Closure of Anterior Palate Fistulae

JAMES A. LEHMAN, JR., M.D.

PAUL CURTIN, M.B., F.R.C.S.

DAVID G. HAAS, D.D.S.Akron, Ohio 44302

Attempts at. closure of anterior palate fistulas using local tissue have resulted in a highrate of failure. In addition most of these patients have associated maxi/lary collapse whichmust be corrected prior to surgery. A technique using a buccal mucosal flap to gainunscarred tissue for the anterior closure and bone grafts to fill the bony defect has beenperformed in nineteen patients with anterior palate fistulas. The results have beensatisfactory from a functional and esthetic standpoint. In addition associated deformitieshave been corrected simultaneously.

Secondary palate fistulae are a not uncom-

mon complications following cleft palate re-

pair. They may occur at any point along the

line of the repaired cleft, but this paper is-

concerned with those fistulae of the alveolus

and hard palate that are difficult to close

(Figure 1) and for which the most practical

solution often seems to be an obturator. Small

fistulae may be asymptomatic but patients

commonly complain of regurgitation of liq-

uids into the nose, and food may become

impacted with resultant malodor. A fistula

need have an area of only 5mm." (Converse,

1964) to interfere with speech and an even

smaller fistula can disrupt the suction needed

to retain dentures. The nasal mucosa adjacent

to the fistula undergoes hypertrophy and fre-

quently results in increased nasal discharge.

The most practical solution to these prob-

lems often seems to be an acrylic obturator

especially if it can also carry replacements for

missing anterior teeth and function as a re-

tainer after orthodontic expansion. From the

dentists' point of view, removable plastic ap-

pliances in general have certain disadvan-

tages. Their presence is associated with a

sharp increase in oral bacterial counts and

the resultant increase in the incidence of den-

tal caries. These dentures must fit closely

Dr. Lehman is Chief, Division Plastic Surgery, Chil-dren's Hospital ofAkron. Dr. Curtin is Resident in PlasticSurgery, Akron City Hospital and Dr. Haas is Chief ofOrthodontics, Akron Facial Malformation Center.

Presented at The American Cleft Palate AssociationMeeting, May, 1976, in San Francisco, California.

33

around the necks of the teeth for retentive

purposes, and this results in a chronic gingi-

vitis. They are cheap to produce and are

aesthetically pleasing, but a not uncommon

sequel to a "partial" is a tooth-by-tooth de-

cline into full dentures.

The only acceptable dental answer is a

fixed bridge which will not only replace miss-

ing teeth but, if placed between the segments,

will also maintain any orthodontic expansion

(Ramstad, 1973). The fixed bridge unfortu-

nately will not close a palate fistula, and a

surgical approach is necessary.

Small fistulae can be successfully closed

with turnover flaps of adjacent muco-perios-

teum (Hynes, 1957), but the rigidity of the

palatal mucosa, especially if it is already

scarred, presents a problem with fistulae

greater than 0.5 cm. or in those that extend

between the alveolar segments into the buccal

sulcus. Distant tissue can be imported using

cheek and nasolabial flaps (Georgiade, 1969),

and tube pedicles (Campbell, 1962); Gillies,

(1957), but the tissue is thick and immobile,

the technique laborious, and further facial

scarring is not well received by the patient

who already has a cleft. Other techniques

which are applicable in limited circumstances

include hemipalatal island flap (Maisels,

1969) and Stenstrom and Thilander's gingivo-

labial flap (1963).

The development of the tongue flap

(Guerro-Santos and Altamirano, 1966) has

been a real advance in the management of

large palate fistulae. Since, however, it is a

two-stage procedure and necessitates some de-

34 Cleft Palate Journal, January 1978, Vol. 15 No. 1

FIGURE 1A. Large bilateral fistula in 17-year-oldgirl.

FIGURE 1B. Result one year after palate closurewith bone graft and bilateral buccal flaps.

gree of airway obstruction with minor anes-

thetic difficulties, it would seem reasonable

to reserve this procedure for those extremely

large and relatively uncommon fistulae where

other maneuvers will not suffice.

A procedure first described by Jackson

(1972) for the reliable closure of anterior pal-

ate fistulae using local tissue flaps and bone

grafts has been utilized in nineteen patients.

