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 Table of Contents  
CASE REPORT
Year : 2023  |  Volume : 10  |  Issue : 1  |  Page : 45-47

Dermal substitute reinforced single-layer closure of the palatal fistula


Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta – The Medicity, Gurgaon, Haryana, India

Date of Submission21-Dec-2022
Date of Acceptance10-Jan-2023
Date of Web Publication14-Mar-2023

Correspondence Address:
Dr. Hardeep Singh
Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta – The Medicity, Sector 38, NCR, Gurgaon - 122 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_29_22

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  Abstract 


Postoperative palatal fistulas are common after surgery to correct a cleft palate. The repair is hindered by palatoplasty-related scar tissue, reduced vascularity, and restricted mobility of flaps. Surgical repair of fistulae is often effective, but recurrence is common. A 3.5-year-old boy presented with anterior palatal fistula. The presence of peri-fistulous scarring prevented two-layered closure. Nasal layer closure was achieved but not the oral layer. The dermal matrix was reinforced in a one-step procedure over the nasal layer and fixed in place using a gel foam. At 6 months, the fistula almost completely healed, with only a pinpoint track remaining that occasionally leaked into the nasal cavity. These results indicate that the application of dermal matrix is a promising technique to repair fistula with surrounding scarring, but larger, prospective trials are needed to confirm its potential benefits.

Keywords: Dermal matrix, fistula repair, nasal layer, palatal fistula


How to cite this article:
Singh H, Khazanchi RK. Dermal substitute reinforced single-layer closure of the palatal fistula. J Cleft Lip Palate Craniofac Anomal 2023;10:45-7

How to cite this URL:
Singh H, Khazanchi RK. Dermal substitute reinforced single-layer closure of the palatal fistula. J Cleft Lip Palate Craniofac Anomal [serial online] 2023 [cited 2023 Mar 30];10:45-7. Available from: https://www.jclpca.org/text.asp?2023/10/1/45/371646




  Introduction Top


Cleft palate repair is associated with a risk of postoperative palatal fistulas, occurring in 8.6% of cases overall.[1] Closure of the palatal fistula is done by achieving a tension-free two-layer closure using turnover and vomerine flaps for nasal lining and locoregional flaps.[2] This can be difficult due to the presence of scar tissue, reduced vascularity, and restricted mobility from previous attempts.[2],[3] Recurrence of the fistula is relatively common and dependent on the technique used.[4] To reduce the risk of recurrence, some authors have reported the use of acellular dermal matrix sandwiched between oral and nasal layers.[2],[5] Acellular dermal matrices (ADM) are widely and successfully used in reconstructive surgeries and wound healing.[6],[7] ADM has been shown to accelerate cell invasion, cell elongation, and proliferation, and limit myofibroblast formation and contraction.[8] This is a case report of a patient where ADM was used to reinforce a single-layer closure of a large palatal fistula. The report adheres to the Declaration of Helsinki and STROBE guidelines.


  Case Report Top


A 3.5-year-old boy, operated case of left-sided cleft lip and palate, presented to the outpatient department with a palatal fistula [Figure 1]. He had been experiencing nasal regurgitation of oral contents during eating, leading to repeated respiratory tract infections. Surgery for his cleft lip and palate had been performed at the age of 3 and 9 months, respectively. Soon after the palatoplasty, he had developed the palatal fistula. No surgical details were available because they had taken place in a different center. On examination, there was an anterior palatal fistula measuring 1.5 cm × 1 cm. Multiple scars from the previous surgical incisions were present around the site of the palatal fistula. The presence of scars and lack of an alveolar cleft precluded local or facial artery myomucosal flap. Options of tongue flap and a free flap were considered, but none were acceptable to the parents.
Figure 1: Persistent anterior palatal fistula

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Tension-free closure of the nasal layer was achieved using fistula margin-based turnover mucoperiosteal flaps. This defect was resurfaced with 2-mm thick layer of ADM, (MatriDerm® MedSkin Solutions Dr. Suwelack AG) tucked under the oral flaps to keep it in place and to increase the area of contact of the matrix with the nasal layer [Figure 2]. The matrix was stabilized by using a gel foam and absorbable sutures over it [Figure 3]. The gel foam performed two functions – keep the dermal matrix in place and avoid direct contact with saliva, hence increasing its chances of taking.
Figure 2: In a one-step procedure, dermal matrix (2 mm) was used to fill the defect

