOLOGY
Tension at the site of closure Necrosis(Greater Palatine nerve injury) Infection Hematoma Mechanical trauma
CLASSIFICATION
SIMPLE
Local transposition flap Tubed pedicle flaps Abdomen Arm Neck Cervicothoracic Cheek Nasolabial Temporalis muscle
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 twolayer 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)
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.OJI MI and UTSUGI
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 deepithelialized 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
Overall results
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(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.
2.
3.
4. 5.
No detrimental after-effects occur at the donor site.Mouth opening does not become limited. No distress occurs during healing and it is not necessary to restrict speech A normal diet may be resumed soon after operation Ordinary oral intubation possible 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
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