What Free Flaps Are Surgeons Using for Palatal Fistula Repair in Patients with Cleft Palate? A Systematic Review.

OBJECTIVE: Recalcitrant palatal fistulas in patients with cleft palate history sometimes require free flap reconstruction. This study reviews the literature on described flaps and outcomes. DESIGN: A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. SETTING: All study designs were included. Non-English articles were excluded. PATIENTS AND PARTICIPANTS: Patients with a history of cleft palate who underwent free flap reconstruction for a oronasal fistula. INTERVENTIONS: Free tissue transfer for a palatal fistula repair. MAIN OUTCOMEE MEASURES: Information regarding defect and flap characteristics were reviewed. Surgical outcomes such as flap loss rates, rates of recurrent fistula formation, and speech outcomes were also obtained. RESULTS: Our search returned 894 articles, of which 23 were included. All studies were retrospective case series and reports. A total of 65 patients were described with an average age of 19.3 (range 3-55) years and a median fistula size of 8.00 cm2 (range 2.54 cm2 - 24 cm2). The most common flap was the radial forearm flap (n = 37). Nine patients (13.8%) had recurrent fistula formation with surgical revision successful in all cases in which the patient returned to the operating room. There were two partial flap losses and no total flap losses. Speech outcomes showed improvement in 27 patients across 10 studies. CONCLUSIONS: Palatal fistula repair with free tissue transfer is safe with an acceptable risk profile and low flap loss rate. Early recurrence due to partial flap necrosis and dehiscence are successfully managed with flap readvancement.

Oronasal Fistula Closure and Defect Reconstruction: Two Case Reports Using Periodontal Plastic Surgery Principles.

OBJECTIVES: Oronasal fistulas are common sequelae following cleft lip and palate surgery and can significantly impact a patient's quality of life. They result from various factors, including surgical techniques, tissue management, and patient-specific factors. This case report explores the modern approach to oronasal fistula closure using periodontal plastic surgery principles. MATERIALS AND METHODS: The report presents two cases of patients with oronasal fistulas due to previous maxillofacial surgical intervention. These patients underwent microsurgical procedures that involved partial flap thickness preparation of the fistula areas, the use of connective tissue grafts from the palate, and meticulous suturing techniques to ensure graft integrity. The procedures were performed in stages, and postoperative care was provided. RESULTS: Both cases demonstrated successful fistula closure and graft survival. The patients reported improvements in breathing, speech, aesthetics, and quality of life. The second case also included guided bone regeneration and implant placement. CONCLUSIONS: Oronasal fistulas resulting from maxillofacial surgery can be effectively treated using periodontal plastic surgery techniques, significantly improving patients' quality of life and aesthetic outcomes. This approach represents a valuable addition to the existing repertoire of oronasal fistula closure methods.

Synergistic benefits of hyperbaric oxygen therapy for postoperative palatal oro-nasal fistula following segmental Le Fort 1 osteotomy.

Segmental maxillary osteotomy, a surgical technique used in orthognathic surgery, involves the risk of palatal mucosa tearing, which can lead to severe complications. Herein, we report the case of a woman with Angle class II malocclusion who underwent multiple elective segmental maxillary osteotomy and augmentation genioplasty procedures for the correction of her malocclusion and the enhancement of her facial profile. A week after surgery, the patient developed a palatal ulcer. We adopted a comprehensive treatment approach involving 14-day hyperbaric oxygen therapy and conventional modalities; this approach resulted in favorable outcomes. Our case underscores the importance of immediate intervention and the synergistic potential of the comprehensive approach against oronasal fistula formation. Our findings indicate that hyperbaric oxygen therapy promotes wound healing, particularly in patients with complications arising from maxillofacial surgery.

Comparison of modified Furlow palatoplasty using small double-opposing Z-plasty and conventional Furlow palatoplasty: A long-term outcome study.

BACKGROUND: The aim of palatoplasty is to create a functional palate to achieve normal speech, while minimizing post-operative complications. This study aimed to compare the long-term outcomes of modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ) and conventional Furlow palatoplasty (conventional-DOZ) performed in a single center. METHODS: A retrospective review of consecutive patients who underwent Furlow palatoplasty between May 2007 and March 2014 was executed. Non-syndromic patients subjected to palatoplasty prior to 24 months of age and followed-up until at least 9 years of age were included. RESULTS: A total of 196 small-DOZ and 280 conventional-DOZ palatoplasty patients were included in this study. Overall, 14 patients (2.9%) developed oronasal fistula, and 40 patients (8.4%) received velopharyngeal insufficiency (VPI) surgery. In comparisons, oronasal fistula rate was significantly higher in conventional-DOZ (0.5% vs. 4.6%, p = 0.01), and the VPI prevalence was not significantly different (9.2% vs. 7.9%, p = 0.62). Patients who developed fistula had a significantly higher likelihood of developing VPI than patients without oronasal fistula (50.0% vs. 7.1%, respectively; p < 0.01), with an odds ratio of 13.0. CONCLUSION: Both modalities of palatoplasty yielded commendable velopharyngeal function in the long-term follow-up. The small-DOZ with reduced tension lowered the risk of oronasal fistula.