An important aspect of this technique is that

it also stabilizes orthodontically realigned

arch segments and provides the opportunity

for simultaneously correcting a variety of sec-

ondary deformities.

Almost invariably these patients demon-

strate some degree of upper arch collapse and

a vital preliminary to surgery is the expansion

of the maxillary segments and the alignment

of teeth as needed. The rapid expansion tech-

nique as described by Haas (1961) expands

the segments over a three-week period using

an appliance (Figure 2) which incorporates a

small screw which the patient turns daily.

This procedure brings the maxillary segments

FIGURE 2A. Palate fistula in a 7-year-old girl witha unilateral cleft lip and palate.

FIGURE 2B. Following rapid palate expansion thetrue extent of the defect is evident.

FIGURE 2C. Result one year following fistula clo-sure, bone graft, and buccal sulcus flap.

into proper occlusal relationship and im-

proves facial contour while at the same time

unmasking the true dimensions of the palatal

defect. Palatal expansion can be carried out

in any child after eruption of the primary

second molars.

Surgical Technique

The three essentials of the surgical tech-

niques are: 1) accurate closure of the nasal

and oral mucosal layers; 2) cancellous bone

grafts to fill the space between the mucosal

layers; and 3) the use of a buccal flap for

closure of the anterior defect. The nasal mu-

cosa is approached anteriorly through the

pyriform aperture or by division of the lip

should this require revision. The mucosa of

the vomer and lateral nasal wall are elevated

so that the mucosal edges of the fistula may

be trimmed and approximated accurately

without tension. This assures closure of the

- nasal floor (Figure 3). Care must be exercised

not to perforate the nasal mucosa posterior

to the hard palate where closure is difficult.

Veau flaps are then raised from the palate,

and it is important to excise all hypertrophied

mucosa especially anteriorly. These flaps are

sutured to close the oral mucosa, but they

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Jy ad

Lehman et al., PALATE FISTULAE 35

will reach to a point only about 1 cm. behind

the alveolus (Figure 4).

Cancellous bone grafts from the iliac crest

are then packed into the space between the

nasal and oral mucosa and onlaid under the

alar base as needed (Figure 5). The difficult

alveolar gap and anterior palate are closed

with a local transposition flap based ante-

riorly from the vestibular sulcus. The opening

of the parotid duct is the limiting factor in

the size of this flap, and the donor site is

closed primarily (Figure 6). The anterior soft

tissue closure is then completed and other

secondary deformities corrected.

Postoperatively some form of orthodontic

appliance is needed to maintain the expanded

arch form until a fixed bridge can be fitted.

Undoubtedly the bone graft helps to stabilize

arch segments in their expanded position, but

it seems likely nevertheless that some degree

of collapse would occur if no retainer were

used.

Discussion

This technique has been used successfully

in 19 patients who were seen by one of the

authors (JAL) for secondary surgical correc-

tion of severe cleft lip and palate deformities.

MOBILIZATION

OF NASAL

fi MUC OS A

a- {MW< mG PelRy

[¢~*// r M- "

~ C f\\ (kg

7. (M7LCC

FIGURE 3. Exposure of defect and elevation of nasal lining from vomer.

36 Cleft Palate Journal, January 1978, Vol. 15 No. 1

V EAU FLAP

PALATE C LOSURE

FIGURE 4. Elevation of palate flaps with subsequent closure of oral and nasal lining. Insert shows gap betweenthe closure which will be filled by bone.

/ ‘ _ BONEGRAFT

BONE GRAFT UNDERALAR BASE

\\ \\\\’

”NJ|

(Disfi

\\I

Al

\&

GCglam/{Bad

FIGURE 5. Cancellous bone chips are placed into the gap between the closure of the oral and nasal lining andalso under the alar base if needed.

BUCCAL FLAP

INCISION P«L'

PAROTID DUCT

37Lehman et al., PALATE FISTULAE

BUCCAL FLAP

PLACEMENTé

FIGURE 6. The difficult anterior gap is then closed with the buccal sulcus flap.

The age range was from six to 55 years, butthe majority were in their mid to late teens.The fistulae were of variable sizes, but mostwere greater than 1.0 cm. in width, and allinvolved some part of the hard palate andalveolus.Most of the patients had undergone multi-

ple operations beforehand. One 17-year-oldgirl had undergone 18 operations to repair abilateral cleft lip and palate and had a 20mm.anterior fistula extending across both rightand left alveolar margins with a mobile pre-maxilla (Figure 1). The series contained fourother complete bilateral cleft cases, with var-iable degrees of persisting fistulae.

