The Vertical Proximally Based Turn Over Gingivolabial Myomucosal Flap for Closure of Anterior Palatal Fistula

INTRODUCTION
Palatal fistula is the most common complication
of cleft palate surgery with a reported incidence
between four and 58% [1-3]. The most common
reported cause is tension at suture line [4]. The
common sites are anterior portion of hard palate
and the junction between the hard and soft palate
[5].
Wide size fistula is leading not only to escape
of fluid and food into the nasal cavity but also to
nasal tone due to escape of air during speech [6].
The currently available techniques for fistula
repair are mucoperiosteal flaps, tongue flaps, skin
25
flaps, buccal fat pads, a cellular dermal matrices,
lip myomucosal flaps, buccinators musculomucosal
flaps and free tissues [7-13].
Jensen et al., 2010 denotes that gingival, labial,
buccal and palatal vessels are richly anastomosed
with periodental plexus and hence the bases for
this study [14].
The aim of this study is evaluation of usefulness
of vertical proximally based turn over gingivolabial
myomucosal flap in closure of anterior palatal
fistulas.
PATIENTS AND METHODS
Between December 2015 and January 2019 (37
months) in Plastic Surgery Department, Zagazig
University a total of 34 children's were presented
with anterior palatal fistulas post repair of cleft
palates. In this study the most anterior located
palatal fistulae (just behind the alveolar margins)
were chosen for the study as the flaps has limited
lengths. Twenty patients were operated for first
time for residual anterior fistulas after cleft palate
repair while 14 patients were operated two times
or more. All fistulas were large sizes (more than
5mm according to classification done by Cohen et
al., 1991) [15]. The mean defect size was 10.3mm
(ranged from 5mm to 20 mm). Twelve of them had
also repaired cleft lip as well but no other congenital
anomalies. Eighteen were males and sixteen were
females. The mean age was five years with range
between three and nine years and ages more than
this were excluded. The elected procedure was
approved from the university review committee.
Written informed consents were taken from all
parents. Patient's demographic flaps characters
were illustrated in Table (1).
Operative technique:
Under general anesthesia with oral endotracheal
intubation, a dingman mouth gag was used to
adequately expose the affected area. A single dose
of prophylactic antibiotic cefazolin (25 milligram
per each kilogram) was given at time of induction.
Measurement of the defect size was first done.
Marking of the flap at inner surface of the upper
lip was designed just opposite to the defect. It is
vertical in all except three patients where distal
end of the flap was slightly angled to increase its
length and to fit to defect shape Fig. (1A,B) and
Fig. (2A,B).
The mucoperiosteum was elevated from the
edges of the fistula which could not close the nasal
side because of fistula size and or tissue fibrosis.
The myomucosal flap was then elevated starting
distally just proximal to the red margin then proceeded
proximally where a part of the orbicularis
muscle included at the flap undersurface in the
aim of achieving good vascularity. The flap base
to width ratio is either one to two or one to three
to avoid vascular compromise. The proximal part
of the flap as well as the way till the fistula defect
was deepithelialized. The flap was turned upside
down between the incisor teeth which were spaced
in this age group. Fig. (1C,D) and Fig. (2C). The
area between two teeth is then deprived from its
epithelium. This will help the deepithelialized part
of the flap to adhere to this area (that's why it is
a single stage repair). The mucosa of the flap was
then sutured to the elevated mucoperiosteum making
the nasal layer. The muscle surface was sutured
to the surrounding tissues (oral mucosa). The oral
surface was left to reepithelialize from the adjacent
oral mucoperiosteum. The donor site was closed
in two layers with muscle layer first then the
mucosa.
The patients given oral feeding same day with
only cups neither straws nor spoons were allowed
for two weeks. The children's were kept for 48
hours in the hospital till the flap viability was
ascertained.
RESULTS
All fistulae were an anterior of large sizes.
Nasal sides were closed completely at time of
operations. All oral side wounds achieved healing
by reepithelialization within two to three weeks.
Follow-up in outpatient clinic done at regular
intervals of one week, one month then afterwards
every two months.
26 Vol. 44, No. 1 / The Vertical Proximally Based Turn Over Gingivolabial Myomucosal Flap
During post-operative evaluation only two flaps
(5.8%) suffered distal necrosis but after debridement
and secondary sutures they did well. During
early week's post-operatively mild gingival thickening
were seen but became not noticeable after
two to three months as the muscular part atrophies.
We achieved complete sealing of all fistulas. There
were no evidence of recurrences, wound dehiscence,
nor wound infections within a mean followup
of 18 months (ranged between five and 32
months). In all cases the flaps passed between the
incisor teeth and the mucosa in between was ablated
so the flaps under surfaces adhere to it and no need
for secondary stages. Donor sites were healed
without any complications. We noticed difficulty
of feeding within first two days but as parents
were learned how to feed their children's, they
become compatible thereafter Fig. (1E), Fig. (2D),
(Table 1).
Table (1): Patient's demographics, anterior palatal fistula
characters and complications.
