Cleft Palate Fistula Closure Utilizing Acellular Dermal Matrix

Interposition grafting of collagen-gelatin sponge impregnated with basic fibroblast growth factor in primary palatoplasty

INTRODUCTION

An oronasal fistula is a challenging post-operative complication of palatoplasty due to impaired velopharyngeal function or its high recurrence rate. Muscle repositioning, a key procedure in palatoplasty, causes dead space at the junction between the hard and soft palates. Consequently, thin oral and nasal mucosae are prone to break down and form fistulas. In this study, we used basic fibroblast growth factor-impregnated collagen gelatin sponge (bFGF-CGS) in primary palatoplasty to reduce fistula formation.

METHODS

This retrospective study assessed the complications and efficacy of bFGF-CGS to reduce fistula formation. Patients who underwent primary palatoplasty with bFGF-CGS were included. The same number of patients who underwent primary palatoplasty without bFGF-CGS was included as a control group. The outcomes included post-operative oronasal fistula formation, delayed healing, bleeding, and infection.

RESULTS

Both groups included 44 patients. Except for age at palatoplasty, there were no statistically significant demographic differences between the two groups; however, the rates of fistula formation in the study and control group were 2.3% and 13.6%, respectively. There were no infections among the patients.

CONCLUSIONS

The grafting of bFGF-CGS in primary palatoplasty was safe and probably effective in reducing post-operative oronasal fistula formation.

Current insights in the preclinical study of palatal wound healing and oronasal fistula after cleft palate repair

Poor palatal wound healing after cleft palate repair could lead to unfavorable prognosis such as oronasal fistula (ONF), which might affect the patient's velopharyngeal function as well as their quality of life. Thus, restoring poor palatal wound healing for avoiding the occurrence of ONF should be considered the key to postoperative care after cleft palate repair. This review provided current insights in the preclinical study of poor palatal wound healing after cleft palate repair. This review comprehensively introduced the animal model establishment for palatal wound healing and related ONF, including the models by mice, rats, piglets, and dogs, and then demonstrated the aspects for investigating poor palatal wound healing and related treatments, including possible signaling pathways that could be involved in the formation of poor palatal wound healing, the related microbiota changes because of the deformity of palatal structure, and the studies for potential therapeutic strategies for palatal wound healing and ONF. The purpose of this review was to show the state of the art in preclinical studies about palatal wound healing after cleft palate repair and to show the promising aspects for better management of palatal wound healing.

An Algorithmic Approach for Deploying Buccal Fat Pad Flaps and Buccal Myomucosal Flaps Strategically in Primary and Secondary Palatoplasty

OBJECTIVE

Recent publications have introduced the use of buccal myomucosal and fat pad flaps to augment palatal repairs with autologous tissue. We propose a workflow for intraoperative decision-making to introduce these adjuncts into standard palatoplasty procedures.

DESIGN/PATIENTS

A retrospective chart review of a single-surgeon series of patients undergoing primary and secondary palatoplasties performed between October 2017 and November 2020 was completed after Institutional Review Board approval.

MAIN OUTCOME MEASURES

Patient demographics, phenotype, operative details, and postoperative complications were recorded.

RESULTS

Fifty-eight patients were included in a review. For those undergoing primary repair, 23.3% underwent a Furlow palatoplasty alone, 46.3% had a Furlow palatoplasty accompanied with acellular dermal matrix (ADM) and/or a buccal fat flap (BFF). A unilateral buccal myomucosal flap (BMMF) with or without augmentation with BFF or ADM was employed in 16.3% of the cases. Fourteen percent required a bilateral BMMF+/- ADM. Fistula occurrence was 2.3% (n = 1). For revisions, 27% underwent only a conversion Furlow palatoplasty, 26% had a conversion Furlow palatoplasty accompanied with ADM and/or a BFF, 33% had a unilateral BMMF or BMMF/ADM, and 14% required a bilateral BMMF+/- ADM.

CONCLUSIONS

In severe phenotypes or complicated cases, buccal fat flaps and myomucosal flaps may be utilized. This approach has mostly replaced the use of ADM over time. An algorithmic approach to palatoplasty allows surgeons to tailor the extent of surgery to the needs of each patient.

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.

Large Anterior Oronasal Fistula Repair Using Pedicled Buccal Fat Pad and Fibroepithelial Tissue

Oronasal fistula (ONF) is the most common complication after palatoplasty in patients with cleft lip and palate (CLP). When left untreated, it may negatively affect the quality of life, leading to development of other comorbidities. This study reports for the first time, the use of a portion of a hyperplasic tissue associated with pedicled buccal fat pad flap to repair a large anterior ONF in a 60-year-old man. The hyperplasic tissue may have developed due to the combination of a loose fitting upper denture and long-term use of dihydropyridine calcium channel blocker (amlodipine besylate). There is controversy in the literature about use of pedicled buccal fat pad flap in the anterior region. However, in this study, we report successful repair of a large anterior ONF using a portion of a fibroepithelial hyperplasic tissue associated with pedicled buccal fat pad flap.

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.