All of the patients had preoperative ortho-dontic expansion using the rapid expansiontechnique. It has been our experience thatbone grafting of the palate after adequateexpansion can be performed as early as agesix since there is no significant growth in thewidth of the palatal arch after that age. Nopatient preoperatively was judged to havemuscle union across the upper lip and so thelip was divided to effect a muscle repair andto improve the lip scar in some cases. Asmentioned previously, division of the lip isnot essential for access. In all cases the nasalala on the cleft side was found to be depressedso the underlying periosteum was elevated

and bone onlayed in the hypoplastic area ofthe maxilla. Adjustments of the nasal tip car-tilages were carried out in four patients, anda nasal vestibular web was corrected in onepatient. One fifty-five-year-old edentulous pa-tient who had a 20mm. palate fistula andcould not maintain suction on his denturehad a pharyngeal flap simultaneoulsy. Twopatients have been followed up for only sixmonths, but the remainder have been fol-lowed for one to three years. No maxillarycollapse has occurred. One patient had a re-current small fistula which was closed at the

FIGURE 7A. Large bilateral palate fistula in 23-year-old college student.

38 Cleft Palate Journal, January 1978, Vol. 15 No. 1

FIGURE 7B. Residual small fistula one year later.

FIGURE 7C. Final result after secondary closure offistula at time of pharyngeal flap.

time of a subsequent pharyngeal flap (Figure

7).

The arch of the palate tends to be some-

what flattened by the procedure, but this did

not interfere with dentures worn by several

of the patients. There is some obliteration of

the vestibular sulcus in the region of the buc-

cal flap, but again this has not given rise to

any inconvenience.

Summary

Nineteen patients have been presented with

anterior palate fistulas of various sizes follow-

ing cleft palate repair. Satisfactory closure

has been obtained in all patients, and it is

felt that surgical correction is preferable to

the use of an obturator. The technique in-

volves the use of local flap tissue and bone

grafts and also presents a convenient oppor-

tunity for the correction of other secondary

cleft problems.

Since presentation, 20 additional patients

have been operated on with complete closure

of their fistulae.

References

CamPBELL, R., Rein, D. A., Fistula in the hard palatefollowing cleft palate surgery, Brit. J. Plast. Surg., 15,377, 1968.

ConvERsE, J. M., Reconstructive Plastic Surgery. Vol.III P. 1425. Philadelphia. W. B. Saunders Co., 1964.

GrorctaADE, N. G., Mrapick, R. A., and THORNE, F.L. The nasolabial tunnel flap, Plast. reconstr Surg., 43,463, 1969.

GiLL1Es, H. D. and EvANS, A. J., Experiences of the tubepedicle flap in cleft palate, "Transactions of the Inter-national Society of Plastic Surgeons, First Congress",P. 208. Baltimore: Williams and Wilkins, 1957.

GUERRERO-SANTOS, J. and ALTAMIRANO, J. T., The useof lingual flaps in repair of fistulas of the hard palate,Plast. reconstr. Surg. 38, 123, 1966.

Haas, A. J., Rapid expansion of maxillary dental archand nasal cavity by opening mid-palatal suture, Angle.Orthod. 31, 73-90, 1961.

Hyn®s, W. The examination of imperfect speech follow-ing cleft-palate operations, Brit. J. Plast Surg 10,114-121, 1957.

Jackson, L. T., Closure of secondary palatal fistulaewith intraoral tissue and bone grafting, Brit. J. Plast.Surg., 25 93, 1972.

MaiseELs, D. O. and GIEDROJCG-JURAHA, Z. L., Recon-struction following partial maxillectomyincorporatinga mucoperiosteal island flap, Brit. J. Plast. Surg., 22,48, 1969.

RamstaD, T. Post-orthodontic retention and postortho-dontic occlusion in adult complete unilateral and bi-lateral cleft palate subjects, Cleft Palate J., 10, 35, 1973.

SteEnsTROM, S. J. and THILANDER, B. L., Bone graftingin secondary cases of cleft lip and palate. Plast. reconstr.Surg. 32, 353, 1963.