Maxillary reconstruction with horizontally oriented scapular tip free flap: outcomes in orbital support and palate closure.

BACKGROUND: Current indications of maxillary reconstruction with scapular tip free flap (STFF) are palatoalveolar defects associated with zygomaticomaxillary buttress and/or orbital floor defects. STFF can be placed either horizontally or vertically. Horizontal placement usually allows ideal palatal conformation, preventing oronasal communication, but has been argued to compromise orbital support and projection of the midface, whereas vertical placement is advocated for midface support but may be insufficient for the complete closure of the palate. The present study focuses on the horizontal placing of STFF to allow complete palate reconstruction and fistulae prevention while still obtaining optimal midface projection and orbital support. MATERIALS AND METHODS: This study included 21 case complex maxillary reconstructions with this flap, in which the horizontally placed scapular tip component replaced the palate, a muscular flap component was included for midface volume restoration, and an alloplastic implant was utilized for supporting the orbital content when needed. RESULTS: None of the patients presented palatal fistulas or alterations in the orbital support. CONCLUSION: A multilevel approach was proposed according to the maxillectomy defect. This experience supported the horizontal insetting of STFF to allow palatal fistulae prevention while still obtaining an optimal midface projection and orbital support.

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.

The use of surgical template for palatal fistula repair in cleft palate using tongue flap: 3 case report.

INTRODUCTION AND IMPORTANCE: The occurrence of a palatal fistula after surgical correction in a cleft palate patient is the most common complication in cleft palate surgery. This condition might be due to poor tissue quality and vascularity, an error in the surgical technique, the size of the defect, the age of the patient, and infection. CASE PRESENTATION: Three patients with fistula in the anterior and mid-palate regions asked for correction. In past history, all cases had received multiple surgical corrections, and the result showed with recurrent fistula. DISCUSSION: Surgical interventions for correction of palatal fistula might be difficult as the surrounding tissue has lost its quality, especially in secondary surgery or after multiple surgical interventions. Flap taken from the tongue can be chosen as an alternative source to close the fistula based on the consideration that the tongue has a favourable position, and located as the nearest tissue directly opposite to the palatal region, and has good vascularity. The aim of this report is to show the advantages of the use a surgical template made from alumina foil to measure the size and shape of the flap in accordance with the form and size of existed fistula. The surgical template was used as a guidance during drawn the design of the flap on the surface of the tongue. CONCLUSION: The use of surgical templates was very useful as guidance during the marking procedure on the surface of the tongue for designing an individual tongue flap form.

Anatomical and Surgical Implications of the Usage of Bichat Fat Pad in Oroantral Communication, Maxillary, Palatal, and Related Surgeries-Narrative Review.

The buccal fat pad, also called the Bichat's fat pad (BFP), is an encapsulated fat mass located in the cheek. This type of specialized fat mass can be used both as a pedicular or free graft in various surgeries and approaches. Due to its easy access from the oral cavity approach, it is commonly used for oroantral and palatal fistula closure. The knowledge of its anatomy and surrounding tissues plays a role in its mobilization and suturing onto the desired defect in the palatal or maxillary region. The BFP is mostly associated with the primary approach used for a fistula or bone surgery. Alternatively, the procedure can be performed with a single approach incision, which does not compromise the appearance or the function of the operating or adjacent areas. The most important inclusion criteria for BFP usage and surgical limitations are highlighted. The BFP is used for multiple purposes in reconstructive and oncology surgery and also has its use in esthetic and facial contouring procedures. The amount, volume, and shape of the BFP are mostly associated with the scope of their usage. The aim of the following narrative review is to present the surgical and anatomical implications of fat pads in maxillary and palatal surgeries.

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.

Tratamiento de comunicaciones bucosinusales y buconasales: Reporte de cinco casos de diferente etiología / Treatment of oroantral and oronasal communications: report of five cases with different etiology

