A Toolbox of Surgical Techniques for Palatal Fistula Repair

Managing massive palatial defect secondary to palatoplasty failures: an in-depth analysis

PURPOSE OF REVIEW

Massive palatal defects resulting from palatoplasty failures arising from cleft palate repair complications present ongoing challenges in clinical practice. The purpose of this review is to provide up-to-date insights into aetiology, risk factors, surgical techniques, and adjunctive therapies, aiming to enhance the understanding of such complex cases, and optimize patient outcomes.

RECENT FINDINGS

Primary palatoplasty has fistula recurrence rates ranging from 2.4% to 55%. Factors such as cleft width, surgical repair method, and patient characteristics, influence the likelihood of failure. Classifications such as the Pakistan Comprehensive Classification and Richardson's criteria aid in assessing defects. Surgical options range from local flaps and revision palatoplasty to regional flaps (e.g., buccinator myomucosal, facial artery-based flaps, tongue flaps, nasal septal flaps) to free microvascular flaps. Alternative approaches include obturator prostheses, and acellular dermal matrix has been used as an adjuvant to multiple repair techniques. Hyperbaric oxygen therapy has emerged as an adjunctive therapy to enhance tissue healing.

SUMMARY

This comprehensive review underscores the intricate challenges associated with massive palatal defects resulting from palatoplasty failures. The diverse range of surgical and nonsurgical options emphasizes the importance of patient-centric, individualized approaches. Practitioners, armed with evidence-based insights, can navigate these complexities, offering tailored interventions for improved patient outcomes.

Secondary Procedures on the Palate to Correct/Improve Speech: Past, Present and Future

Speech production in general and in patients with cleft palate in particular is multifactorial. In addition to the complex velopharyngeal mechanism, all structures of the oral cavity have some contribution for correct speech production. Therefore, in addition to the velopharynx the surgeons and other cleft/craniofacial team members need to perform a thorough and complete evaluation of all structures to fully appreciate the causative factor(s) responsible for inadequate speech production after palatoplasty and to prescribe the most appropriate, personalized management plan. The purpose of this communication is to stress the importance of areas other than the velopharyngx that could have a negative impact on speech. More specifically, the issues of palatoplasty failures and palatal revisions will be presented. This is an area of significant importance and could represent the first line of defense before considering procedures altering the anatomy of the velopharynx, such as pharyngeal flaps, pharyngoplasties, and others. Issues covering the effects of skeletal and dental problems, such as malocclusion, partial or complete edentulism can also affect speech but are outside the scope of this communication.

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.

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.

Impact of a Palatal Fistula After Cleft Palate Repair on Velopharyngeal Closure

PURPOSE

A palatal fistula is an adverse outcome of cleft palate repair. It is unknown if a palatal fistula will influence velopharyngeal closure, even after repair of the fistula. This study determines the effect of a soft palate fistula on the risk of developing velopharyngeal insufficiency.

METHODS

A retrospective chart review was conducted on patients who underwent primary cleft palate repair between 2000 and 2015, with complete records at 4 years of age. Fistulae involving the secondary palate following primary palatoplasty were classified as the soft or hard palate. A forced-entry multivariate logistic regression model was built to detect predictors of velopharyngeal dysfunction.

RESULTS

Records of 329 patients were analyzed with a mean follow-up of 8.7 years. A palatal fistula was identified in 89/329 patients (27%) and 29/329 patients (9%) underwent an independent fistula repair. Of the patients with fistula, 44% were located in the hard palate only and 56% had soft palate involvement. Compared to patients without a fistula, rates of velopharyngeal dysfunction were significantly higher in patients with a fistula involving the soft palate (OR 3.875, CI: 1.964-7.648, P < .001) but not in patients with a hard palate fistula (OR 1.140, CI: 0.497-2.613, P = .757). Veau class, age at primary repair, and syndromic status were not significant predictors of VPI (0.128≤P ≤ .975).

CONCLUSIONS

A palatal fistula involving the soft palate is a significant predictor for development of velopharyngeal dysfunction after primary palatoplasty. Surgical intervention, at the time of fistula repair, to add vascularized tissue may be indicated to prophylactically decrease the risk of velopharyngeal dysfunction.

Analysis of risk factors affecting poor wound healing after primary cleft palate surgery

OBJECTIVES

To study the risk factors of poor wound healing after primary cleft palate surgery.

METHODS

In this study, 980 cases of congenital cleft palate treated by Sommerlad-Furlow in the Department of Cleft Lip and Palate Surgery of Sichuan University from 2017 to 2021 were continuously analyzed. Indicators included patient's age, gender, body weight, cleft palate type, width of the widest fistula, cleft palate index (width of the widest fistula/width at the posterior edge of the maxillary tubercle plane), preoperative white blood cell count, preoperative hemoglobin level, preoperative antibiotic use, doctor's seniority, use of relaxation incision, operation time, postoperative upper respiratory tract infection, and postoperative wound healing. The postoperative wound healing was divided into normal healing, delayed healing, and palatal fistula. Both delayed healing and palatal fistula were classified as poor healing. The factors that may affect the healing outcome of the palatal wound after primary cleft palate repair were analyzed using SPSS 26.0 software.

