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Free vastus lateralis muscle flap for closure of recurrent oronasal fistula: a case report.

INTRODUCTION: Palatal fistula is the commonest complication associated with cleft palate surgery, the rate of palatal fistula after palatal surgery varies from 4-35%, [1] Recurrent palatal fistula rate is 25% on an average after first attempt of repair. [2] Incidence of fistula is more in case of bilateral than in unilateral cleft lip with palate. [3] Due to undue tension at repair site with compromise in vascularity with super added infection is the cause for wound breakdown and resultant fistula formation, By bringing in well vascularised tissue from the distant site and reparing the fistula in single stage with minimum tension at operated site gives good result. Various free flaps have been explained for reconstruction of fistula including free radial artery for arm flap, dorsalispedis flap, scapular flap. On reviewing the literatures only few cases have undergone free vastus lateralis muscle flap for reconstruction of oronasal fistula. [4] With this back ground here by presenting a case of palatal fistula repair using free vastus lateralis muscle flap.

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 [5] and chen et al [6] 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, [7] scapular flap [8] lateral forearm flap, [9] Anterolateral thigh flap. [10] 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.

DOI: 10.14260/jemds/2015/1320

REFERENCES:

[1.] Cohen SR, Kalinowski J, La Rossa D, Randall P. Cleft palate fistulas: A multivariate statistical analysis of prevalence, etiology, and surgical management. Plast Reconstr Surg 1991; 87: 1041-7.

[2.] Partha S. Oronasal fistula in cleft palate surgery. Indian J Plast Surg 2009 Vol; 42: S123-8

[3.] Musgrave RH, Bremner JC. Complications of cleft palate surgery. Plast Reconstr Surg 1960; 26: 180-9.

[4.] Christiano JG, Dorafshar AH, Rodriguez ED, Redett RJ. Repair of recurrent cleft palate with free vastuslateralis muscle flap. Cleft Palate Craniofac J 2012;49:245-8.

[5.] Colletti G, Allevi F, Valassina D, Bertossi D, Biglioli F. Repair of cocaine-related oronasal fistula with forearm radial free flap. J Craniofac Surg 2013; 24: 1734-8.

[6.] Chen HC, Ganos DL, Coessens BC, Kyutoku S, Noordhoff MS. Free radial forearm flap for closure of difficult oronasal fistulas in cleft palate patients. Plast Reconstr Surg 1992; 90: 757-62.

[7.] Ninkovic M, Hubli EH, Schwabegger A, Anderl H. Free flap closure of recurrent palatal fistula in the cleft lip and palate patient. J Craniofac Surg 1997; 8: 491-5.

[8.] Schwabegger AH, Hubli E, Rieger M, Gassner R, Schmidt A, Ninkovic M. Role of free-tissue transfer in the treatment of recalcitrant palatal fistulae among patients with cleft palates. Plast Reconstr Surg 2004; 113: 1131-9.

[9.] Krimmel M, Hoffmann J, Reinert S. Cleft palate fistula closure with a mucosal pre-laminated lateral upper arm flap. Plast Reconstr Surg 2005; 116: 1870-2.

[10.] Ozkan O, Ozkan O, Coskunfirat OK, Hadimioglu N. Reconstruction of large palatal defects using the free anterolateral thigh flap. Ann Plast Surg 2011;66:618-22.

Prakash Kumar M. N (1)

AUTHORS:

(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.

E-mail: pritamprakesh97@yahoo.co.in

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
Words:1013
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