Abstract
Palatal fistula as a complication of palatal surgery is difficult to manage due to the presence of fibrotic and scarred tissue and the absence of local virgin tissue. Recurrence rates are high. To investigate the efficacy of repairing small and medium sized palatal fistulas using the buccal fat pad (BFP), 20 patients (aged 2.5–19 years) with palatal fistula (10–20 mm) underwent closure surgery using a pedicled BFP flap. The nasal layer was closed by a local mucosal flap (turn down flap) and the pedicled BFP flap was used for oral lining. Full epithelialization of the BFP layer was observed within 4 weeks in all patients. A 2 mm defect in the anterior part of the previous fistula location remained in one case, which spontaneously healed after 2 months; all others closed successfully. Mild pain and cheek swelling occurred in 10 patients, which disappeared within 5 days with no surgical intervention. This study suggests the pedicled BFP flap is a simple and relatively secure method for palatal fistula management. It is recommended for fistulas less than 20 mm in length located in the posterior two-thirds of the palate.
Palatal fistulas after reconstructive cleft palate surgery are a problem for patients and surgeons. The presence of scarred tissues, the absence of local virgin tissues and high rates of recurrence have forced surgeons to consider surgical treatment only for symptomatic patients . Small fistulas following cleft palate reconstruction usually close spontaneously and large fistulas are usually managed with a temporalis muscle flap, facial artery musculo-mucosal (FAMM) flaps or free flaps . Medium sized fistulas are repaired with local palatal flaps, vestibular and buccal mucosal flaps. These random flaps are associated with ischemia and recurrence.
Using buccal fat pad (BFP) flaps for reconstruction of oral defects was introduced by E geydi and has since been used by many surgeons for oral reconstruction . In the following study, BFP flaps are used as oral lining in the management of palatal fistulas less than 20 mm in size. The advantages, limitations and complications of the method are discussed.
The BFP has complex three-dimensional anatomy with neurovascular structures coursing through and around it. It consists of a main body and four extensions: the buccal, petrygoid, superficial and deep temporal processes . The body is located centrally and is smaller than the buccal extension. The buccal extension, which is the largest and most superficial component, is deep or medial to the masseter muscle and superficial to the buccinator muscle and buccopharyngeal fascia. It accounts for 30–40% of the total weight of BFP. Its volume and size are usually stable during life and constant between people .
The buccal extension is free, unfixed and can be excised easily through an intra oral incision, whereas the main body is difficult to remove . The authors use the buccal extension for coverage of the oral layer.
Patients and methods
Patients with fistulas less than 20 mm in their longest diameter, referred to the authors’ centre between March 2003 and August 2005, underwent surgery using BFP flaps. Only patients whose fistula was located in the middle or posterior of the palate were included in the study. 20 patients (13 male; 7 female) were entered in the study; their age range was 2.5–19 years. The fistulas were 10–20 mm in their longest diameter. In 14 cases the reconstructive surgery was the first fistula repair, it was the second in 14 cases, and the third in 5 cases. The fistulas were secondary to congenital cleft palate repair in all patients. Table 1 gives data about patient demography, and the size and location of the defect.
| Patient | Sex | Age | Size of fistula** (mm) | Location | Procedure |
|---|---|---|---|---|---|
| 1 | F | 3 | 20 × 10 | Mid-palate | Local flap and BFP * flap |
| 2 | F | 14 | 20 × 10 | Soft palate | Local flap and BFP flap |
| 3 | M | 16 | 10 × 13 | Mid-palate | Local flap and BFP flap |
| 4 | F | 10 | 10 × 12 | Distal hard palate | Local flap and BFP flap |
| 5 | F | 19 | 15 × 10 | Distal hard palate | Local flap and BFP flap |
| 6 | M | 3 | 17 × 12 | Distal hard Palate | Local flap and BFP flap |
| 7 | M | 2.5 | 15 × 10 | Soft palate | Local flap and BFP flap |
| 8 | M | 4 | 13 × 9 | Soft palate | Local flap and BFP flap |
| 9 | F | 5 | 17 × 14 | Mid-palate | Local flap and BFP flap |
| 10 | M | 8 | 20 × 10 | Mid-palate | Local flap and BFP flap |
| 11 | F | 6 | 15 × 9 | Soft palate | Local flap and BFP flap |
| 12 | M | 4 | 12 × 8 | Mid-palate | Local flap and BFP flap |
| 13 | M | 9 | 15 × 6 | Soft palate | Local flap and BFP flap |
| 14 | M | 6 | 13 × 7 | Soft palate | Local flap and BFP flap |
| 15 | F | 13 | 20 × 9 | Mid-palate | Local flap and BFP flap |
| 16 | M | 14 | 15 × 7 | Soft palate | Local flap and BFP flap |
| 17 | M | 7 | 13 × 11 | Soft palate | Local flap and BFP flap |
| 18 | M | 9 | 14 × 8 | Distal hard palate | Local flap and BFP flap |
| 19 | M | 17 | 16 × 9 | Distal hard palate | Local flap and BFP flap |
| 20 | M | 8 | 17 × 11 | Soft palate | Local flap and BFP flap |
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