Number
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
Age
3
6
8
5
6
5
4
4
3
6
5
3
4
6
9
4
9
5
4
6
8
5
3
6
5
4
4
6
5
4
3
7
5
3
Male
Female
Male
Female
Female
Female
Male
Female
Male
Female
Female
Female
Male
Female
Female
Female
Male
Female
Male
Male
Male
Female
Male
Male
Female
Male
Female
Male
Male
Male
Male
Female
Male
Male
Sex
Type of
operation
First
First
Third
Second
First
Second
First
First
First
Second
First
First
Second
First
Third
First
Third
First
First
Second
Third
First
First
Second
First
First
First
Third
Second
First
First
Third
Second
First
Defect
size mm
8
7
14
9
7
10
6
9
8
7
8
9
20
7
9
8
20
8
8
15
16
7
5
18
7
10
8
14
12
6
8
17
20
7
Complications
No
No
No
No
No
Distal flap necrosis
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Distal flap necrosis
No
No
No
No
No
No
No
No
No
No
No
No
No
First operation means that only done cleft palate repair and
complicated by anterior palatal fistula and this is the first attempt,
while two or more operations mean that more than one or more failed
previous attempts at fistulas repair were done. Defect size represented
by its widest dimension.
Egypt, J. Plast. Reconstr. Surg., January 2020 27
Fig. (1A): Pre-operative 4 years child with anterior palatal
fistula measuring 2cm X 1cm at its widest dimensions
with premaxilla cleft which was operated
two times before.
Fig. (1B): Flap design and the part to be depithelialized is
marked by dots.
Fig. (1C): Elevated flap. Fig. (1D): An intraoperative photo shows depithelialized
gingivolabial turn over flap inset.
Fig. (1E): Six months post-operatively, complete closure of
the fistula achieved using vertical proximally based
turn over gingivolabial myomucosal flap with
premaxillary defect also closed after paring of its
epithelium. Donor site shows no any morbidity.
Fig. (2A): A child 6 years presented with anterior palatal
fistula operated one time. Defect size is about
1.5cm X 1cm.
DISCUSSION
Palatal fistula is the most common complication
of cleft palate repair with reported incidence ranged
from four to 58% [1-3]. Tissues around the fistula
are usually stiff, fibrotic and difficult to mobilize
[16]. Fistula repair has high rate of recurrence which
ranged from 33 to 37% [15,17,18].
Several procedures have been performed to
repair palatal fistula [15,18,19]. Mucoperiosteal flaps
although can be used for repair but it can be difficult
if the fistula size is large and more anterior placement
[20]. Tongue flaps are good options for large
anterior fistulas but its drawbacks are two stage
procedures, risk of flaps breakdown, difficulty of
intubation during flap division and it interfere with
speech and eating [21].
The posterior based buccinator myomucosal
flap is a good option with reliable blood supply
but it only used for posterior fistula and unreliable
28 Vol. 44, No. 1 / The Vertical Proximally Based Turn Over Gingivolabial Myomucosal Flap
for anterior one and if used for anterior one it
requires a procedure to maintain open bite [22-24].
Anterior based mucosal and or myomucosal flaps
were tried for anterior fistula but the angle of
rotation sometimes causes flaps loss and also two
stages [12].
Upper lip myomucosal flap was tried by
Elsherbiny et al., but their procedure was two
staged and also their technique had 30% recurrence
rate [25].
This study evaluated the use of the vertical
proximally based turn over gingivolabial myomucosal
flap for closure of anterior palatal fistula.
The flap has rich blood supply due to the rich
anastomisis between labial, buccal, gingival, palatal
and periodontal plexuses [14].
The flap harvest technique is a simple one. The
flap is turned upside down up on itself and as its
blood supply comes from its back so no affection
of its vascularity. Donor site was closed primary
without any morbidity. The flap is a single stage
so only one hospitalization. The results proved
high success rate in closure of anterior fistula
without any recurrence or interference with eating
or speech during the long follow-up period.
The limitations of this technique are it is only
applicable for anterior located palatal fistulas in
ages with deciduous teeth and it is not suitable for
very large sized fistulas because of difficulty of
donor site closure.
Conclusion:
The vertical proximally based turn over gingivolabial
myomucosal flap is a simple, single stage
technique. The flap is a reliable good option for
Fig. (2D): Seven months post-operative of six years old child
with complete fistula closure without any donor
site morbidity.
Fig. (2B): Marking of the vertical proximally based turn over
gingivolabial myomucosal flap about 20% more
than defect size with slight inclination to increase
flap length and dotted area point to the deepithelialized
part.
Fig. (2C): An intraoperative photo showing suturing of deepithelialized
turned upside down gingivolabial flap
and donor site closure.
Egypt, J. Plast. Reconstr. Surg., January 2020 29
closure of anterior palatal fistula without donor
site morbidity. The only limitations are size (no
more than 2cm), age (we chose ages between 3
and 9 years) and site of fistula (good results are
achieved with most anterior located fistula).
Conflicts of interest:
None declared
Funding:
None