An effective way to provide a two layer repair in an oronasal fistula is by using the tongue flap.
A tongue flap can be based either posteriorly or anteriorly depending on defect location and size. To illustrate the procedure we will show the use of an anteriorly based tongue flap.
2. Closure with tongue flap
Preparation of the recipient site
The nasal mucosa may be repaired by designing turn-over palatal flaps.
An incision is made on the palatal mucosa in proximity to the defect to allow for tension free nasal closure.
Preparation of the flap
A longitudinal myo mucosal flap of adequate thickness is taken from the mid portion of the dorsal tongue.
The donor site is closed to as near as possible to the base of the flap.
The undersurface of the pedicle is left to heal by secondary intention.
Closure of the defect
The flap is turned over and sutured into the palate defect.
The raw edge of the flap is left to heal by secondary intention.
Division of the pedicle
After 10 - 14 days the pedicle is divided and the anterior segment of the flap may be inset to its initial donor location.
3. Aftercare following corrections of secondary deformities of the alveolus and palate
Analgesia as necessary
Antibiotics (many surgeons use perioperative antibiotics). There is no clear advantage of any one antibiotic but evidence supports their use for 24h. The spectrum should be according to the existing bacterial flora, especially in the combined intra oral and paranasal sinuses.
Steroids may help with postoperative edema.
Regular perioral and oral wound care has to include disinfectant mouth rinse, lip care, etc.
Antibiotic ointment is used on skin incision (when indicated) for 72 hours.
Reconstruction with free flap
When a free flap is utilized, it should be regularly monitored to ensure vascular integrity. Physical examination, assessing the flap color, turgidity, and capillary refill should be routine for at least the first 48 hours postoperatively. Hand-held Doppler probes can be used to assess blood flow. In case of doubt of the vitality of the flap, pin-prick assessment with a 25 gauge needle to look for bright red bleeding. In cases of buried flaps, an implantable Doppler placed just distal to the venous anastomosis can be utilized. Radial forearm free flap The radial forearm free flap donor site should be closed with a skin graft and a bolster placed over the area. The arm is then cast or placed in a volar splint for 7 days prior to removal to ensure graft take. If bone is taken and the radius plated, appropriate follow-up with an orthopedic or hand specialist should be arranged.
Fibula free flap After a fibula free flap, the donor lower leg should be cast with the ankle slightly dorsiflexed for 5 days. The patient can touch-down their body weight as tolerated. After the cast is removed they can ambulate and work with physical therapy to optimize leg function. A splint should be placed to keep the foot flexed when in bed.
Scapula free flap Flaps from the subscapular system require no particular rehabilitation care but closed suction drains should remain until a minimal output is still draining to avoid seroma formation.
Rectus abdominis and iliac crest Rectus abdominis and iliac crest donor sites require that the patient not strain or lift heavy objects for at least 4 weeks to avoid hernia formation.
Anterolateral thigh Patients should avoid climbing stairs for 2-4 weeks after surgery. They should also be observed for seroma formation at the wound bed.
Remove sutures from skin after approximately 7 days if non resorbable sutures have been used. Moisturizing lotion should be used on the skin wounds to minimize excessive scarring after sutures are removed. Avoid sun exposure and tanning to skin incisions for several months.
Diet depends on the correction method.
For patients with free flap reconstruction of the maxilla, a feeding tube is placed during sugery allowing the patient to be kept nil per os for 5-7 days. If issues develop with velopharyngeal insufficiency or dysphagia, assessment by a speech and swallowing rehabilitation specialist may be indicated. When the lateral nasal wall is reconstructed, especially when a bulky soft tissue flap is used, the nasal airway should be stented with gauze packing or a merocel sponge for five days.
Patients with intraoral incisions and/or wounds must be instructed in appropriate oral hygiene procedures. A soft toothbrush (dipped in warm water to make it softer) should be used to clean the surfaces of the teeth. Chlorhexidine oral rinses should be prescribed and used at least 3 times a day to help sanitize the mouth. For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris.
Typically the patients are seen in clinical follow-up one week after discharge, and then on a weekly basis until such time the clinician determines that less frequent follow ups are needed.