Objetivo: Las comunicaciones bucosinusales y buco- nasales son condiciones patológicas que se caracterizan por la presencia de una solución de continuidad entre la cavidad bucal y el seno maxilar o la cavidad nasal respectivamente. Una vez que se ha instalado una comunicación es deseable ce- rrar este defecto, evitando así la infección del seno maxilar y posibles dificultades en la deglución, fonación y masticación. Se han propuesto diferentes tratamientos para su resolución, algunos no quirúrgicos y otros quirúrgicos. Los quirúrgicos pueden realizarse desplazando tejidos locales, regionales o injertando. El presente trabajo tiene como objetivo presentar situaciones clínicas de comunicaciones bucosinusales y buco- nasales con diferentes etiologías y sus distintos tratamientos según tamaño y ubicación del defecto. Casos clínicos: Se identificaron pacientes que asistie- ron al Servicio de Cirugía Maxilofacial del Hospital Piñero presentando cuatro comunicaciones bucosinusales agudas y crónicas y una comunicación buconasal crónica. Los casos analizados fueron tratados de manera quirúrgica utilizando di- versos colgajos según tamaño y ubicación del defecto (AU)

Aim: Oroantral and oronasal communications are patho- logical conditions characterized by the presence of a solu- tion of continuity between the oral cavity and the maxillary sinus or nasal cavity respectively. Once a communication has been installed, it is desirable to close this defect, thus avoid- ing infection of the maxillary sinus and possible difficulties in swallowing, phonation, and mastication. Different treatments have been proposed for its resolution, some non-surgical and others surgical. Surgical procedures can be performed by dis- placing local or regional tissue or by grafting. The aim of this case report is to present clinical situations of oral sinus and oral nasal communication with different etiologies and their different treatments according to the size and location of the defect. Clinical cases: A group of patients who attended the Maxillofacial Surgery Service of Piñero Hospital presenting four acute and chronic oral sinus and one oronasal communi- cations were identified. The analyzed cases were treated sur- gically using different flaps according to the size and location of the defect (AU)

Prophylactic Antibiotics After Cleft Lip and Palate Reconstruction: A Review From a Global Health Perspective.

Orofacial clefts are common congenital deformities. Global initiatives have increased access to cleft care and reconstruction surgeries for cleft lip with or without cleft palate (CL/P), but there is no consensus on the use of postoperative prophylactic antibiotics. We conducted a narrative review using PubMed on the use of postoperative prophylactic antibiotics in CL/P surgery. A search of PubMed identified 30 potentially relevant articles, of which 15 were reviewed. There was no consensus among surgeons on prescribing patterns, but there was limited evidence that postoperative antibiotics reduce palatal fistulas. Notably, microbiological screening is not used to guide the choice of antimicrobial or to predict postoperative complications. Based on limited available data, we cannot make any strong evidence-based recommendations on prescribing postoperative antibiotics; however, we recommend that each cleft surgeon performing these procedures in lower-income countries without access to tertiary care centers consider the cost-benefit analysis of prescribing antimicrobials postoperatively, without antimicrobial screening, which showed no benefit.

Evaluation of the effect of a resorbable membrane on the closure of palatal fistulas.

Purpose: A palatal fistula following the closure of palatal clefts remains a difficult clinical complication. Surgical treatment of fistulas is often complicated, with high recurrence rates. We present our results of fistula closure augmented with GTR, a resorbable membrane designed to promote guided tissue regeneration. Methods: We reviewed the records of 75 patients operated on between 2008 and 2022 for closure of the palatal fistula. The patients included 24 who underwent fistula closure augmented with GTR and 51 who underwent fistula closure with other techniques. We reviewed the age at surgery, sex, fistula location, and outcome. Operation success was defined as an asymptomatic patient with a healed fistula on clinical examination. Results: The overall fistula closure rate was 79.1% in the GTR group and 76.5% in the non-GTR group(p = 0.79). Discussion: The success rate of fistula closure in the GTR group is comparable to that in the non-GTR group in this study. An additional advantage is that this procedure does not require harvesting any autologous tissue and reduces tissue damage in the long term.

Congenital Palatal Fistula with Cleft of the Soft Palate.

Congenital palatal fistula or perforation is rare, unlike the acquired form which commonly results from cleft palate repair. Congenital palatal fistulae are often associated with submucous cleft palate. Only a few of this fistulae are diagnosed shortly after birth. We present the case of a 3-year old girl with congenital palatal fistula coexisting with cleft of the soft palate that was noticed shortly after birth. The palate was repaired using Bardach's palatoplasty and the client was subsequently referred to a speech therapist.

Management of Palatal Defects after Free-Flap Reconstruction and Radiotherapy.

Palatal fistulas have significant effects on quality of life. Traditional prosthetic rehabilitation and surgical reconstruction of palate defects in radiation-naïve tissues are well described. However, palatal fistulas developing after initial tumor extirpation, free-flap reconstruction, and adjuvant radiation or chemoradiation are associated with challenging secondary tissue effects. In this review, we will discuss the management of palatal fistulas after surgical reconstruction and radiotherapy.

