PURPOSE

Palatal fistulas may result from trauma or iatrogenic injury.  They lead to problematic oro-nasal regurgitation, as well as difficulties with speech and eating.  In addition, several mechanisms of injury, such as chronic cocaine abuse, cause damage to surrounding tissues, which in turn compromises options available for reconstruction.  Closure of small oro-nasal fistulas may be performed with local flaps, if healthy.  However for large symptomatic defects, treatment options are limited, and include simple obturation, regional flaps, and free tissue transfer.  As an alternative for recurrent, large oro-nasal fistulas, the authors describe reconstruction of the palate with a three-layer closure consisting of a facial artery musculomucosal (FAMM) flap, acellular dermal matrix, and a mucosal turnover flap.

METHOD

A 40 year-old female presented with a 2 cm by 1.5 cm oro-nasal communication, which developed as a small perforation three years prior to presentation and had slowly increased to its current size.  An attempt at palatal reconstruction with local flaps had failed.  She gave a seven-year history of nasal cocaine abuse, however denied cocaine use for the past two years.

A 50 year-old female presented with a large palatal defect following previous resection of a pleomorphic adenoma of the oral cavity two years earlier.  In the interim, she underwent unsuccessful closure and wore an obturator to improve her hypernasal speech.  The fistula was 2 cm by 1.5 cm in the anterior portion of the soft palate.

Both patients complained of regurgitation of both solids and liquids via the nose in addition to hypernasal speech.  Each was reconstructed in two-stages using a three-layered repair.  A thin sheet of acellular dermal matrix was sandwiched between oral mucosa pedicled on the margins of the wound and turned into the center of the wound for the nasal layer and an inferiorly based FAMM flap for the oral layer.  Intraoperatively, a bite block was placed to prevent injury to the pedicle from the molar teeth.  At a second procedure, the pedicle was ligated and the flap was fully inset.

RESULTS

Both patients were followed postoperatively for one year.  Clinical examination demonstrated no infection, dehiscence, or clinical recurrence of the oro-nasal fistula and the patients reported improvement in vocal resonance, oro-nasal regurgitation, and decreased nasal tone.  The FAMM flap brought well-vascularized soft tissue, which helped integrate the acellular dermal matrix, and the turnover flap provided nasal mucosal lining.  The acellular dermis acted as a scaffold for migration of host tissue, resisting contraction and adding strength to the repair.

CONCLUSION

The authors present two patients with oro-nasal fistulas reconstructed with acellular dermal matrix sandwiched between a FAMM flap and a mucosal turnover flap.  The FAT reconstruction is an extension of the FAMM flap, adding additional support to the repair with vascularized tissue on either side of the avascular dermal substitute.  The acellular dermis is readily available, requires no donor site, and is easy to handle.   It may be utilized as a useful tool in the closure of difficult wounds of the palate.