RESULTS

A total of 825 patients (84.2%) had normal healing, 112 patients (11.4%) had delayed hea-ling, and 43 patients (4.4%) had palatal fistula. Doctor's seniority, width of the widest fissure, cleft palate index, and operation time influenced the wound healing effect after cleft palate surgery (P<0.05). Doctors with low seniority, wide width of the widest fistula, large cleft palate index, and long operation time were the risk factors of poor wound healing.

CONCLUSIONS

Doctor's seniority, width of the widest fissure, cleft palate index, and operation time are related to the effect of healing effect after cleft palate surgery.

Evaluation of a Novel Technique for Closure of Small Palatal Fistula

A palatal fistula is a pathological condition that connects the nasal cavities with the oral cavity. An oral-nasal fistula is reported as a possible post-surgical complication after the removal of oral carcinomas. The presence of a palatal fistula affects the patient's quality of life, making it necessary to apply a prosthetic device, such as a palatal plate, to keep the nasal cavities separated from the oral one. There are several surgical techniques to close a palatal fistula, but it is not possible to define the optimal technique as the approach is extremely dependent on the characteristics of the fistula. The aim of this article is to propose a minimally invasive technique to reduce the size of palatal fistulae and to reduce the surgical difficulty (NSPF). A total of 20 patients fulfilled the inclusion criteria and were checked every two weeks. The fistula was injured with a needle every 2 weeks. Fifteen patients who healed with complete closure of the fistula reported no need for a palatal protection plate to eat, drink and speak normally. It is possible to conclude that the NSPF protocol is a valid approach for the non-surgical reduction of palatal fistulae, and it is possible, when the appropriate conditions are present, to achieve complete closure.

Management of Palatal Fistula Using Superficial Circumflex Iliac Artery Perforator Flap With Intraoral Anastomosis and Supermicrosurgery Techniques

ABSTRACT

Postoperative palatal fistula following primary cleft palate repair, especially wide and recurrent defects, presents significant challenges to management. When the fistula is surrounded by limited and scarred regional tissues, vascularized free flaps are recommended. The authors propose a novel method to repair a wide and recurrent palatal fistula resulting in excellent aesthetics and minor donor-site complications. The superficial circumflex iliac artery perforator flap was transferred with the application of intraoral anastomosis and supermicrosurgery techniques for palatal fistula closure.

Effect of antibiotic pack on hard palate after fistula closure on nasal airflow and reoccurrence rate

This parallel blocked randomized controlled trial was done in two groups of 30 patients each to determine if placement of an antibiotic oral pack on the hard palate after hard palatal fistula repair reduces nasal air emission and fistula re-occurrence. Group A had an oral pack on the hard palate for 5 days post-operatively while group B did not. In group A, percentage of nasal air emission was tested using nasometry with and without pack. Paired t-tests were performed to compare nasal emissions for patients with and without pack. Recurrence of fistulas after 6 months between group A and B was tested using odds ratio. Effect of nasal air emission on fistula rates was tested using paired t-tests. There was a significant increase (p < 0.0001) in nasal emission after removal of the pack in group A. Fistula re-occurrence tended to be higher in group B (no pack) than group A but this was not significant (p = 0.242). There was no correlation between nasal air emission and fistula rates. In patients with recurrent fistulae, placement of an oral pack after fistula repair diminishes nasal air emission. Whether this has an impact on re-occurrence of fistulae needs to be investigated further.

Comparison of recurrence rate and speech outcome between two different techniques for cleft palatal fistula closure: A retrospective cohort study

The aim of this retrospective cohort study was to compare the recurrence rate and speech outcomes between two techniques for palatal fistula closure of cleft palate (CP). Patients with CP who underwent secondary palatal fistula closure using the single hinge-flap method with double-breasted mattress suture (hinge-flap group) and those who were treated with the conventional sliding palatal flap method (sliding-flap group) were retrospectively evaluated for demographic and perioperative variables. Recurrence rate of palatal fistula, perceptual speech outcomes, and nasalance scores were further reviewed in patients who met the inclusion criteria. A total of 31 patients, 21 in the hinge-flap group and 10 in the sliding-flap group, were included in this study. The fistula recurrence rate in the hinge-flap group (0%) was significantly lower than that in the sliding-flap group (30.0%) (P = 0.027). In the speech assessment, hypernasality and nasalance scores decreased post-operatively in both groups and significance was observed in the hinge-flap group (P = 0.013, P < 0.001, respectively). Articulation disorders were significantly improved in the hinge-flap group (P = 0.001). Within the limitations of the study it seems that the single hinge-flap method with double-breasted mattress suture should be preferred whenever appropriate.

Prevention and management of oronasal fistulas

PURPOSE OF REVIEW

The aim of this article is to present the current opinion on the prevention and management of oronasal fistulas in cleft palate patients.

RECENT FINDINGS

Though cleft palate repair has seen numerous modifications and improvements, oronasal fistulas remain one of the most common complications of palatoplasty. There are various techniques available for preventing and managing this complication.

SUMMARY

Oronasal fistulas can be minimized by employing proper principles for palatoplasty. Once a fistula occurs, the repair technique should be appropriate for the fistula type. Oronasal fistula classifications, various repair techniques, tissue adjuncts, and biomaterials used in both the primary palate repair and oronasal fistula repair are discussed in this review.

Addition to the Toolbox of Surgical Techniques for Palatal Fistula Repair

In response to the article by Rothermel and colleagues, the authors suggest the use of cancellous bone graft for repair of fistulae of the hard palate as an addition to the proposed toolbox.