Role of tongue flap in palatal fistula repair: A series of 41 cases

Introduction:

Despite the improved techniques of repair of cleft palate, fistula occurrence is still a possibility either due to an error in the surgical technique or due to the poor tissue quality of the patient. Though commonly the fistula closure is established by use of local flaps but at times the site and the size of the fistula make use of local flaps for its repair a remote possibility. The use of tongue flaps because of the central position in the floor of the mouth, mobility and the diversity of positioning the flaps make it a method of choice for closure of anterior palatal fistulae than any other tissues. The aim of this study was to analyse the utility of tongue flap in anterior palatal fistula repair.

Materials and Methods:

We had 41 patients admitted to our hospital during the period 2006-2012 for repair of palatal fistula and were enrolled into the study. In the entire 41 cases, fistula was placed anteriorly. The size of the fistulae varied from 2 cm × 1.5 cm to 5.5 cm × 3 cm. The flaps were divided after 3-week and final inset of the flap was done.

Observation and Result:

None of the patients developed flap necrosis, in one case there was the dehiscence of the flap, which was reinset and in one patient there was bleeding. None of our patients developed functional deformity of the tongue. Speech was improved in 75% cases.

Conclusion:

Leaving apart its only drawback of two-staged procedure and transient patient discomfort, tongue flap remains the flap of choice for managing very difficult and challenging anterior palatal fistulae.KEY WORDS: Anteriorly based tongue flap, anterior palatal fistula, cleft palate repair, cleft lip repair, hyper nasality, speech     

Tracheoesophageal puncture site closure with sternocleidomastoid musculocutaneous transposition flap

Introduction:Tracheoesophageal voice prosthesis is highly effective in providing speech after total laryngectomy. Although it is a safe method, in certain cases dilatation or leakage occurs around the prosthesis that needs closure of tracheoesophageal fistula. Both non-surgical and surgical methods for closure have been described. Surgical methods are used when non-surgical methods fail. We present the use of the sternocleidomastoid musculocutaneous (SCMMC) transposition flap for the closure of tracheoesophageal fistula.Results:This study was done prospectively over a period of 1 year from June 2012 to May 2013. This technique was used in patients with pliable neck skin. In nine patients, this procedure was done (inferior based flap in nine cases) and it was successful in eight patients. In one case, there was dehiscence at the leading edge of flap with oesophageal dehiscence, which required a second procedure. In two cases, there was marginal necrosis of flap, which healed without any intervention. Nine patients in this series were post-radiation.Conclusion:This method of closure is simple and effective for patients with pliable neck skin, who require permanent closure of the tracheoesophageal fistula.KEY WORDS: Sternocleidomastoid musculocutaneous flap, tracheoesophageal puncture (TEP) closure, flap for Tracheoesophageal puncture site     

The free radial forearm flap with and without bone for closure of large palatal fistulae

Three cases of palatal fistulae closed by microvascular transfer of radial forearm flaps are presented. Vascularised bone was included in one flap and all operations were free of complications. Facial scarring is minimal and the secondary deformity in the arm has not been significant. It is suggested that this procedure presents fewer difficulties than other techniques for treating the large palatal fistula and may prevent the collapse of the alveolar arch which follows the scarring associated with closure by local tissue.     

Reconstruction of the wide palate defects with temporal osteocutaneous island flaps

Summary The temporal osteocutaneous island (TOCI) flap was first performed in reconstruction of palatal defects by Furnas [8]. It consists of temporoparietal fascia, galea, pericranium and the cortical layer of parietal bone covered with pericranium. In this study, we present five patients with wide palatal defects treated by TOCI flaps. The causation of the wide palatal defects were gun-shot wounds in two patients and unsuccessful reconstruction of congenital cleft palate during early childhood in three patients. All patients were adult. TOCI flaps were performed in two stages. At first, the TOCI flap was elevated and covered with a split thickness skin graft. In the second stage (approximately 1.5 months later), the flap was elevated based on the superficial temporal artery as an island flap. It was then transferred to the palatal defect via a cheek tunnel and sutured to the edges of the defect. There was no need for bone fixation. The length of the pedicle of the flap was sufficient in size to easily reach the anterior part of the palate. No serious complications were seen. One minor oronasal fistula occurred; this was repaired by local flaps. The TOCI flaps improved speech only partially. In conclusion, we believe this procedure is a good method for reconstruction in wide palatal defects which need three layer closure. This procedure is not a satisfactory solution for complete correction of speech defects.     

