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Repair of Recurrent Cleft Palate With Free Vastus Lateralis Muscle Flap

Jose G. Christiano, M.D., Amir H. Dorafshar, M.B.Ch.B., Eduardo D. Rodriguez, M.D., D.D.S.,
Richard J. Redett, M.D.

A 6-year-old girl presented with a large recalcitrant oronasal fistula after

bilateral cleft lip and palate repair and numerous secondary attempts at fistula
closure. Incomplete palmar arches precluded a free radial forearm flap. A free
vastus lateralis muscle flap was successfully transferred. No fistula recurrence
was observed at 18 months. There was no perceived thigh weakness. The
surgical scar healed inconspicuously. Free flaps should no longer be
considered the last resort for treatment of recalcitrant fistulas after cleft palate
repair. A free vastus lateralis muscle flap is an excellent alternative, and
possibly a superior option, to other previously described free flaps.

KEY WORDS: cleft palate, free flap, vastus lateralis

Numerous flaps have been described for repair of The large size of the defect precluded closure with a
oronasal fistulas. Yet, the recurrent palatal fistula poses a tongue flap. Bilateral incomplete palmar arches found on
challenge to those involved in its operative care. Multiple arterial duplex mapping contraindicated the use of a free
failed repairs cause enlargement of the original defect radial forearm flap. Decision was made to use a free
and significant scarring of the surrounding tissues, which vastus lateralis muscle flap, which should provide adequate
further compromises the use of local flaps for closure. In amount of tissue for closure, with a long vascular pedicle.
this select group of patients, free tissue transfer may be While one team harvested the vastus lateralis muscle
required for successful repair (Ninkovic et al., 1997; Turk flap (Fig. 2), another team debrided the oronasal fistula,
et al., 2000; Krimmel et al., 2005). We describe the use of a created a nasal lining with bilateral palatal mucosa hinge
free vastus lateralis muscle flap for closure of a large flaps, and prepared the recipient facial vessels. The flap was
recurrent oronasal fistula in a patient born with cleft palate. then transferred, anastomosed, and inset. The flaps vas-
cular pedicle exited the oral cavity through an existing
CASE REPORT alveolar cleft.
The patient was extubated on the second postoperative
A 6-year-old girl presented to our clinic with a recurrent day and discharged to home 4 days later. On the following
oronasal fistula following repair of bilateral cleft lip and day, she returned to the hospital with complete dehiscence
palate. She had undergone three failed attempts of surgical of the flap, which remained attached only by its pedicle.
repair, starting at 2 years of age: two local turnover flaps, Upon reoperation, the flap was found to be viable and was
followed by a facial artery myomucosal flap. reinset (Fig. 3). Tongue sutures were placed to prevent the
Physical exam showed a large anterior palatal fistula patient from applying undue tension on the flaps suture
involving almost the entire anterior palate (Fig. 1). Bilateral lines.
clefts at the alveolus were seen, as well as angle class III She progressed with no other complications. At 6 weeks,
dental malocclusion. Evaluation of her speech revealed complete coverage of the muscle flap by oral mucosa was
several deficiencies, among which severe hypernasality was noted. The 18-month follow up showed no recurrence of
felt to be caused by the fistula. the fistula (Fig. 4). The donor site healed well, leaving an
inconspicuous scar. There was no perceived extensor
muscle weakness in the thigh. Exposure of the facial vessels
left a small 3-cm scar at the inferior border of the mandible.
Dr. Christiano is Assistant Professor, Division of Plastic Surgery, Speech evaluation showed significant improvement, with
University of Rochester, Rochester, New York; Dr. Dorafshar is
complete resolution of the hypernasality encountered pre-
Assistant Professor and Dr. Rodriguez and Dr. Redett are Associate
Professors, Department of Plastic and Reconstructive Surgery, The Johns operatively. As expected, there were no changes in speech
Hopkins Medical Institute, Baltimore, Maryland. deficiencies related to the patients malocclusion.
Submitted January 2011; Accepted July 2011.
Address correspondence to: Dr. Richard J. Redett, Department of DISCUSSION
Plastic and Reconstructive Surgery, The Johns Hopkins Hospital
Outpatient Center, 601 N Caroline Street, McElderry 8152C, Baltimore,
MD 21287. E-mail In the last decade, modifications in surgical technique
DOI: 10.1597/11-008 and perioperative care led to a considerable decrease in the

246 Cleft PalateCraniofacial Journal, March 2012, Vol. 49 No. 2

FIGURE 1 Large anterior palatal defect. FIGURE 3 Vastus lateralis muscle flap inset intraorally.

incidence of oronasal fistulas complicating cleft palate et al., 1993), but they require small defects and the presence
repair, with reported fistula rates falling mainly between 3% of healthy local tissue.
and 13% (Muzaffar et al., 2001; Phua and de Chalain, Microsurgical transfer of vascularized flaps for the
2008). Within this range, higher fistula rates are associated treatment of oronasal fistulas is warranted in cleft palate
with more severe clefting, which may help explain why patients when the size of the defect and quality of the
surgical repair of complicating oronasal fistulas has still surrounding tissues preclude the use of pedicled flaps
been plagued by high failure rates. Muzaffar et al. (2001) (Ninkovic et al., 1997; Turk et al., 2000; Krimmel et al.,
reported a fistula recurrence rate of 33% after attempted 2005). Traditionally, consideration was given after local
repair of the primary fistula. and regional flap options were exhausted. Turk et al. (2000)
Various treatments have been described for oronasal reported a case of a young male referred to their plastic
fistulas. Nonoperative approaches may rely on the use of surgery clinic only after 17 failed palatoplasty attempts.
palatal appliances (Berkman, 1978). Surgical techniques In our opinion, the association of a large anterior palatal
using local and regional tissues include undermining and defect, significant scarring of the surrounding tissues, and
primary closure, mucoperiosteal flaps, vestibular mucosal a history of at least one failed attempt of repair, as seen in
flaps, buccal myomucosal flaps, tongue flaps, vomer flaps, our patient, renders further use of local or regional flaps
Le Fort I osteotomies, nasolabial flaps, buccal fat flaps, unadvisable, based on a high likelihood of failure (Schultz,
and temporalis muscle flaps, among others (Guerrero- 1989; Ninkovic et al., 1997). For such patients, we have
Santos and Altamirano, 1966; Mukherji, 1969; Jackson, turned to free tissue transfer as the primary means of
1972; Abyholm et al., 1979; Pigott et al., 1984; Argamaso, reconstruction. It allows us to perform a tension-free repair
1990; Cohen et al., 1991; Pribaz et al., 1992; Cordeiro and of palatal defects of any size, in a single stage, with pliable,
Wolfe, 1996; Baumann and Ewers, 2000; Ercocen et al., well-vascularized healthy tissue. With modern success rates
2003; Robertson et al., 2008). Another option is the use of
nonvascularized grafts, such as dermis (Vandeput et al.,
1995) or conchal cartilage (Matsuo et al., 1991; Ohsumi

FIGURE 4 Healed palate with no cleft recurrence at 8 months

FIGURE 2 Vastus lateralis muscle flap harvested with its vascular pedicle. after surgery.
Christiano et al., REPAIR OF CP WITH FREE VLM FLAP 247

of up to 95%, microsurgical free tissue transfer should no muscle flap as an excellent alternative, and possibly a
longer be considered the last resort in the treatment of superior option, to other previously described free flaps.
complicated fistulas after cleft palate repair (Correa Chem
and Franciosi, 1983; Chen et al., 1992; Ninkovic et al., REFERENCES
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