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.

Expanding Horizons: A Case Report of Cleft Expansion in the Mixed Dentition Stage.

A nine-year-old boy with a cleft lip and palate had midface retrusion as a result of maxillary complex growth inhibition. He sought treatment for total crossbite with a Class III skeletal pattern. The maxillary expansion widened the maxilla to improve the sagittal and transverse skeletal relationship. In skeletal Class III patients with a repaired cleft lip and palate, maxillary expansion and protraction usually provide effective improvement. The individual growth of the maxilla and mandible is crucial to the success of the orthopedic procedure.

The use of acellular dermal matrix in palatoplasty to decrease the rate of postoperative oronasal fistula.

Different cleft palate repair techniques have been described to achieve optimum results and minimise complications. Postoperative fistulae are one of the most challenging complications after palate repair. In this clinical study, we reviewed the records of patients who underwent palatoplasty using acellular dermal matrix (ADM) as an addition to facilitate difficult cleft palate and palatal fistula closure. It was a retrospective, comparative, single-centre study, in which records of patients who underwent cleft palate surgeries between 2015 and 2018 were reviewed. Patients who underwent cleft palate or palatal fistula repair with and without ADM were included. Fischer's exact test was used to compare the two groups (primary cleft palate repair with and without ADM) in relation to the rate of fistula occurrence postoperatively. Charts of a total of 31 patients were reviewed. ADM was used in 13 patients; 8(61.5%) were primary repairs and 5(38.5%) were fistula repairs. Eighteen patients were repaired without ADM, of whom 16(88.9%) were primary cleft palate repairs and 2(11.1%) were fistula repairs. The statistical analysis showed no significant difference in fistula formation rate or recurrence in both the groups. ADM is a simple, safe, and helpful tool for augmenting cleft palate repair, mainly in relatively wide and high-tension cleft palate repairs. In our study, a trend showing decreased complications with ADM was observed. Therefore, we recommend a multi-centre study with a larger sample to assess the significance of ADM in cleft palate and palatal fistulae repair.

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.

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.

Factores de riesgo de fístulas palatinas en pacientes tratados quirúrgicamente mediante palatoplastias / Risk factors for palatal fistulas in patients surgically treated with palatoplasty

La fisura palatina es una malformación congénita que afecta al paladar. Una fístula es la falla en la cicatrización en el sitio de reparación quirúrgica. Está presente en nuestro medio en un importante número de fístulas oronasales posterior a palatoplastias. El objetivo del presente trabajo es determinar los factores de riesgo de fisuras palatinas en pacientes tratados quirúrgicamente mediante palatoplastias La población de estudio fueron 82 pacientes que ingresaron al Servicio de Cirugía Pediátrica del Hospital Materno Infantil. En los resultados, la media de edad en el grupo de pacientes con fístula fue 1 año 2 meses, en el grupo sin fístula fue de 1 año. El más afectado es el sexo masculino y aumentan el riesgo de fístula los grados moderado y severo en 1.22 veces. También la exposición a más de dos cirugías aumenta 2.65 veces, el grado 4 aumenta 3.1, la desnutrición representa 2.93 veces. La prevalencia de fístulas es del 13%. Los factores de riesgo son: grado de fisura palatina moderado y severo, haber estado sometido a más de dos cirugías. De acuerdo al defecto primario el grado 3 y el grado 4 y la desnutrición también son factores de riesgo.

Cleft palate is a congenital malformation that affects the palate. A fistula is the failure of healing at the site of surgical repair. It is present in our environment in a significant number of oronasal fistulas after palatoplasty. The objective of this study is to determine the risk factors for palatal clefts in patients surgically treated with palatoplasty. The study population consisted of 82 patients who were admitted to the Pediatric Surgery Service of the Maternal and Child Hospital. In the results, the mean age in the group of patients with fistula was 1 year 2 months, in the group without fistula it was 1 year. The most affected is the male sex and the moderate and severe degrees increase the risk of fistula by 1.22 times. Exposure to more than two surgeries also increases 2.65 times, grade 4 increases 3.1, malnutrition represents 2.93 times. The prevalence of fistulas is 13%. The risk factors are: moderate and severe degree of cleft palate, having undergone more than two surgeries. According to the primary defect, grade 3 and grade 4 and malnutrition are also risk factors.

