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Hi. This is Dr. Amit T. Suryawanshi. Oral & Maxillofacial surgeon from Pune, India. I am here on slideshare.com to share some of my own presentations presented at various levels in the field of OMFS. Hope this would somehow be helpful to you making your presentations. All the best & your replies are welcomed!
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Palatal Fistula and Syndromes associated with CLCP
Part - II
Dr. Amit T. Suryawanshi
Oral and Maxillofacial Surgeon
Pune, India
Contact details :Email ID - [email protected]
Mobile No - 9405622455
Treatment Modalities for palatal fistula
Surgical Treatment
Local Flaps
Palatal flap
Vomer flap
V-Y ward Kilner Procedure
Distant flaps
Tongue Flap
Nasolabial flap
Buccal musculomucosal flap
Recent Techniques
Tissue expander
Microvascular surgery
Conservative Treatment
Obturators
Fixed
Removal
Other material
Local Flaps
Palatal Flap
• Palatal flap
Axial flap based on the
Greater palatine artery,
Macronet – Connection
between two greater
palatine arteries across
the midline
• Palatal flaps have been used routinely for the
correction of hard palatal, partial soft palatal,
and retromolar defects.
• The ultimate flap design is dependent on the
size and location of the area to be reconstructed.
The flap has the ability at maximum to provide
approximately 10 cm2 of tissue
The recipient site is prepared with the creation of
surgical margins for flap placement,
The greater palatine foramen with its vascular
supply is identified by manual palpation of the
palate.
A full-thickness incision is made lateral to the
vascular supply and can extend to 1 mm short of
the palatal side of the teeth.
In the absence of dentition, the flap can be
raised to the point of the palatal alveolar crest.
This incision is carried anteriorly and can extend
up to the palatal mucosa of the central incisors if
necessary. A similar incision can be made on the
contralateral side if the entire palate is to be
used in the flap.
• Care is taken as the vascular supply is
approached. Once the flap is elevated, it is
rotated or inverted into place. Care should be
taken to ensure that the flap is free from
tension, which may cause dehiscence or
vascular compromise and flap necrosis.
If increased laxity is necessary, the hamulus can
be fractured, which will provide additional length
to the flap. Once in place, the flap is sewn to the
prepared mucosal edges.
Care should be taken to avoid any pressure on
the vascular pedicle
• Postoperatively, patients begin with clear
liquids, which are advanced to a regular diet
on postoperative day 3.
• Advantages
Relatively easy to harvest
Rotation about a 180-degree axis and the ability to
invert the flap allow coverage in any direction.
(Oral Maxillofacial Surg Clin N Am 15 (2003) 467–473 )
• Disadvantages
The flap is limited by its neurovascular supply,
which emerges from the bony canal of the
greater palatine foramen.
(Oral Maxillofacial Surg Clin N Am 15 (2003) 467–473 )
Vomer Flap
• Vomer flap
Midline Structure
Used for reconstruction of palatal fistula
Very easy to use
• Classification:
Vomer flap
• Advantage
Simplicity & ease of execution of flap,
Minimal surgical trauma & time,
Provide effective nasal lining,
Quality of tissue is very similar to nasal mucosa,
Good vascularity of flap.
• Disadvantage
The technique can be used only when the vomer is
of an adequate size or when it is readily visible.
May cause growth disturbance in midface.
Cleft palate- craniofacial journal january 2006, vol.43 no.1
Veau- Wardill- Kilner Flap
• V-Y pushback repair ( Veau- Wardill- Kilner )
(International Journal of Pediatric Otorhinolaryngology 74 (2010) 1054–1057)
Marking for incision
Pre Operative Palatal fistula
Intra-operativeImmediate Post-operative
Post operative After 7 days
Distant flap
Buccal Musculomucosal Flap
• Buccal Musculomucosal Flap
First palatal mucosa around fistula is deepithealised,
Flap developed from the side of buccal mucosa, ( width < 1.5 cm).
(British Journal ofPlastic Surgery (1990). 43,452-456)
Care must be taken not to injure the orifice of
parotid duct,
Flap is musculomucosal includes the buccinator
muscle
Donor site is closed primarily,
Plastic protector made to prevent flap bitten by
teeth,
Flap pedicle divided approx. after 10-14 days.
Blood supply – Facial artery
(British Journal ofPlastic Surgery (1990). 43,452-456)
British Journal ofPlastic Surgery (1990). 43,452-456
Outline of flap Raised Flap
British Journal ofPlastic Surgery (1990). 43,452-456
Attached flapSecond Stage- Flap detachment
• Advantages:
1. No detrimental after-effects occur at the donor site.
2. No distress occurs during healing and it is not necessary to restrict
speech. With our buccal musculomucosal flap, special attention is
not necessary if a bite block is used.