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Figure 3: Dermal substitute fixed in place with gel foam and absorbable sutures

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The patient was started on a liquid diet the same day and discharged the following day. The patient was kept on clear liquids for 1 week. He was examined every 3rd day. During follow-up, the gel foam resorbed over time, enabling the dermal matrix to adhere well to the nasal layer and slowly get mucosalized. At 6 months [Figure 4], there was near complete healing of the fistula apart from a pinpoint track at the anterior end of the original fistula that occasionally leaked into the nasal cavity.
Figure 4: Results at 6 months showed near complete healing of the fistula

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  Discussion Top


Surgeons who manage patients with cleft palate are often challenged by the postoperative formation of palatal fistulas. Indications for repair depend on associated symptoms,[9] such as leakage of fluid and food into the nasal cavity (as in our case), but nonproblematic fistulas are often not repaired.[3] Although surgery can successfully repair fistulae, recurrence is a problem.[4] There is a need for a relatively simple, less invasive, and effective method to potentially repair all palatal fistulae.

Our case study is the first to report the use of ADM (MatriDerm®) in a one-step procedure as an onlay method to close a recalcitrant palatal fistula, with an almost totally successful outcome despite the presence of scarring. Other studies have used different ADM to repair palatal fistulae. In 30 children with an oronasal fistula after palatoplasty, a 100% closure rate was achieved after using an ADM compared with no use.[2] In 12 children with a difficult anterior palatal fistula, an ADM was used as an inlay graft to provide an oral lining for the large fistulae during a flap procedure.[10] The overall success rate was 83.3%, with complete closure in 66.7% of patients and symptom reduction in 16.7%. Using an ADM during palatal fistula repair has been shown to be safe and effective over time compared with conventional surgical techniques, reducing the failure rate from 16.7% to 0%.[5] All these studies have used ADM as sandwich between the oral and nasal layer, whereas we got the healing by using only the nasal lining and ADM on it.

Overall, these results indicate that the use of a dermal matrix such as MatriDerm is a promising technique to repair fistulae after palatoplasty. However, the recommendation for routine use in fistula repair must be based on larger, prospective trials to confirm its potential benefits.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hardwicke JT, Landini G, Richard BM. Fistula incidence after primary cleft palate repair: A systematic review of the literature. Plast Reconstr Surg 2014;134:618e-627e.  Back to cited text no. 1
    
2.
Calì Cassi L, Massei A. The use of acellular dermal matrix in the closure of oronasal fistulae after cleft palate repair. Plast Reconstr Surg Glob Open 2015;3:e341.  Back to cited text no. 2
    
3.
Emodi O, Ginini JG, van Aalst JA, Shilo D, Naddaf R, Aizenbud D, et al. Cleft palate fistula closure utilizing acellular dermal matrix. Plast Reconstr Surg Glob Open 2018;6:e1682.  Back to cited text no. 3
    
4.
Mahajan RK, Kaur A, Singh SM, Kumar P. A retrospective analysis of incidence and management of palatal fistula. Indian J Plast Surg 2018;51:298-305.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Steele MH, Seagle MB. Palatal fistula repair using acellular dermal matrix: The University of Florida experience. Ann Plast Surg 2006;56:50-3.  Back to cited text no. 5
    
6.
Albanna MZ, Holmes J H. Skin Tissue Engineering AQ5 and Regenerative Medicine. Ch. 6. Boston: Academic Press; 2016. p. 109-24.  Back to cited text no. 6
    
7.
Petrie K, Cox CT, Becker BC, MacKay BJ. Clinical applications of acellular dermal matrices: A review. Scars Burn Heal. 2022;8:1-32.  Back to cited text no. 7
    
8.
Dill V, Mörgelin M. Biological dermal templates with native collagen scaffolds provide guiding ridges for invading cells and may promote structured dermal wound healing. Int Wound J 2020;17:618-30.  Back to cited text no. 8
    
9.
Murthy J. Descriptive study of management of palatal fistula in one hundred and ninety-four cleft individuals. Indian J Plast Surg 2011;44:41-6.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Richardson S, Hoyt JS, Khosla RK, Khandeparker RV, Sukhadia VY, Agni N. Use of regenerative tissue matrix as an oral layer for the closure of recalcitrant anterior palatal fistulae: A pilot study. J Korean Assoc Oral Maxillofac Surg 2016;42:77-83.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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