The versatility of the tongue flap in the closure of palatal fistula

Oronasal fistula reconstruction using tongue flap with simultaneous iliac bone graft: a case report

The ultimate goal of cleft palate repair is to achieve an intact palate with the separation of the oral and nasal cavities. However, some patients develop an oronasal fistula in the secondary palate after palatoplasty. Postoperatively, a secondary palatal oronasal fistula may develop, leading to functional problems. In this study, we describe a patient with recurrent oronasal fistula and alveolar cleft with multiple failed previous reconstructions at another clinic. The oronasal fistula and alveolar cleft were repaired using a tongue flap and an iliac bone graft, respectively. The patient demonstrated excellent clinical progress with no recurrence of the oronasal fistula at the 1-year follow-up.

Tongue Flap for Closure of Complex Oronasal Fistula

Complex oronasal fistula is one of the most frequent secondary complications of cleft palate correction and is considered a reconstructive challenge. Tongue flaps are one of the procedures for the treatment of complex fistulas associated or not with multiple previous procedures, offering a high success rate, few complications, and problems during its development. This study evaluates the efficacy in terms of functionality, esthetic, donor area morbidity and clarifies surgical technique steps. Descriptive cohort study was performed between August 2011 to August 2021 where an anteriorly based dorsal tongue flap was performed in 30 patients with complex palatal fistulas, evaluating outcomes in terms of technique reproducibility and flap viability, correction of oronasal regurgitation, speech, donor site morbidity, complications, and esthetics. The senior author has used this technique with consistent clinical outcomes to improve complex oronasal fistula with minimal complications, with a good success rate in terms of correction of the palatal defect with imperceptible alteration of the lingual donor area. In addition, establishes a specific definition of persistence and recurrence of oronasal fistula. The tongue flap is considered the gold standard in complex oronasal fistula reconstructions with satisfactory outcomes, and it offers an adequate amount of vascularized tissue achieving fistula closure without functional or esthetic impairment of the donor area and is a highly reproducible technique.

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.

Reconstruction of persistent oronasal communication using an anteriorly based tongue flap following failed cleft palate repair-Report of two cases

The tongue flap is a suitable alternative to local mucoperiosteal flaps in closure of wide, persistent oronasal communications, surrounded by scarred and fibrotic tissue as a result of previously attempted palatoplasty. Herein, we report two cases with large recurrent oronasal communication closed using the anteriorly based dorsal tongue flap.

Cleft Palate Fistula: A Review

Background

The development of postoperative oronasal fistulae (ONF) is a complication that plagues all cleft surgeons to varying degrees. There is extensive literature discussing the incidence, functional impact, and treatment of ONF. The goal of this article is to provide an extensive review of the literature discussing the incidence, causative factors, functional impact, classification systems, and treatment of ONF.

Methods

A literature review was performed using PubMed using the Medical Subject Heading terms "cleft palate" AND "fistula" OR "palatal fistula" OR "oronasal fistula". After review, a total of 356 articles were deemed relevant for this study.

Results

Information regarding ONF care, prevention, and management in patients with cleft palate was collected from the articles included in this review. Treatment of ONF remains a challenging problem as there is not a consensus in the available literature on the best palatoplasty techniques for their prevention and treatment. A myriad of reconstructive options and adjunctive therapies exist, and their use is guided by the size and location of the fistula.

Conclusions

Fistula treatment should be tailored to the specific needs of the patient, and consideration must be given to not only the ONF itself but also the patient's stage of growth and development. Large-scale, multicenter studies are needed in which ONF are described using standardized nomenclature, and improved outcomes reporting is necessary to better define an algorithm for a truly holistic approach to palate surgery and reduce the incidence of palatal fistula.

Reconstruction of Oronasal Fistula with Tongue Flap: A Cleft Palate Report

Oronasal fistula can persist after conventional secondary alveolar bone graft surgery, which may lead to functional issues, such as regurgitation of fluids from the oral to the nasal cavity. This manuscript describes a clinical case of a patient with a bilateral cleft lip and palate that underwent tongue graft surgery for closure of an oronasal fistula after three failed local mucosa flap surgeries. The multidisciplinary treatment was comprised of orthodontic treatment, mucosa and alveolar grafts for palate closure and aesthetic rehabilitation of the anterior maxillary teeth. Smile aesthetics were noticeably improved, enhancing the patient’s self-perception and confidence.