Cleft Palate Repair by Otolaryngologist-Head and Neck Surgeons: Risk Factors for Postoperative Fistula.

OBJECTIVES/HYPOTHESIS: To assess the incidence of palatal fistula after primary repair of the cleft palate among two cohorts of Otolaryngologist-Head and Neck Surgeons and to identify patient and surgeon characteristics that may predict fistula development. STUDY DESIGN: Retrospective case series with chart review. METHODS: Children who underwent primary repair of cleft palate at one of two multidisciplinary cleft centers over a 10 year period were identified. Charts were reviewed for the presence of palatal fistula; chi square test and multivariate logistic regression analysis were performed to determine variables associated with fistula formation. RESULTS: From 2007 to 2017, 477 patients underwent primary repair of cleft palate by one of 6 Otolaryngologist-Head and Neck Surgeons. Twenty-four children had incomplete charts, allowing 453 patients to be included in the final analysis. The pooled mean incidence of palatal fistula was 6.6% (P = .525) and varied significantly by cleft type. Logistic regression analysis controlling for multiple variables, showed that Veau IV classification had the highest risk of fistula (OR = 10.582; P = .004). Repair by a specific surgeon was not a significant risk factor for fistula development (P > .07 for each surgeon). CONCLUSIONS: Among six Otolaryngologist-Head and Neck Surgeons with fellowship training in cleft palate repair postoperative fistula rates were consistent and compared favorably to standards in the Cleft and Craniofacial surgery literature established by other surgical specialties. Consistent with larger database studies involving multiple surgical specialties, Veau IV classification was the strongest predictor of palatal fistula development, even after adjusting for multiple variables, including differing levels of experience. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1281-1285, 2021.

Comparison of the Interrupted and Continuous Suture Techniques for the Closure of Oral and Nasal Mucosal Layers in Cleft Palate Surgery.

Background Cleft lip and palate are common congenital craniofacial anomalies, treated conventionally by surgery at the ages of six to 18 months. Mostly, the interrupted suture technique is used to close the nasal and oral layers of the palate. In some studies, the interrupted suture technique was compared with continuous suture techniques for the closure of oral and nasal layers and found that there was less utilization of time and suture materials in the continuous technique. This study was designed to see the outcomes of interrupted versus continuous suture techniques. Materials & methods A total of 36 patients were included in the study and were divided into two groups according to the type of suturing technique. The time utilized for the repair of the oral and nasal layers of the cleft palate, the number of suture packs utilized, and the incidence of fistula formation were noted and compared between the two groups. Out of 36 patients, 17 were included in group A (operated by interrupted techniques), and 19 were included in group B (operated by the continuous technique). Results The mean time taken to close nasal layer in Group A was 18.12 ± 1.16 minutes and in Group B was 8.37 ± 0.89 minutes (p-value < 0.001), whereas for oral layer closure, it was 14.00 ± 1.17 minutes in group A and 6.00 ± 0.57 minutes in group B (p-value < 0.001). The average usage was 2.26 ± 0.45 suture packs for repair with the continuous technique and 4.00 ± 0.35 suture packs when repaired via interrupted stitches. There was no difference noted in postoperative outcomes in both groups in terms of postoperative fistula and wound dehiscence. Conclusion A continuous suture technique for closing the oral and nasal layers in patients with cleft palate is recommended, as it is more beneficial in terms of time, cost-effectiveness, and utilization of suture material.

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.

Advances in classification and reconstruction of palatal fistula after cleft palate operation / 口腔疾病防治

@#Postoperative fistulae are one of the most significant complications of cleft palate repair. They usually has an adverse effect on patients’ oral hygiene, speech and even mental health. There has been a wide range of rates of fistula occurrence, from 0.8%-60%, with the classification and definition of fistulae differing from one author to the next. In this paper, the definition and classification of palatal fistulae and their reconstruction method are reviewed. At present, there is a lack of a consistent definition of palatal fistulae and a classification that can fully reflect the characteristics of palatal fistula. Adjacent flap is mainly used for repairing small fistulae with an adequate amount of surrounding tissue; anteriorly based dorsal tongue flaps are a safe and reliable method for large fistulae; free flap is beneficial for refractory and complicated palatal fistulae that are difficult to repair by the local and pedicle flap; and different synthetic materials are used in multilayer repair of fistulae; among them, composite polymer membrane is highly biocompatible, promoting cell attachment and proliferation in animal models, but its security in the human body needs further research.