岛状颊肌粘膜瓣修复腭瘘的临床研究

目的：探索应用岛状颊肌粘膜瓣方法修复较大面积腭瘘的临床实践,探讨该方法的优缺点。方法：应用蒂在前上的岛状颊肌粘膜瓣修复腭瘘4例;应用蒂在后的岛状颊肌粘膜瓣修复腭瘘14例,其中有7例在修复腭瘘的同时延长软腭以矫正腭咽闭合不全。结果：共修复腭瘘患者18例;其中15例腭部瘘孔获得关闭,颊肌黏膜瓣成活良好,无感染、腮腺导管损伤或阻塞、面神经损伤,无张口受限、瘢痕挛缩及咀嚼障碍;2例因岛状颊肌粘膜瓣远端愈合不良再次出现硬腭前端瘘口,但面积较原来明显减小,其中1例再发腭瘘应用已转移到腭部的颊肌粘膜瓣组织行二次手术修复后愈合;1例岛状颊肌粘膜瓣部分坏死。结论：应用蒂在前上和蒂在后的岛状颊肌粘膜瓣修复腭瘘是一种比较安全可靠的方法,其成活率高,可以灵活转移修复各个部位的腭瘘,在修复软硬腭交界部位腭瘘的同时可延长软腭、矫正腭咽闭合不全。即使腭瘘再发,可以应用已转移到腭部的肌黏膜瓣修复之。     

A novel method of closing a palatal fistula: the free fascial flap

The closure of a large palatal fistula with a free fascial forearm flap based on the radial vessels is described. The benefits of this flap are discussed with particular reference to this site.     

Der Verschlu\ von großen vorderen Gaumendefekten unter Verwendung eines Zungenlappens

Zusammenfassung Die Verwendung des Zungenlappens zum Verschluß von großen vorderen Gaumendefekten wird gezeigt und vier Fälle beschrieben.Die Vorteile gegenüber anderen Methoden des Verschlusses werden gezeigt.

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Closure of large anterior palatal fistulae using a tongue flap

Summary Effective closure of small or moderate-sized anterior fistulae may be obtained using the combined palatal and buccal flap method described by Jackson (1971). In large fistulae with insufficient palatal mucosa anteriorly or laterally the tongue flap method of Guerrero Santos and Altamirano (1966)—with some modifications — has been used.We feel that the fistula must be enlarged with, if possible, exposure of the palatal shelves. After secure nasal closure has been obtained, a very wide and long anteriorly based flap can then be raised on the dorsum of the tongue and carefully sutured into the defect. This large insertion and long pedicle helps to add security to the method. No other form of tongue or flap fixation is used.Division and complete fistula closure is performed in approximately ten days. Local anaesthesia is used to divide the flap, and following this general anaesthesia is induced.On the four occasions this procedure has been used, closure has been successful and no problems have been encountered.

     

Esophagocutaneous fistula after anterior cervical spine surgery and successful treatment using a sternocleidomastoid muscle flap. A case report

An esophagocutaneous fistula following anterior cervical fusion is rare. A 61-year-old man had cervical myelopathy because of ossification of the posterior longitudinal ligament of the cervical spine. Anterior decompression of the cervical spine and anterior fusion with strut bone grafting were performed. A second anterior fusion was done because the graft was dislodged after the patient fell out of bed one month after surgery. An esophagocutaneous fistula occurred three months after the second anterior surgery. One of the causes of this esophagocutaneous fistula was considered to be a pressure necrosis of the esophagus because of to projection of the bone graft. Conservative treatment, which consisted of wound drainage and intravenous administration of antibiotics, was tried but was unsuccessful. A good result was achieved by cancellous bone grafting, closure of the esophageal fistula, and transposition of a sternocleidomastoid muscle flap to the interspace between the esophagus and the cervical spine.     