What We Learned from Performing the Inverse Malek Procedure to Repair Bilateral Cleft Lips and Palates: A Single-Center Retrospective Study.

Background: This study reviews the surgical and functional outcomes of children diagnosed with a bilateral cleft lip and palate and treated by the same surgical team following specific surgical protocols 18 years after surgery and during the follow-up. Methods: Based on a single-center retrospective design, demographic and surgical data were gathered by the authors from international institutions. Most of the data were quantitative in nature, and descriptive statistical and non-parametric tests were employed for analysis. All children born with a bilateral cleft from 1982 to 2002 were considered. Children affected by a syndrome were excluded. Complications and speech results were the main items measured. Results: Thirty patients were selected; 73.3% were treated using the inverse Malek procedure, and 26.7% underwent a modified two-stage procedure. Seventy percent developed an oronasal fistula. An alveolar bone graft was performed in 83%, and 53.3% underwent Le Fort osteotomy. Thirty-six percent required a pharyngeal flap, with good speech results. The median number of times general anesthesia was used among all the interventions considered was 5.5 (4.25-6). Conclusions: This study presents the long-term results of using the inverse Malek procedure to treat children with a bilateral cleft lip and palate. It is shown that this is related to a high risk of developing a fistula, but has good long-term speech results.

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.

Application of double layer with collagen-elastin matrix (Matriderm®) and polyglycolic acid sheet (Neoveil®) for oroantral and oronasal fistula closure after maxillectomy: a retrospective single center experience.

PURPOSE: This study investigates the effectiveness of a new double-layer approach for closing oroantral and oronasal fistulas (OA/ONFs) using Matriderm® and Neoveil®. Matriderm®, an acellular dermal matrix composed of collagen and elastin fibers, supports tissue regeneration, while Neoveil®, a biodegradable mesh sheet, serves as a barrier to prevent leakage and scarring. MATERIAL AND METHODS: A retrospective study of 12 maxillectomy patients with oral cancer between January 2022 and May 2023 was conducted. Patient data, including tumor stage, bone invasion, and defect size, were analyzed. Surgical techniques included sinus mucosa preservation, and either buccal fat grafting combined with the double layer technique or the double layer technique alone, with statistical analysis performed using R software to evaluate outcomes. RESULTS: The results indicate a 41.7% incidence rate of fistula formation with lower T stages, absence of bone invasion, smaller defect dimensions, and intact sinus mucosa correlating with reduced fistula risk (p < 0.05). Notably, no patients required fistula-related surgical revisions, validating the efficacy of the approach. CONCLUSION: This study introduced a novel double-layer technique using Matriderm® and Neoveil® for closing OA/ONFs after maxillectomy. The technique demonstrated promising outcomes in addressing these post-operative complications. Lower tumor stages, no bone invasion, smaller defects, and intact sinus mucosa correlated with reduced fistula risk. This technique holds potential to enhance maxillectomy outcomes, offering a comprehensive approach to functional concerns, but warrants further investigation.

Use of a barrier membrane to repair congenital hard palate defects and to close oronasal fistulae remaining after cleft palate repair: seven dogs (2019-2022).

OBJECTIVE: To describe the use of a barrier membrane in dogs for repair of congenital hard palate defects and closure of oronasal fistulae (ONF) remaining after previous cleft palate (CFP) repair. ANIMALS: 7 client-owned dogs. METHODS: The hard palate defect was closed with medially positioned flaps (Von Langenbeck technique) or pedicle flaps (2-flap palatoplasty) and a membrane composed of autologous auricular cartilage from the pinna or allogenous fascia lata underlying the mucoperiosteal flaps. RESULTS: All palate defects were considered to have a high risk of dehiscence based on their type and size and the characteristics of the surrounding tissue. The barrier membrane was used in 5 dogs for repair of congenital hard palate defects and in 2 dogs for closure of ONF remaining after previous CFP repair. Resolution of clinical signs occurred in all cases. Complete success (ie, complete closure of the palate defect and absence of clinical signs) was achieved in 5 dogs (4 with congenital hard palate defects and 1 with an ONF remaining after previous CFP repair). The persistent ONF in 1 dog with functional success (incomplete closure, but no clinical signs) was smaller than prior to surgery. CLINICAL RELEVANCE: Barrier membranes underlying mucoperiosteal flaps may constitute an alternative technique in dogs for repair of congenital hard palate defects and closure of ONF remaining after previous CFP repair.

