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

Revision Palate Surgery

Oronasal fistulae and velopharyngeal insufficiency are common and interdependent complications after cleft palate surgery. Bone grafting can complement cleft habilitation. Early identification and intervention are vital for optimal outcomes. Collaboration with experienced healthcare professionals is crucial to develop a comprehensive treatment plan which considers speech therapy, prosthetic devices, and surgery. This article aims to review the current literature on the management of VPI and oronasal fistulae following cleft palate surgery and additionally highlight the role of alveolar bone grafting to improve outcomes for these patients.

Nasoplatine Island Advancement Flap for Closure of Anterior Palatal Fistula in Patient With Isolated Cleft Palate

Palatal fistula is common in cleft patients. Palatal fistula repair is difficult, and there is 10% to 30% recurrence rate. Application of nasopalatine Island advancement flap for easy closure of medium size anterior palatal fistula in isolated cleft patient is demonstrated. Anatomic basis, advantages, and limitations of this new flap are explained. Nasopalatine Island advancement flap is a useful aid for easy closure of medium size anterior palatal fistula in isolated cleft patient.

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.

A Straightforward Technique to Repair a Residual Oronasal Fistula in Bilateral Cleft Lip and Palate Patients

PURPOSE

An anterior palatal oronasal fistula in a bilateral cleft lip and palate is a challenging clinical dilemma. The purpose of this article is to present a 2-stage technique to repair the fistula in consistent fashion. The technique was developed to avoid more complicated procedures that had greater morbidity for larger oronasal defects that could not be treated in a single procedure.

MATERIALS AND METHODS

This is a retrospective study performed over 15 years using this technique in a private practice setting. From 2002 to 2017, 15 7- to 12-year-old patients (11 boys and 4 girls) were treated. They were seen in a multispecialty clinic for anterior residual fistulae, and impressions were obtained. Then, they were scheduled for first-stage closing of the fistulae. Data were retrospectively analyzed. The first stage started with closing the central portion of the fistulae. For the second stage 6 months later, the residual nasoalveolar cleft was closed and grafted in standard fashion. The first stage involved posteriorly reflecting a full-thickness mucoperiosteal flap and inserting it into the palatal soft tissue and stabilizing the segment with a splint for 3 weeks. The premaxillary segment was left denuded.

RESULTS

Fourteen of 15 patients (93%) had the central portion of the oronasal fistulae successfully closed. One patient had partial breakdown when the splint was prematurely removed at 2 weeks. The patient underwent successful closure by the same procedure at a later date. All patients had successful second-stage grafting of their nasoalveolar clefts.

CONCLUSIONS

An alternative technique is presented to treat clinically challenging oronasal fistulae. This 2-stage closure of a palatal fistula is straightforward, allows consistent closure of soft tissue defects, and avoids complex alternative procedures with serious surgical morbidities.

Remifentanil for sedation and analgesia during awake division of tongue flap in children: a report of two cases

Background

The tongue flap is an accepted treatment method for cleft palate repair. Orotracheal or nasotracheal intubation using a fiberoptic scope is preferred for the division of the tongue flap. We report two cases of tongue flap division in which the patients received adequate sedation and analgesia without tracheal intubation.

Case presentation

Twelve- and 13-year-old male patients were treated at our hospital for tongue flap division, performed as part of a cleft palate repair. We planned to divide the tongue flap under sedation with remifentanil (1 μg/kg/min continuous infusion) and local anesthesia, followed by induction of general anesthesia, and orotracheal intubation after the tongue flap was divided. During the procedure, patients were breathing spontaneously and were cooperative. Patients were able to follow the surgeons' verbal cues to thrust out the tongue during the procedure, so that the surgeons could easily insert the sutures.

Conclusions

During the division of the tongue flap in two children, excellent sedative and analgesic effects were achieved using continuous remifentanil infusion.