Tongue Flap for Management of Large Palatal Fistulas

ABSTRACT

One of the worst complications after a primary palatoplasty is the lesion of the neurovascular bundle, results into a type of flap necrosis, having as a final consequence a residual palatine fistula.In our institution the authors usually use tongue flap to repair large fistulas.The authors retrospectively reviewed all patients with large palatal fistulas that were repaired with tongue flap at Fundacion Gantz between January 2002 and December 2020.Fundacion Gantz has 1.067 patients with palatal surgeries, with an incidence of 5,8% for palatal fistulas and 3,2% (n = 2) were considered large.Surgery was done on 24 patients with large residual palatal fistula, all of them with tongue flaps as outpatient surgery. Fifteen were girls and 9 were boys, between 13 and 40 years.The average size of the fistula was 2,5 cm and 100% are localized in the anterior palate.The incidence of complications with tongue flap was 12, 5%: 2 dehiscences and 1 persistent residual fistula. The authors had no complications in phonation due to the lingual donor area.The authors consider that this outpatient surgery, is a reprodutible and safe technique, with a low rate of complications, which allows us to recommend it for the treatment of large palatal fistulas.

Facial Artery Musculomucosal Flap in Alveolar Cleft Surgery

INTRODUCTION

Large anterior palatal fistula and special alveolar clefts, such as edentulous atrophic premaxilla and absent premaxilla (premaxillectomy or agenesis), as well as wide unilateral alveolar cleft, are complicated cases in alveolar cleft bone grafting surgery. A superiorly-based buccinator myomucosal flap is suitable in this regard.

MATERIALS AND METHODS

The cleft patients whose large anterior palatal fistula and superiorly based buccinator myomucosal flap had been used for palatal or alveolar reconstruction were recruited in the study. The reconstruction method of the nasal floor, follow-up time, and hospital length of stay were recorded.

RESULTS

A total of 10 patients had been treated by this method. The majority of them were male (6/10), the age range of the patients was 14-25 years. All flaps survived and a case of partial necrosis occurred.

CONCLUSION

As evidenced by the obtained results, a superiorly-based facial artery musculomucosal flap is suitable when the palatal fistula is continuous with the alveolar cleft. Transmaxillary transfer is the other option in patients with closed maxillary arch.

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.

For Patients With Isolated Cleft Palate Does Revision Palatoplasty Have an Increased Risk of Inpatient Complication Compared to Primary Palatal Repair?

OBJECTIVE

The purpose of this study was to determine whether revision palatoplasty was associated with increased rates of inpatient complication and wound dehiscence compared to primary palatal repair.

MATERIALS AND METHODS

This was a retrospective study of patients with isolated cleft palate treated with primary palatoplasty or revision surgery for fistula repair. The records were obtained from the Kids' Inpatient Database between 2000 and 2014. The primary predictor was the type of surgery, classified as either primary or revision palatoplasty. Secondary predictors included demographics and comorbidities. Primary study outcomes were the postoperative complication and dehiscence rates as noted during the hospitalization course. The secondary outcomes related to health care utilization as measured through length of stay (LOS) and hospital charges.

RESULTS

A total of 5357 total admissions (95.5% primary, 4.5% revision) were included in the final sample. Fistula repairs (odds ratio = 14.37, P < .01) had significantly greater odds of wound dehiscence. The rates of inpatient complication ranged from 3.5% to 3.7%, and there were no significant differences between primary and revision surgery (P = .82). Complications were independently associated with insurance status and congenital anomalies. Complications and wound dehiscence both significantly increased the LOS and the hospital charges. Fistula repairs had a shorter mean LOS (P = .02), however this did not translate into cost savings (P = .60).

CONCLUSIONS

Although the rates of inpatient complications were not significantly different, revision palatoplasty was associated with a greater odds of wound dehiscence. Failure of a primary repair may portend an increased risk of wound failure with subsequent surgeries.

The tongue flap for large palatal fistulas, a success or a failure? Our 15-year experience

Large palatal fistulas after cleft palate surgery are difficult to treat using local mucoperiosteal flaps alone, particularly if multiple attempts to close the fistulas have resulted in tissue scarring. In this study, we present our 15-year surgical experience with tongue flaps for large palatal fistulas. A total of 34 patients who underwent tongue flap surgery at our institution between January 2000 and January 2015 were retrospectively analyzed. An anteriorly-based dorsal tongue flap was used for the treatment of anteriorly localized large palatal fistulas in all patients. Data including demographic characteristics of the patients, previous surgeries, localization of the fistula, time between the first and second surgery, and complications were recorded. Factors affecting the surgical success were evaluated. Of the patients, 21 were males and 13 were females with a mean age of 11.7 ± 6.9 (range: 4 to 29) years. Detachment of the tongue flap was observed in nine patients after surgery. Seven of the patients with detachment were male aged ≤6 years (p < 0.05). Resuturing the flap back to the defect did not significantly affect the results. Our study results suggest that proper patient selection and attentive and rigorous surgical technique have a critical importance in the tongue flap repair and tongue flap is not recommended for patients who are under seven years of age.