Alveolar cleft reconstruction using iliac bone graft: a clinical case report.

Introduction and importance: Alveolar clefts are frequently occurring congenital anomalies that can significantly impact both the functional and aesthetic aspects of an individual's life. Thus, reducing the quality of life. These clefts can give rise to difficulties in feeding, speech, and dental development. Furthermore, the presence of a gap in the alveolar ridge can disrupt the proper alignment and eruption of permanent teeth. Various techniques have been developed to effectively repair these defects and restore oral function and rehabilitation. Case presentation: An 18-year-old girl is presented with unilateral alveolar cleft which was successfully repaired by utilizing iliac bone grafting and augmenting the defect to restore proper bone architecture and gain suitable support for dental prostheses. Therefore, enhancing oral health by closing the oronasal fistula and improving aesthetics and functional abilities including speech. Clinical discussion: Having an alveolar cleft can lead to challenges which may require a multidisciplinary approach, including surgical intervention, orthodontic treatment, and dental rehabilitation. The primary goal is to close the cleft, restore normal speech and feeding functions, and promote proper dental development. Conclusion: Patients who suffer from alveolar clefts need appropriate treatment. This case report suggests a surgical technique of utilizing the combination of hard and soft tissue management to fix the problem for such individuals and achieve improved oral health, speech, and overall enhancement in quality of life.

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.

Self-Curing Glass Ionomer Cement Covered by Photopolymerizable Adhesive for Protection of Mucoperiosteal or Gingival Flap Sutures in Canine Oral Surgery.

Periodontal disease is one of the main affections of the oral cavity of dogs. Its main complication is the formation of periapical abscess, which, when affecting the maxillary canine teeth, can lead to the formation of oronasal fistulae. The objective of this study was to evaluate the efficiency of self-curing glass ionomer cement, covered by photopolymerizable adhesive, as a protective element for mucoperiosteal or gingival flap sutures in oral surgery of dogs. We studied 15 dogs from the clinical routine of the dental service of a teaching veterinary hospital, which needed oral surgeries to correct oronasal fistulae, defects or oral cavity communications, regardless of the causal agent. Group one (G1) was composed of seven animals that presented oronasal fistulae after the extraction of maxillary canine teeth compromised by severe periodontal disease. These fistulae were reduced by the double-mucoperiosteal-flap technique, 15 days after the dental extraction. Group two (G2) was composed of five other dogs that presented oronasal fistulae after the extraction of maxillary canine teeth compromised by severe periodontal disease. In this group, the fistulae were reduced by the single-flap technique, immediately after the dental extraction. Group three (G3) was composed of three animals, two of which presented oronasal fistulae due to maxillary fracture and the third one after excision of oral neoplasia. In all groups, simple interrupted sutures were used with 3.0 nylon, and a thin layer of self-curing glass ionomer cement was applied immediately over the operated area. After cement's settling time, a thin layer of photopolymerizable adhesive was applied to the already polymerized cement. In G1, the protective cement was removed on average at 15 (±2) postoperative days, in G2 at 6 (±1) days and in G3 at 11 (±9) days. In the postoperative period, the animals received antibiotics and anti-inflammatory drugs, and they received their usual dry dog food diet. No Elizabethan collar or any other protective measure was used for suturing or the surgical wound. The result was healing of 100% of the oronasal fistulae, without suture dehiscence or the need for new surgical interventions. Thus, it was concluded that the use of self-curing glass ionomer cement covered by photopolymerizable adhesive was fully satisfactory, providing protection of sutures and surgical wounds and showing the potential for routine use in oral surgery in dogs.

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)

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.

A Review of the Use of Buccal Fat Pad in Cleft Palate Repair.

OBJECTIVE: To review the available evidence on the use of the Buccal Fat Pad in primary and secondary Cleft Palate repair. METHODS: This is a narrative review. A computerized literature search was conducted for articles published till February 2022 using the Mesh phrases buccal fat pad AND cleft palate, Bichat's Fat pad AND cleft palate, buccal fat pad OR Bichats Fat pad AND cleft palate. RESULTS: A total of 35 articles were included in this review based on the set eligibility criteria. Most of the studies were retrospective case reviews (n = 16, 45.7%), and the aggregate number of patients from all included studies was 666. Reported uses of the buccal fat pad (BFP) in association with cleft palate repair include the closure of central cleft palate defect and nasal floor in primary cleft palate repair, oronasal fistula repair following primary repair of cleft palate, and closure of relieving incision defect in primary repair of cleft palate. Complications reported were 24 cases of Oronasal Fistula (ONF), 2 dehiscences, and 4 transient mucosal defects. CONCLUSION: The high success rate, vascularity, ease of tissue harvest, and low donor site morbidity all support its use as an adjunct flap in cleft palate repair, especially in the closure of wide palatal clefts, to prevent post-palatal repair fistula, wound contracture, and subsequently velopharyngeal insufficiency and possibly midface hypoplasia.

