Role of free-tissue transfer in the treatment of recalcitrant palatal fistulae among patients with cleft palates

Recurrent palatal fistulae present a particularly vexing problem for patients with cleft lips and palates and their surgeons. When primary closure fails, conventional wisdom and the standard of care suggest local flap techniques for defect closure. For the large majority of patients, this approach is successful. There is, however, a small subset of patients who undergo multiple surgical procedures in unsuccessful attempts to close recalcitrant fistulae, particularly at the anterior, densely scarred, hard palate. In this setting, repair calls for the introduction of well-vascularized pliable tissue to close the defect and to avoid hampering further palatal growth. Local muscle flaps and oral axial pattern flaps have been advocated and used successfully. However, those approaches have their own drawbacks, such as multiple surgical interventions, patient compliance, and intraoral scarring. In an effort to avoid the problems associated with local flaps, distant microvascular tissue transfers were investigated. During a 6-year period, six free-tissue transfers were performed as a primary means of treating recalcitrant palatal fistulae. Three dorsalis pedis flaps and three osseous angular scapular flaps were used. The conditions of all patients improved, with five patients achieving complete long-term closure of the palatal defect. This experience indicates that modern microvascular techniques have reached a level of success commensurate with that of other flap techniques; therefore, it is concluded that free-tissue transfer should be considered as a primary means of addressing these difficult cleft problems.