Double Tongue Flaps for Anterior Huge Palatal Fistula Closure

Even though it is widely accepted that the tongue flap is effective and feasible for repair of huge palatal fistula, there still exist a few failed cases due to the severity or complicated situation. The aim of this paper is to report the validity and feasibility of using double tongue dorsal flaps to repair a huge anterior fistula. A 10-year-old boy diagnosed with Van de Woude syndrome with repaired bilateral cleft lip and palate presented with a huge anterior fistula divided by septum. A double tongue dorsal flap was designed to cover the fistula. The huge unusual anterior palatal fistula was repaired successfully by usage of double pedicle tongue flaps with a follow-up period of 1 month. The double tongue flap is an alternative choice to handle a large residual fistula in anterior part of palate which was divided into 2 fistulas by septum. This technique was indicated in the situation of large residual fistula in anterior part of palate which was divided into 2 fistulas by septum after bilateral cleft palate repair.

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.

Tongue flap as salvage procedure for recurrent and large palatal fistula after cleft palate repair

BACKGROUND

Recurrent palatal fistula is a common complication of cleft palate repair. The main causes are poor surgical technique or vascular accidents and infection. Local flaps are not adequate for larger and recurrent fistula. The aim of this study is to analyze the utility of tongue flap in recurrent and large palatal fistula repair.

MATERIALS AND METHODS

From January 2008 to July 2016, 18 patients with recurrent palatal fistula were included in the study. All the patients had undergone repair of cleft palate and fistula previously. Tongue flap repair of the recurrent palatal fistula was performed in all 18 patients. The flaps were divided after 3 weeks and final inset was done. Flap viability, fistula closure, residual tongue function, esthetics, and speech impediment were assessed.

RESULTS

In all the patients, fistula could be closed primarily by tongue flap. None of the patients developed flap necrosis while flap dehiscence and bleeding were observed in one patient each. No functional deformity of the tongue and donor-site morbidity was seen. Speech was improved in 80% cases.

CONCLUSION

The central position, mobility, excellent vascularity, and versatility of tongue flap make particularly suitable choice for the repair of large fistula in palates scarred by previous surgery. It is very well tolerated by children. We, therefore, recommend tongue flap for large and recurrent palatal fistula in children.

Techniques to Improve Reliability and Predictability of the Dorsal Pedicled Tongue Flap in Closure of Palatal Defects and Oronasal Fistulae

Introduction

Despite the improvement in surgical techniques in cleft palate surgery, oronasal fistulas continue to remain a challenge, usually the result of residual palatal and alveolar clefts and post-palatoplasty defects. The tongue flap is an extremely versatile, sturdy, reliable and efficient means of closure of anterior as well as posterior, unilateral and bilateral palatal defects, effectively functionally obliterating the oronasal communication, owing much of its success to its highly vascular structure, good mobility, texture match, central location and low donor site morbidity. However, it has a few drawbacks. Flap dehiscence and detachment during the early postoperative period is a troublesome complication owing to tongue movements during normal activities such as speaking, swallowing, yawning and coughing.

Aim

This article describes some of the methods which can be used to effectively alleviate these shortcomings.

Methods

A protocol of immobilizing the tongue by tethering it to the maxillary teeth for the 3-week postoperative period, and also maintaining the patient on nasogastric feeding, until the patient is taken up for surgical separation the pedicle, was employed in all patients in this case series.

Results

There was a successful and predictable take of the tongue flap at the donor site, namely the palatal/oronasal fistula with its successful closure, in all the patients.

Conclusion

Treatment of the oronasal fistula using a two-layer closure using the nasal mucoperiosteum together with an anteriorly based dorsal tongue flap is an easy and efficient method, whose reliability can be further increased by avoiding a common complication, namely tongue flap detachment in the postoperative period brought on by movements of the tongue, by immobilizing the tongue by tethering it to the maxillary teeth and also maintaining the patient on nasogastric feeding for the 3-week postoperative period.