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.

Endoscope-Assisted Multilayered Repair in Oronasal Fistula.

Oronasal fistula following cleft palate repair is a considerable complication with a recurrence rate of 33% to 37% and remains a challenging problem for surgeons. Furthermore, many patients have undergone several operations and experienced scar problems and other forms of morbidity. Therefore, we report a multilayered technique for oronasal fistula closure using an endoscopic nasal inferior turbinate composite graft with a palatal advance flap. This will increase the success rate after closure of small-sized oronasal fistula surgery without complications or recurrence (IRB: 2020-1671-0001).

Rapid Additive Manufacturing of a Superlight Obturator for Large Oronasal Fistula in Pediatric Patient.

This study developed a novel digital workflow to fabricate a 3D printed hollow obturator for the prosthetic reconstruction of palatal fistula. It will provide cleft surgeons and therapists a choice for treating children with large palatal fistula before the appropriate age for surgical reconstruction. Laryngoscope, 133:1507-1512, 2023.

A Case of Eosinophilic Angiocentric Fibrosis With Palatal Fistulas.

Eosinophilic angiocentric fibrosis (EAF) is a rare, but benign, tumefactive lesion of the head and neck regions. It was initially discovered in 1983 but has recently been connected to the spectrum of immunoglobulin G4-related disease (IgG4-RD). It commonly presents with symptoms of nasal obstruction, structural deformities of the external nose, and involvement of the nasal septum and lateral nasal wall. Our patient presented with a saddle nose deformity, a septal perforation, and palatal fistulas. Laboratory testing for EAF is often negative for the presence of antinuclear cytoplasmic antibodies (ANCA). A definitive diagnosis of EAF can be made through histopathological analysis of the lesion. The appearance of "onion-skin" fibrosis with perivascular infiltration of primary eosinophils is pathognomonic for EAF. While there is a presence of ulceration tissue, EAF does not have any histological signs of necrosis. EAF is a very uncommon etiology of nasal obstructive symptoms; therefore, it is necessary to rule out more conventional pathologies. Even though it appears as a malignant process, it has an excellent prognosis. The common treatment modalities for an active lesion of EAF involve either surgical resection of margins alone or a combination of corticosteroids and resection. Rituximab has also shown benefits in the management of IgG4-RD as a corticosteroid-sparing treatment. Rituximab was chosen for treatment in our patient because surgical resection was not possible due to the absence of an active lesion. In this article, we provide a brief review of EAF and provide a unique case of EAF presenting with oronasal palatal fistulas.

Obturator Manufacturing for Oronasal Fistula after Cleft Palate Repair: A Review from Handicraft to the Application of Digital Techniques.

An oronasal fistula (ONF) is an abnormal structure between the oral and nasal cavities, which is a common complication of cleft palate repair due to the failure of wound healing. When some patients with ONF are unsuitable for secondary surgical repair, the obturator treatment becomes a potential method. The objectives of the obturator treatment should be summarized as filling the ONF comfortably and cosmetically restoring the dentition with partial function. The anatomy of patients with cleft palate is complex, which may lead to a more complex structure of the ONF. Thus, the manufacturing process of the obturator for these patients is more difficult. For performing the design and fabrication process rapidly and precisely, digital techniques can help, but limitations still exist. In this review, literature searches were conducted through Medline via PubMed, Wiley Online Library, Science Direct, and Web of Science, and 122 articles were selected. The purpose of this review was to introduce the development of the obturator for treating patients with ONF after cleft palate repair, from the initial achievement of the obstruction of the ONF to later problems such as fixation, velopharyngeal insufficiency, and infection, as well as the application of digital technologies in obturator manufacturing.

Treatment of Adenoid Cystic Carcinoma of the Palate and Reconstruction of Defect With Nasoseptal Flap: A Clinical Case and Review of Literature.

Adenoid cystic carcinoma (ACC) is a malignant tumor arising from the salivary glands. While surgery is the mainstay of treatment for ACC of the palate, adjuvant radiotherapy and/or chemotherapy should be considered in high-risk cases. Oronasal fistula, a complication of palatal surgery, may cause speech disturbance and food regurgitation; the nasoseptal flap is a potential option to repair this defect as it is readily available and reliable. Here, we present a case of locally advanced ACC of the palate in a patient who underwent endoscopic-assisted transoral tumor excision with nasoseptal flap reconstruction postoperative chemoradiotherapy.