Flaps for cleft lip and palate surgery

The advantages of palate repair by double opposing Z-plasty include excellent access for complete mobilization of the palatal muscles, construction of an overlapping muscle sling, and avoidance of the growth-limiting horseshoe-type scars of the hard palate that result from lateral relaxing incisions or pushback procedures. The excellent speech that results seems to justify use of the procedure. An Abbé flap designed to mimic the normal philtrum placed over an interlacing orbicularis reconstruction that is well supported superiorly can salvage a thin, scarred upper lip and improve its mobility. The lateral gingival flap provides excellent esthetic reconstruction of the cleft alveolus, secure cover over an alveolar bone graft, and ease closure of an anterior oronasal fistula.     

Complications following laryngectomy

The complications following 100 consecutive laryngectomies performed at our hospital during a recent 18-month period are reviewed. The complication rates for total laryngectomy (63 patients) and extended laryngectomy (37 patients) were 19% and 49%, respectively, while the fistula rates were 8% and 27%, respectively. These rates were influenced primarily by the extent of surgery and the type of reconstruction, which during this interval included primary closure, pectoralis major myocutaneous flap, or gastric transposition. In comparison to our previous study, when the deltopectoral flap was used for patching the pharynx, the fistula rate for extended laryngectomy has decreased as a result of our use of myocutaneous flaps and greater experience with gastric transposition. Currently, we use the pectoralis major myocutaneous flap for pharyngeal repair if the mucosa would otherwise be closed under tension. All circumferential defects are repaired with a gastric transposition.     

Repair of large, anterior palatal fistulas using thin tongue flaps: long-term follow-up of 10 patients

Anteriorly based, thin tongue flaps were used in 10 patients to close large, anterior palatal fistulas. All 10 flaps (100%) survived, and complete closure was obtained in all patients, with the exception of a recurrent fistula that occurred in 1 patient during maxillary expansion (10%). Another patient (10%) demonstrated postoperative bleeding that required formal hemostasis under general anesthesia. No other complications were encountered. The results of this series indicate that the tongue flap is a safe technique for closure of large, anterior palatal fistulas. This thin, long flap is also reliable for orthodontic maxillary expansion.     

A novel route for placing free flap pedicle from a palatal defect

One of the better options available to repair a large palatal defect is by employing a free flap. Almost all the times such free flaps are plumbed to facial vessels. The greatest challenge in such cases is the placement of the pedicle from palatal shelf to recipient vessels because there is no direct route available. As majority of large palatal fistulae are encountered in operated cleft palates there is a possibility of routing the pedicle through a cleft in the maxillary arch or via pyriform aperture. When such a possibility doesn’t exist the pedicle is routed behind the maxillary arch. We describe a novel technique of pedicle placement through a maxillary antrostomy, in this case report, where a large palatal fistula in a 16 year old boy was repaired employing a free radial artery forearm flap. The direct route provided by maxillary antrostomy is considered the most expeditious of all possibilities mentioned above.KEY WORDS: Free radial artery forearm flap, large palatal fistula, maxillary antrostomy, palatal fistula repair     

Transthoracic closure of a postpneumonectomy bronchopleural fistula with coils and cyanoacrylate

Standard treatment for persistent bronchopleural fistulas involves thoracotomy with primary closure and transposition of a vascularized muscle flap to the bronchial leak site. This major operation may be ineffective or medically contraindicated. We successfully treated 2 patients by insertion of coils and cyanoacrylate glue into and adjacent to the fistula of a postpneumonectomy bronchial stump with computed tomographic-guided transthoracic needle. The coils served as scaffolding for cyanoacrylate glue to control the bronchopleural fistula.     