Comparison of Clinical Outcome of Facial Artery Myomucosal Flap and Tongue Flap for Closure of Large Anterior Palatal Fistulas

Closure of large anterior palatal fistula has high recurrence rate. The objective of this study was to compare the clinical outcome of facial artery myomucosal flap (FAMM flap) and tongue flap used for closure of large anterior palatal fistula. This study was conducted from March 2008 to March 2014. Thirty-nine patients, aged 2 to 40 years, who had anterior palatal fistula 5 to 20 mm in width with associated alveolar cleft and repaired with either a tongue flap or FAMM flap were included. Patients were excluded if they had adequate local palatal tissue for closure, mid, posterior or multiple fistulae, fistula width >20 mm. Closure was performed in 2 layers. Turndown flap of oral mucoperiosteum was used to reconstruct nasal layer and oral layer was reconstructed with FAMM flap in 16 and tongue flap in 23 patients. Mean(SD) pain score was 3(1) and 7(1) in FAMM flap and tongue flap groups respectively with a P value <0.096. All patients in tongue flap group experienced difficulty in speaking and eating whereas in FAMM flap group 2 had eating problem and 2 experienced speech difficulty. Mean(SD) total operative times for FAMM flap and tongue flap were 155(38) and 242(10) minutes, respectively, P value <0.002. There was no difference for other complications and no recurrence at 1 year follow-up in both groups. The authors concluded that FAMM flap should be considered first choice for closure of large anterior palatal fistulas associated with alveolar cleft as it requires less total operative time and has less early postoperative complications.

Versatility of Tongue Flaps for Closure of Palatal Defects- Case Report

Palatal defects following congenital anomalies, traumatic injuries, benign and malignant pathologies frequently require resection and reconstruction. Reconstruction of these defects is challenging and complex due to the amount of tissue left for primary closure after excision, compromised vasculature as on repaired cleft palate and limited pedicled flaps around the lesion. Tongue flap though doesn't fulfil all the ideal requirements of a flap, however because of its flexibility, good blood supply and position it can be considered as the best among other flaps for reconstruction of oral and palatal defects. In this article we describe two different cases in which tongue flap was used to reconstruct palatal defects, one an oroantral communication secondary to a tumour excision and the other an oro-nasal fistula secondary to cleft palate repair.

Single-layer Closure with Tongue Flap for Palatal Fistula in Cleft Palate Patients

Background:

Tongue flap is a good option to close a complicated palatal fistula in cleft patients. Most surgeons advocate a double-layer closure to decrease the recurrence rates. In this study, we have reported our experience with a modified single-layer closure with tongue flap in cleft patients.

Method:

All cases done by a single surgeon using this modified technique in a period of 10 years were retrospectively reviewed. A thorough description of this technique is also provided in the study.

Results:

Only 5 cases were operated on using this technique. The success rate of all these cases was 100%, with no recurrence of fistula and few complications.

Conclusions:

This technique provides a way to avoid nasal layer closure in cases where nasal layer is difficult or impossible to close. It also limits the need for a second flap for nasal layer closure.

Esthetic and functional rehabilitation in patients with cleft lip and palate

Oral rehabilitation of missing teeth in cleft patients has acceptable success rates. A two-stage approach is indicated; however, timing of implant placement in the grafted maxilla varies within existing protocols. This case highlights successful implant osseointegration and esthetic oral rehabilitation following placement of two implants at 5 months after maxillary grafting (alveolar bone grafting) with a corticocancellous block obtained from the iliac crest. A 31-year-old male patient had already undergone repair of his bilateral cleft lip and soft palate according to established guidelines for cleft patients. Initial closure of his alveolar clefts and further correction of the maxillary hypoplasia with a bi-maxillary osteotomy were completed in 2002. However, bone resorption due to infection in 2003 necessitated removal of all maxillary incisors. The patient was not satisfied with the removable partial denture provided. In 2007, he did undergo anterior maxillary augmentation under general anesthesia, and 5 months later two implants were placed. A 3-unit bridge did replace functional and esthetic demands. Postoperative recovery was uneventful, and overall bone loss, and oral health remain within standards 28 months following implant placement. Optimal outcome is achievable when replacing missing teeth in cleft patients when timing does not exceed approximately a 6-month interval from bone grafting to implant placement. This article demonstrates that overall esthetic and functional rehabilitation is feasible in cleft lip and palate patients. In this patient, overall oral treatment was achieved with an implant prosthesis.

Closure of huge palatal fistula in an adult patient with isolated cleft palate: a technical note

Closure of huge palatal fistula surrounded by fully erupted permanent dentition in the adult patients with cleft is a challenge. Posteriorly based buccinator myomucosal flap is a neurovascular pedicled flap, with inherent nature of thin thickness, saliva secretion, and axial pattern blood supply. Vicinity of donor site to the palate and low donor-site morbidity are the other advantages. It is an ideal choice in such situation. In this article, the details of surgical technique and the effectiveness of this method are presented.