Free vastus lateralis muscle flap for closure of recurrent oronasal fistula: a case report.
CASE REPORT: A 10 years-old girl presented to outpatient department, patient is a know case of bilateral cleft lip and palate was evaluated for oronasal fistula in the anterior hard palate. She had undergone cleft lip repair and multiple attempts of palatal repairs with the resultant fistula measures 3.1x2.8 cm defect with severely scarred surrounding palatal tissues. [Fig. 1, Fig. 2] Patient was worked up for Free ALT flap, reconstruction of fistula, palatal mucoperiosteal turnover flaps were raised to form nasal lining. Approximately about 1.2cm diameter defect of the nasal lining, couldn't be closed for lack of adequate tissue just behind the right lateral incisor. Standard markings for free anterolateral thigh flap was done on right thigh and exploratory incision was made, cutaneous perforator supplying the skin paddle was not reliable, Hence A vastus lateralis muscle with a 8-cm pedicle was Harvested. Only a 4.5 x4x1cm segment of muscle was harvested thus sparing remaining muscle. Flap was brought to recipient site and inset given, and the pedicle was passed through the gap in the nasal lining, and the right alveolar cleft, subcutaneous tunnel was created in the cheek and pedicle was brought close to facial vessels.
Facial artery and vein were used for vascular anastomosis.On the post-operative day 6 flap was found congested and patient was taken up for exploration at anastomosis site, vein was found kinked at anastomosis site and venous return was found hampered [Fig. 3] venous anastomosis was revised and venous flow was reestablished. Following which closure of fistula was achieved and muscle flap was mucosalised over a period of time, [Fig. 4] No significant morbidity was noticed due to harvesting muscle flap, no obvious fuctional disability noted, thigh scar healed well. [Fig. 5]
DISCUSSION: Oronasal fistula is the common complication following palatal repair, there are variety of option for reconstruction, local flaps, regional flaps and distant free flaps. Due to improved microsurgical skills and post-operative monitoring and intervention, results are good with microvascular reconstruction of palatal fistula. Variety of free flaps has been used to repair large oronasal fistulas. Free radial forearm flap have been used for reconstruction by Colletti et al  and chen et al  with closure of fistula but leaving behind scar over forearm. There are lot other free flaps have been used for reconstruction which includes Dorsalispedis flap,  scapular flap  lateral forearm flap,  Anterolateral thigh flap.  In our case report initial we planned for Free anterolateral thigh flap for reconstruction, but significant cutaneous branch was not found in our case, hence we planned for free vastuslateralis muscle flap for reconstruction of fistula. Vastus lateralis muscle flap derives its robust blood supply from descending branch of lateral circumflex femoral artery with good length of pedicle free segmental muscle flap can be used for reconstruction of recalcitrant palatal defects,.
CONCLUSION: To conclude free vastus lateralis muscle flap can be a good option for reconstruction of oronasal fistula without any significant morbidity.
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Prakash Kumar M. N (1)
(1.) Prakash Kumar M. N.
PARTICULARS OF CONTRIBUTORS:
(1.) Associate Consultant, Department of Plastic Surgery, Apollo Hospital, Bengaluru.
FINANCIAL OR OTHER COMPETING INTERESTS: None
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Prakash Kumar M. N, No-11, Chennakeshava Nilaya, 2nd Cross, Srirampura, B engaluru-560021.
Date of Submission: 19/06/2015.
Date of Peer Review: 20/06/2015.
Date of Acceptance: 23/06/2015.
Date of Publishing: 26/06/2015.
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|Title Annotation:||CASE REPORT|
|Author:||Prakash, Kumar M.N.|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Jun 29, 2015|
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