改良瓦合瓣修复上颌骨骨折后腭部穿孔的效果评价

目的评价改良瓦合瓣修复上颌骨骨折后腭部穿孔的效果。方法 2015年至2017年,采用改良瓦合瓣修复10例上颌骨骨折后腭部穿孔患者。结果所有患者愈合良好,术后随访1～6个月,患者腭部形态良好,功能未见明显异常。结论通过合适病例的选择,改良瓦合瓣修复上颌骨骨折后腭部缺损可取得良好的术后效果,简单实用,手术创伤小。     

Temporal osteocutaneous island flaps for complete reconstruction of cleft palate defects

In each of four patients, closure of a wide cleft palate was performed with a temporal osteocutaneous island flap (TOCI flap) based on the superficial temporal artery. These were fabricated island fasciocutaneous flaps composed of temporoparietalis fascia and galea with pericranium, surfaced with split skin grafts. Two flaps carried with them a segment of vascularized parietal bone (TOCI-I). In the other two flaps, the osseus component was supplied by placing an osteogenic powder in a pericranial pocket: a temporal artery "osteogenic" cutaneous flap (TOCI-II). In each case the flap closed the defect and lengthened the palate without the need for elevation of palatal mucoperiosteum. Growth of the parietal bone segment has been observed in the first patient (the only one to have a follow-up CT scan). This patient, the eldest, is developing normal speech so far. The others are still too young for evaluation.     

Successful upper alveolar reconstruction for gingival cancer using a fibular osteoadipofascial flap without osseointegrated implants

An upper alveolar skeletal reconstruction with closure of the palatal fistula using an osteocutaneous free flap is considered an ideal reconstructive strategy after curative surgery for cancer of the lower maxilla. Although installation of osseointegrated implants into the bone has advantages for utilizing a dental prosthesis, it is often time and cost prohibitive. In the case of 1 patient, we reconstructed and fit the patient with a conventional denture, eliminating the need for installation of osseointegrated implants. The patient underwent upper alveolar reconstruction using a fibular osteoadipofascial flap, followed by a skin graft for creation of an alveololabial sulcus. It was then possible for the patient to wear a conventional denture without implants. One explanation for this success is that the regenerated mucosa on the adipofascial flap and skin graft was immobile, which allowed it to serve as a base for the dental prosthesis. The alveololabial sulcus that had been constructed kept the denture in place. This reconstruction confirmed that a fibular osteoadipofascial flap might be a useful choice in restoring a natural upper alveolar osseous and soft tissue structure.     

The Association of Vacuum-Assisted Closure Therapy with Dynamic Volume Change of a Muscle Flap Transposed in an Empyema Cavity for Chronic Empyema: A Case Report

A 62-year-old woman with a history of lung resection for lung cancer was admitted to our hospital due to cough, which became progressively more severe. She was diagnosed with chronic empyema with bronchopleural fistula (BPF) of the right upper bronchial stump. Although a pedicled muscle flap was transposed to the empyema cavity, the fistula remained. We used a vacuum-assisted closure system after open-window thoracotomy and observed the cavity reduction with expansion of the transposed muscle flap. We quantitatively evaluated the dynamics of the cavity change using a three-dimensional image analysis system. A reduction of the volume of the muscle flap by prolonged empyema and expansion of the muscle flap was observed immediately after vacuum-assisted management. However, expansion of the right residual lung was not recognized. Pedicled muscle flap transposition followed by vacuum-assisted management after open-window thoracotomy may be effective for treating chronic empyema caused by BPF.     

腭部黏膜下组织瓣在口腔上颌窦瘘修复中的效果观察

目的评价腭部黏膜下组织瓣在口腔上颌窦瘘修复中的效果。方法对12例口腔上颌窦瘘患者，采用腭部黏膜下组织瓣修复缺损。结果术后创口均愈合良好，黏膜下结缔组织瓣修复区及腭部供区黏膜颜色、光滑度及质地均恢复良好。结论腭部黏膜下组织瓣能有效地修复口腔上颌窦瘘，术后无明显供区并发症发生。     

硬腭黏骨膜瓣翻转衬里修复腭瘘的疗效评价

目的:探讨硬腭黏骨膜瓣翻转衬里修复腭瘘的临床效果。方法:应用瘘口两侧的邻近瓣,将一侧硬腭黏骨膜瓣翻转作衬里褥式缝合修复18例腭瘘患者。结果:18例腭部瘘孔均获得关闭,无感染、复裂等并发症。结论:硬腭黏骨膜瓣翻转衬里修复腭瘘临床效果良好,为腭瘘的修补提供了一种有效安全的方法。