The Nasal Artery Musculomucosal Cutaneous Flap in Difficult Palatal Fistula Closure

Abstract

Palatal fistula is a difficult complication after cleft palate repair. The repair of a palatal fistula can be challenging, particularly in wide and recurrent fistulas (►Fig. 1). Large defects after cleft palate repair produce various symptoms, including regurgitation of fluid into the nasal cavity, hearing loss, and velopharyngeal insufficiency. In these cases, the palatal tissue around the fistula can be quite scarred and in short supply. A variety of reconstructive options are commonly employed, using local flaps of muscle and mucosa or tongue tissue or using distant flaps. 1-3 The combination of buccal mucosal flaps and buccinator muscle as an axial myomucosal flap based on the facial artery has been described by Pribaz et al. 2 This flap consists of mucosa, submucosa, part of the buccinator and orbicularis muscles, and the facial artery with its venous plexus. This is known as the facial artery musculomucosal (FAMM) flap. 2 The FAMM flap can be designed as an anteriorly based (for anterior fistula repair) or posteriorly based (for posterior fistula repair) flap. The facial artery is a branch of the external carotid artery and enters the face at the lower border of the mandible at the anterior border of the masseter muscle. It then passes superiorly and Keywords ► facial artery flap ► palatal fistulas AbstractBackground After cleft palate repair is performed, oronasal fistulas are potential consequences with resultant regurgitation of fluid and food, hearing loss, and velopharyngeal insufficiency. Treatment of oronasal fistulas is a challenge for plastic surgeons especially when the fistulas are large and scarring is significant. The facial artery musculomucosal (FAMM) flap, introduced by Pribaz in 1992, is a reliable and useful procedure for the closure of wide palatal fistulas. A new modification of facial artery composite flap is presented here including a skin component that avoids extended procedures for nasal layer reconstruction and reduces the mucosal component size. The flap described here is the nasal artery musculomucosal (NAMMC) flap; the main blood supply comes from the lateral nasal artery, a terminal branch of facial artery. Methods We present a series of anteriorly and posteriorly based NAMMC flaps, which were used to close large palatal fistulas after cleft palate repair in 12 patients. Results All flaps were successful. One flap had an anterior wound dehiscence in a bilateral case, and we have seen no total flap failure or postoperative palatal fistulas. The aesthetic appearance of the skin donor site was acceptable in all cases. Conclusions The NAMMC flap is a good alternative for closing wide and recurrent fistulas. It is associated with a high rate of success. The traditional FAMM flap should be named as "nasal (lateral) artery musculomucosal flap" because the distal branch of the facial artery is the main blood supply of the flap.

Update on surgery for velopharyngeal dysfunction

“…Anterior or posterior based flaps can be used to close large palatal fistulas contributing to VPD in cleft palate patients. The authors describe the use of this technique in 12 patients and noted a high rate of success, defined as no flap failures or postoperative palatal fistulas, with acceptable esthetic appearing skin donor site [28].…”

Persistent symptomatic anterior oronasal fistulae in patients with Veau type III and IV clefts: A therapeutic protocol and outcomes

“…16 , 21-23 However, the reconstruction of a particular cohort composed of patients with persistent symptomatic anterior oronasal fistulae has only been sporadically reported. [11][12][13][14][15][16][17] Previous studies have included small and/or mixed samples (e.g., only patients with anterior hard palatal fistulae or patients with all Pittsburgh II to VII types, with no specific stratification of fistulae neighboring to the alveolar cleft), which limit the interpretation and/or comparison of described experiences and results. In this study, we reviewed the long-term experience of a single senior surgeon with a therapeutic protocol for the surgical management of persistent symptomatic anterior oronasal fistulae in patients with Veau type III and IV clefts.…”

“…[7][8][9] Oronasal fistula reconstructions by adopting myriad surgical techniques (e.g., local flaps, regional intraoral or extraoral flaps, and free flaps) have been widely addressed in cleft literature, [7][8][9] but the surgical management of persistent anterior oronasal fistulae (Electronic supplementary material 1) neighboring the alveolar cleft (i.e., the Pittsburgh classification type V to VII fistulae 10 ) has only been sparsely reported in sporadic cases. [11][12][13][14][15][16][17] The diagnosis and treatment of patients with persistent anterior oronasal fistulae should be distinguished from the commonly detailed surgical approach of oronasal fistulae characterized as complications of post-cleft palate repairs (i.e., the Pittsburgh classification type I to IV fistulae). 10 In our experience, persistent anterior oronasal fistulae are particularly challenging to repair, as this subgroup of patients is distinct from those who usually have been followed up within our standard cleft protocols.…”

State of the Art in Treating Velopharyngeal Dysfunction

“…46 Patients with large oronasal fistulas as a consequence of cleft repair may benefit from utilization of the nasal artery musculomucosal cutaneous flap, which can either be anteriorly or posteriorly based, depending on the location of the fistula. 47 Another recently described procedure involves the use of buccinator myomucosal flaps to lengthen the palate. 48 Unilateral or bilateral flaps can be used, and this method can be successfully used to repair defects involving the nasal layer, the oral layer, or both these palatal layers.…”