(British Journal ofPlastic Surgery (1990). 43,452-456)
4. A normal diet may be resumed soon after operation.
5. In anaesthesia, ordinary oral intubation is possible for
buccal masculomucosal flap.
6. The flap more closely resembles the palatal mucosa in
appearance than does a tongue flap.
(British Journal ofPlastic Surgery (1990). 43,452-456)
• disadvantages:
1. It is sometimes difficult to close fistulae which
are located in the anterior hard palate
2. Patients sometimes complain of a foreign body
sensation in their mouth due to the bulkiness
of the flap.
Pre Operative Ant. Palatal fistula
Intra-operative Post operative After 4 days
Tongue Flap
• Tongue Flap:
Guerrero-Santos & Altamirano ( 1966 )
Tongue flaps are excellent flaps for palatal fistula closure.
They use adjacent tissue, have an excellent blood supply, and
are associated with minimal morbidity1.
(Haneke E. Surgical treatment of defects on the tip
of the nose. Dermatol Surg 1998;24:711–7)
• A variety of flap designs have been described including anterior-
and posterior-based tongue flaps.
• Blood Supply – lingual artery
Marking
Tongue flapTongue flap
Tongue flap
Immediate Post operative
Post operative After 21 days
• Advantages of tongue flap
1. The tongue has excellent axial and collateral circulation.
2. Sufficient volume.
( Motamedi MH, Behnia H. Experience with regional flaps in the comprehensive
treatment of maxillofacial soft-tissue injuries in war victims. J Craniomaxillofac
Surg 1999;27:256–65)
Selection Criteria for Tongue Flaps
Failed Previous Attempts
Size of the Defect
Site of the Defect
Amount of Existing Scarring
Observation
1. Donor site deformities were minimal.
2. No detectable alteration in
a) Speech
b) Taste
c) Impaired tongue mobility
54
3. Improvement in feeding
4. Noticeable improvement in speech &
articulation
Complications of tongue flap
Palatal dehiscence
Recurrence of fistula
Bleeding
Flap detachment
56
Nasolabial Flap
• Nasolabial flap
Thiersch was first to use this flap for oral cavity
defect.
(Thiersch C: Verschluss eines loches im harten gaumen durch dic weichtheile der wange. Arch Heilkunde 9:159, 1868)
An inferiorly based nasolabial flap is preferred.
The medial incision line precisely follows the
nasofacial fold in its superior two thirds.
Blood supply – Angular artery
( Int. J. Oral Maxillofac. Surg. 1991; 20." 40-43 )
Incision Line
Base of flap <1.5-2.5cm
• Advantages
The nasolabial flap is a simple, effective, and
safe flap with a low complication rate.
Donor site morbidity is negligible
(J Oral Maxillofac Surg 58:1104-1108, 2000)
• Disadvantages
Infection,
Minor or major flap necrosis,
Wound dehiscence,
Asymmetry at the level of the nasolabial fold may
present in unilateral cases.
(J Oral Maxillofac Surg 58:1104-1108, 2000)
Microvascular Flap
• Free flaps used for Palatal defect are:
Fibula
Rectus abdominus
Scapular
Radial forarm
Lattisimus dorsi
• Advantages
Free-flap reconstruction of the palate provides reliable
permanent separation of the oral and sinonasal cavities in one
stage.
The potential for dental rehabilitation with the restoration of
masticatory function and normal phonation exists.
(Otolaryngology- Head & Neck June 1999, Vol 125, No. 6)
Tissue Expander
Tissue expander:
Two stage procedure under GA
First- Placement of tissue expander
Second – after 1 week, removal of tissue expander, palatal
revision, and closure of palatal fistula.
Advantages - Complication are minimal
(Cleft Palate Craniofac j. 2011 Mar;48(2):217-21. Epub 2010 Apr 23)
Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 414e421
Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 414e421
Tissue expander
Obturator
Anterior palatal fistula
Fixed type of Obturator
Removal type of obturator
Skin barrier adhesive patch
• Advantages:
• Improvement in Speech,
• Lesser chance of regurgitation.
(The cleft palate journal, october 1985, vol. 22 no. 4 )
Conclusion :
Prevention is always better than cure, fistulaformation after cleft palate repair willprobably continue to occur even in the best ofhands. It is of the utmost importance to repairsymptomatic fistulas as soon as possible,before further complications and long-termfunctional disability develops.
SYNDROMES ASSOCIATED
• Perry-Robinson Syndrome
• OFDS- More’s syndrome
• Down’s syndrome
Thank you