Fistula are a common complication after a cleft palate repair. The size of the fistulas varies from small to large. Many of the smaller fistulas get closed by re-operative palatoplasty or some local flap closure whereas the larger ones are quite complicated and require a reliable flap for fistula closure surgery.
Closure of a complicated palatal fistula with a tongue flap is a good option. It can be done in two ways double layer closure and modified single layer closure with the help of tongue flap. This technique is the best one to do when it is difficult to close the nasal layer or impossible too. There are certain points to consider to avoid any further complications later on.
The fistula closure surgery procedure is carried out under general anesthesia and nasal intubation. The surgical site is marked and injected local anesthesia with adrenaline to get hemostasis and ease the dissection. the Incision is placed on the fistula margins on the oral side and is turned towards the nasal side without direct closure.
A doughnut shape is achieved with the center of the nasal layer left open. The tongue flap is marked in the desired size as per the length and width of the fistula. The tongue flap is raised with a small amount of muscle(5mm) using cautery to ensure better blood supply and healing. Now there should be a 2 layer closure on the periphery of the fistula i.e, the tongue flap orally and reflected fistula margins nasally. Mattress sutures placed to secure the tongue flap to the doughnut-shaped nasal layer and palatal mucosa orally. The donor site of the tongue is closed using sutures.
The patient is kept under observation for 24 hrs and can be discharged once the patient starts taking a liquid diet. And should make weekly visits until the second stage. After 2 to 3 weeks, the patient is re-operated under general anesthesia. The flap was tested with vascular loop tourniquet for adequate vascularity before separation. After separation, the final resetting of the flap is done. The remaining flap was sutured to the palatal mucosa, and the remaining flap pedicle was trimmed. The tongue donor site is closed fully.