Prelaminated Fascia Lata Free Flap for Oronasal Fistula Reconstruction

Summary:

Oronasal fistulae are frequently symptomatic due to rhinolalia and regurgitation of solid food and liquids through the palate.¹ When asymptomatic, fistulae can be managed with conservative therapies. Local flaps are useful to close small fistulae but cannot be used in bigger ones and cases with bad-quality surrounding tissues. Ideally, a thin double-layer mucosal tissue is required, but there are no suitable donor sites for this tissue in the human body. We report a palate fistula reconstruction with prelaminated fascia lata free flap.

CASE REPORT

A 47-year-old man presented with a history of septal perforation and oronasal fistula related to cocaine abuse. The patient complained about regurgitation and cacosmia. Medical therapy was tried in another hospital, with no result. The patient had undergone a previous reconstruction of the palate with a radial forearm flap that resulted in the above-mentioned fistula.

We performed a 2-stage reconstruction of a full-thickness palate defect measuring 2.0 × 1.5 cm.

METHODS

In the first stage, a fascia lata-only anterolateral thigh flap was harvested based on a single perforating vessel; the vascular proximal pedicle was identified but not dissected. Two 2.0 × 2.0 cm full-thickness skin grafts were taken. The donor site was closed directly. Both grafts were sutured on each side of the fascia lata and covered with silicone sheets to prevent adhesions to surrounding tissue (Fig. 1). A drain was placed, and the wound was closed.

Fig. 1.

Fascia lata-only ALT flap harvested based on a single perforating vessel with the vascular pedicle identified. Two 2.0 × 2.0 cm full-thickness skin grafts sutured on each side of the fascia lata.

Six weeks later, the prelaminated flap was harvested based on the descending branch of the lateral femoral circumflex system. The silicone sheets were removed, noting that both grafts were integrated (Fig. 2). An extra 1 cm fascial margin was harvested with the flap to facilitate insetting. The pedicle was passed subcutaneously, and a termino-terminal anastomosis was performed to the facial vessels at the mandibular border.

Fig. 2.

Prelaminated flap harvested based on the descending branch of the lateral femoral circumflex system. Note, both grafts are integrated each side of the fascia. An extra 1 cm fascial margin was harvested with the flap to facilitate insetting.

RESULTS

The postoperative course was uncomplicated. The flap healed successfully, and no evidence of fistula was observed on the follow-up 36 months after surgery (Fig. 3).

Fig. 3.

Outcome 4 months after surgery.

DISCUSSION

The management of the oronasal fistulae depends on the size and the symptoms produced by the communication between both cavities. The most frequent symptoms are rhinolalia and regurgitation of food through the palate perforation when swallowing.¹ Patients may also complain about anosmia, cacosmia, headache, halitosis, pain, and bleeding. Small fistulae can be treated conservatively with antibiotic ointments, nasal emollients, or saline irrigations. Prosthetic obturators are a helpful therapy until surgery, but these devices do not completely solve the passage of food to the nasal cavity.

When the medical treatment fails, local and regional flaps may be used. The most popular flaps are rotation palatal flaps and facial artery musculomucosal flap. Local palatal flaps were not an option in this case. The main problem of these flaps is the limited amount of tissue provided, so they are only useful to cover small fistulae.^2,3 Also the friability of the surrounding tissues contraindicates the use of local flaps.

The coverage of bigger defects requires the use of free flaps. The radial forearm free flap has been the most widely used option. This flap is usually too thick when used as a double paddle for palatal reconstruction, and it is usually hairy in males. Colletti et al.⁴ describe fistula formation at the junction of palatal mucosa and the skin of the flap. This could be avoided by placing a segment of fascia underneath the surrounding mucosa.

To avoid secondary thinning, fascial flaps are a suitable option. They can be used directly, allowing to heal by secondary intention, but this has the risk of contracture, lack of epithelialization, and the potential risk of fistula recurrence. The flap can be prelaminated for optimal thinness (Fig. 4). As in any prefabrication, the main disadvantage is that it requires a 2-stage procedure.

Fig. 4.

Lateral view of the flap evidencing the width of the composition.

Prelaminated flaps have the advantage of fascial flaps, providing a reliable, pliable, and thin coverage without the need of secondary intervention. This option allows the construction of bilayer flaps to match the reconstructed palate.